Use, re-use or discard? Quantitatively defined variance in the functional integrity of N95 respirators following vaporized hydrogen peroxide decontamination during the COVID-19 pandemic

BACKGROUND

Coronavirus disease 2019 has stretched the ability of many institutions to supply needed personal protective equipment, especially N95 respirators. N95 decontamination and re-use programmes provide one potential solution to this problem. Unfortunately, a comprehensive evaluation of the effects of decontamination on the fit of various N95 models using a quantitative fit test (QNFT) approach is lacking.

AIMS

To investigate the effects of up to eight rounds of vaporized hydrogen peroxide (VHP) decontamination on the fit of N95 respirators currently in use in a hospital setting, and to examine if N95 respirators worn by one user can adapt to the face shape of a second user with no compromise to fit following VHP decontamination.

METHODS

The PortaCount Pro+ Respirator Fit Tester Model 8038 was used to quantitatively define functional integrity, measured by fit, of N95 respirators following decontamination with VHP.

FINDINGS

There was an observable downward trend in the functional integrity of Halyard Fluidshield 46727 N95 respirators throughout eight cycles of decontamination with VHP. Functional integrity of 3M 1870 N95 respirators was reduced significantly after the respirator was worn, decontaminated with VHP, and then quantitatively fit tested on a second user. Furthermore, inconsistencies between qualitative fit test and QNFT results were uncovered that may have strong implications on the fit testing method used by institutions.

CONCLUSIONS

The data revealed variability in the functional integrity of different N95 models after VHP decontamination, and exposed potential limitations of N95 decontamination and re-use programmes.

Decontaminating N95 respirators during the COVID-19 pandemic: simple and practical approaches to increase decontamination capacity, speed, safety and ease of use

Background

The COVID-19 pandemic has caused a severe shortage of personal protective equipment (PPE), especially N95 respirators. Efficient, effective and economically feasible methods for large-scale PPE decontamination are urgently needed.

Aims

(1) to develop protocols for effectively decontaminating PPE using vaporized hydrogen peroxide (VHP); (2) to develop novel approaches that decrease set-up and take-down time while also increasing decontamination capacity; (3) to test decontamination efficiency for N95 respirators heavily contaminated by make-up or moisturizers.

Methods

We converted a decommissioned Biosafety Level 3 laboratory into a facility that could be used to decontaminate N95 respirators. N95 respirators were hung on metal racks, stacked in piles, placed in paper bags or covered with make-up or moisturizer. A VHP® VICTORY™ unit from STERIS was used to inject VHP into the facility. Biological and chemical indicators were used to validate the decontamination process. Findings: N95 respirators individually hung on metal racks were successfully decontaminated using VHP. N95 respirators were also successfully decontaminated when placed in closed paper bags or if stacked in piles of up to six. Stacking reduced the time needed to arrange N95 respirators for decontamination by approximately two-thirds while almost tripling facility capacity. Make-up and moisturizer creams did not interfere with the decontamination process.

Conclusions

Respirator stacking can reduce the hands-on time and increase decontamination capacity. When personalization is needed, respirators can be decontaminated in labelled paper bags. Make up or moisturizers do not appear to interfere with VHP decontamination.

Metastatic adnexal cancer in a man

Primary cutaneous adnexal neoplasms are mostly benign in nature; however, there have been reports of malignant adnexal tumors with distant metastasis to lymph nodes. Adnexal cutaneous malignancy with metastasis to the gastrointestinal tract has never been reported. Here, we present a rare case of a man with primary adnexal cutaneous adenocarcinoma who presented with symptomatic anemia secondary to occult gastrointestinal bleeding, found to be from gastrointestinal metastasis of the adnexal malignancy.

Real-World Sustained Virologic Response Rates of Sofosbuvir-Containing Regimens in Patients Coinfected With Hepatitis C and HIV

BACKGROUND

Patients with hepatitis C virus (HCV) with or without human immunodeficiency virus (HIV) achieve high sustained virological response (SVR) rates on sofosbuvir (SOF)-containing regimens in clinical trials. Real world data on patients coinfected with HCV and HIV treated with SOF-based regimens are lacking.

METHODS

This observational cohort study included HIV/HCV-coinfected adults with genotype 1 HCV who initiated treatment with a SOF-containing regimen between December 2013 and December 2014 (n = 89) at the Mount Sinai Hospital or the Brooklyn Hospital Center. The primary outcome was SVR at 12 weeks after the end of treatment. The secondary outcomes were risk factors for treatment failure, serious adverse events, and side effects. A post hoc per protocol analysis of SVR was performed on patients who completed treatment and follow-up.

RESULTS

In an intention-to-treat analysis, SVR rates were 76% (31/41) for simeprevir (SMV)/SOF, 94% (16/17) for SMV/SOF/ribavirin (RBV), and 52% (16/31) for SOF/RBV. The SVR rates of SMV/SOF/RBV and SMV/SOF did not differ significantly in this small study (P = .15). However the SVR rate of SMV/SOF/RBV was higher than that of SOF/RBV (P < .01). In a per protocol analysis, SMV/SOF/RBV had a higher SVR rate than SOF/RBV: 100% (16/16) vs 57% (16/28) (P < .01). The most commonly reported adverse effects were rash, pruritus, fatigue, and insomnia. One patient who had decompensated cirrhosis prior to treatment initiation died after receiving SMV/SOF.

CONCLUSIONS

SMV/SOF ± RBV is an effective option with minimal adverse effects for most HIV-positive patients with genotype 1 HCV. SMV should be used with caution in patients with decompensated cirrhosis.

Plasma chemistry before and after two consecutive days of racing in sled dogs: associations between muscle damage and electrolyte status

Exercising long distance endurance sled dogs display plasma biochemistry changes characterised by elevations in creatine kinase (CK) and aspartate aminotransferase (AST), hypoproteinemia, hypoglobulinemia and decreases in sodium and potassium. The aim of this study was to compare resting to day 2 racing plasma biochemistry and associations between electrolytes and markers of muscle damage in well-conditioned sled dogs during a stage-stop race. Blood samples were obtained from 23 dogs prior to the start and on day 2, immediately after racing. Results showed significant decreases in potassium (day 0 – 4.7±0.3 and day 2 – 4.2±0.3 mEq/l), total protein (day 0 – 6.0±0.3 and day 2 – 5.5±0.4 g/dl) and albumin concentrations (day 0 – 3.9±0.2 and day 2 – 3.6±0.3 g/dl). Increases in AST (day 0 – 24±7 and day 2 – 137±97 U/l) and CK activities (day 0 – 129±39 and day 2 – 2,047±2,021 U/l) were also observed. Plasma sodium concentrations were not significantly different after day 2 of racing (day 0 – 153±5.2 and day 2 – 151±4.1). Alterations in plasma electrolytes, and increases in AST, CK, alanine aminotransferase and urea nitrogen were similar to those observed in long distance endurance sled dogs. A strong negative association was observed between plasma potassium and increases in plasma CK activity on day 2 (R2=0.69). The maintenance of sodium concentrations with a concurrent potassium decline, suggests sodium conservation via the renin-angiotensin-aldosterone pathway as previously shown in endurance sled dogs. The negative correlation between muscle damage and plasma potassium warrants further investigation regarding its relationship to rhabdomyolysis.

Severe ductopenia and cholestasis from levofloxacin drug-induced liver injury: a case report and review

A 67-year-old woman with hypertension, hypothyroidism, and glaucoma was referred for jaundice and elevated liver function tests. She was treated for streptococcal endophthalmitis with 2 weeks of intravenous (IV) levofloxacin followed by 2 months of oral levofloxacin. The patient had no prior history of liver disease and denied alcohol intake. Her physical exam was remarkable for jaundice and scleral icterus without any stigmata of liver disease. Viral hepatitis serologies and antibodies, including myeloperoxidase, proteinase 3, and antinuclear, antimitochondrial, antiliver kidney microsome, antismooth muscle antibodies, were all within normal limits. The liver biopsy revealed severe cholestasis, extensive bile duct loss, and fibrosis. The patient had no known exposure to any other systemic medications or inciting factors other than levofloxacin. Although there are a few reported cases of drug-induced liver disease (DILI) related to levofloxacin, this case is believed to be the first reported case of ductopenia or vanishing bile duct syndrome (VBDS) associated with levofloxacin. Although fluoroquinolones, such as levofloxacin, are generally considered safe antibiotics, health practitioners must be aware of their association with DILI, as the diagnosis of DILI is one of exclusion and requires a high index of suspicion.

Pretreatment EEG in childhood absence epilepsy: associations with attention and treatment outcome

OBJECTIVE

In children with newly diagnosed childhood absence epilepsy (CAE), determine pretreatment EEG features and their associations with baseline neuropsychological function and short-term treatment outcome.

METHODS

In a multicenter, randomized clinical trial, patients with CAE underwent a pretreatment, 1-hour video-EEG and neuropsychological testing with freedom-from-failure and seizure-freedom (SF) outcome assessed at the 16- to 20-week visit.

RESULTS

Detailed evaluation of the pretreatment EEG was possible for 99.8% of participants (445/446). Median time to first seizure was 6.0 minutes (range 0-59 minutes), median number of seizures was 5 (range 1-60), and median seizure duration was 10.8 seconds (range 3.3-77.6 seconds). Median duration of shortest seizure per EEG was 7.5 seconds (range 3.0-77.6 seconds). Seizure frequency was not associated with baseline measures of attention, executive function, or treatment outcome. Presence of a seizure lasting ≥20 seconds was noted in 29% of subjects (129/440); these children had higher median omissions T score on the Conners Continuous Performance Test (56.3 vs 51.6, p = 0.01). Patients with a shortest seizure of longer duration were more likely to demonstrate treatment success by both freedom-from-failure (p = 0.02) and SF (p = 0.005) criteria, even after controlling for age, treatment group, and number of seizures, with good predictive value (area under the curve 78% for SF).

CONCLUSIONS

CAE is reliably and quickly confirmed by EEG. Occurrence of a seizure ≥20 seconds, but not overall seizure frequency, was associated with differential baseline measures of attention. Patients whose shortest pretreatment EEG seizure was longer in duration were more likely to achieve SF, regardless of treatment.

The experiences and challenges of informal caregivers: common themes and differences among whites, blacks, and hispanics

PURPOSE

This study examined commonalities and differences in the experiences and challenges of White, Black, and Hispanic informal caregivers in New York, NY.

DESIGN AND METHODS

A randomly selected representative cross-section of 2,241 households was contacted through telephone interviews. Complete data were available for 380 eligible participants, who were classified as White (n = 164), Black (n = 129) and Hispanic (n = 87). Descriptive, bivariate, and multivariate analyses were conducted to examine differences in caregiving intensity, reported difficulty with providing care, and having unmet needs with care provision.

RESULTS

Over 70% of caregivers had no help from formal caregivers, even though over 80% had been providing care for at least 1 year, and 40% had been providing this care for 20 or more hr per week. Compared with White caregivers, Black caregivers were more likely to provide higher intensity care, to report having unmet needs with care provision, and to experience increased religiosity since becoming caregivers, but were less likely to report difficulty with providing care. Hispanic caregivers were more likely than White caregivers to have help from formal caregivers and to experience increased religiosity since becoming caregivers.

IMPLICATIONS

Although many similarities exist in the experiences and challenges of informal caregivers, gaining insight from different populations of family caregivers would help program planners, policy makers, and formal caregivers to develop and implement culturally sensitive programs and policies that are supportive of the needs of these caregivers in their ever-expanding roles. Future efforts also should focus on exploring the potentially significant role that community resources, in particular, religious institutions, could play in providing outreach and support to racial/ethnic minority caregivers.

Interaction of temperature, humidity, driver preferences, and refrigerant type on air conditioning compressor usage

Recent studies have shown large increases in vehicle emissions when the air conditioner (AC) compressor is engaged. Factors that affect the compressor-on percentage can have a significant impact on vehicle emissions and can also lead to prediction errors in current emissions models if not accounted for properly. During 1996 and 1997, the University of California, Riverside, College of Engineering-Center for Environmental Research and Technology (CE-CERT) conducted a vehicle activity study for the California Air Resources Board (CARB) in the Sacramento, CA, region. The vehicles were randomly selected from all registered vehicles in the region. As part of this study, ten vehicles were instrumented to collect AC compressor on/off data on a second-by-second basis in the summer of 1997. Temperature and humidity data were obtained and averaged on an hourly basis. The ten drivers were asked to complete a short survey about AC operational preferences. This paper examines the effects of temperature, humidity, refrigerant type, and driver preferences on air conditioning compressor activity. Overall, AC was in use in 69.1% of the trips monitored. The compressor was on an average of 64% of the time during the trips. The personal preference settings had a significant effect on the AC compressor-on percentage but did not interact with temperature. The refrigerant types, however, exhibited a differential response across temperature, which may necessitate separate modeling of the R12 refrigerant-equipped vehicles from the R134A-equipped vehicles. It should be noted that some older vehicles do get retrofitted with new compressors that use R134A; however, none of the vehicles in this study had been retrofitted.

Mutational analysis of Escherichia coli topoisomerase IV. I. Selection of dominant-negative parE alleles

In order to define regions of ParE, one of the two subunits of topoisomerase IV, that are involved in catalysis during topoisomerization, we developed a selection procedure to isolate dominant-negative parE alleles. Both wild-type parC and mutagenized parE were expressed from a tightly-regulated lac promoter on a moderate-copy plasmid. Mutated parE alleles were rescued from those plasmids that caused IPTG-dependent cell death. The mutant ParE proteins could be divided into two groups when reconstituted with ParC to form topoisomerase IV, those that elicited hyper-DNA cleavage and those that affected covalent complex formation.

Hands on/hands off: why health care professionals depend on families but keep them at arm's length

The authors assert that a system that requires ever greater direct and indirect participation from families must change the negative presumption that families equal trouble to one that acknowledges legitimate family interests in decision making and care delivery and treats families as partners in caregiving.

Home sweet hospital: the nature and limits of private responsibilities for home health care

Family caregivers, often called "informal" caregivers, are the unpaid relatives, partners, or close friends who provide directly or manage the health care for individuals who are seriously ill or disabled. As a result of changes in the American health care system, family caregivers confront increasing responsibilities, burdens, and challenges. However, there are limits to family responsibility for caregiving, and whereas families may take the first step toward accepting responsibility for home care, professionals and institutions bear continuing responsibility. Public policies and programs have an enormous impact on the availability of home care assistance and services, the family's ability to afford and provide home care, and a caregiver's continued participation in the workforce. One of the major goals for the future of home care should be to recognize and respond appropriately to diverse family structures, strengths and limitations, and needs.

Needs survey of Canadian rosacea patients

BACKGROUND

In 1995, a Rosacea Awareness Program (RAP) was initiated in Canada to make available educational resources for physicians and rosacea patients. Material is in French or English, and is accessible though physician offices and by toll-free telephone. Information was communicated to the public via noncommercial, editorial media. The RAP created a database of rosacea patients in Canada.

OBJECTIVE

We investigated if individuals in the database had a confirmed diagnosis of rosacea, how they perceived their treatment by the medical system, and identified their needs.

METHODS

A two-page questionnaire was mailed to 7874 individuals registered with the RAP. Thirty percent of these individuals responded. Where comparisons were made a chi-squared statistic was used.

RESULTS

Over 70% learned of the RAP via public media. It took patients an average of 5 years to have a diagnosis made after the first symptoms appeared. In the majority of patients (53%) the diagnosis was ultimately made by a specialist. Fifty-eight individuals said they had not discussed their condition with their doctor. Patients were likely to continue on medication that was prescribed (60%) and topical metronidazole was the most common medication used, mostly the gel formulation. Most patients used these twice daily. Patients were very satisfied with treatments and almost 90% had reduced symptoms. Despite receiving explanations and written material, patients expressed a strong interest in more information being available on skin care, make-up, and psychological aspects of rosacea.

CONCLUSIONS

The RAP provides a needed educational service and is a useful database. Patients are very knowledgeable about their disease, but despite this and excellent therapeutic responses, the patients demand more information.

The economic value of informal caregiving

This study explores the current market value of the care provided by unpaid family members and friends to ill and disabled adults. Using large, national data sets we estimate that the national economic value of informal caregiving was $196 billion in 1997. This figure dwarfs national spending for formal home health care ($32 billion) and nursing home care ($83 billion). Estimates for five states also are presented. This study broadens the issue of informal caregiving from the micro level, where individual caregivers attempt to cope with the stresses and responsibilities of caregiving, to the macro level of the health care system, which must find more effective ways to support family caregivers.

The trouble with families: toward an ethic of accommodation

Although some clinicians are extraordinarily sensitive to the legitimate roles of patients' families in medical crises, a persistent tendency to equate families with trouble is evident in both the literature and the practice of medicine. Some negative presumptions about families derive from western medicine's almost exclusive focus on the individual patient in codes of ethics, training, and practice. Modern bioethics has reinforced this individualistic approach. Physicians' primary responsibilities are unequivocally to their patients, but a complete understanding of the patient's personhood must include consideration of the significant persons who help define the patient's core identity. One source of tension between professionals and families lies in differing perceptions of the roles that family members should play and how they should play them. Members of a family may act as advocates, provide or manage care, serve as trusted companions on the journey through illness and death, and make decisions on behalf of an incompetent patient. Each role presents potential conflicts. Other sources of conflict include disagreement within a family; challenges to physician authority; fear of litigation; and differing religious, ethnic, or cultural traditions. An ethic of accommodation emphasizes the need to negotiate care plans that do not compromise patients' basic interests but that recognize the capacities and limitations of family members. Family caregivers want understandable and timely information, better training, compassionate recognition of their anxiety, guidance in defining their roles and responsibilities, and support for the setting of fair limits on their sacrifices. Health care professionals can better meet these needs through education and skills acquisition, the establishment of partnerships with families, and regular dialogue and communication.

DNA gyrase and topoisomerase IV: biochemical activities, physiological roles during chromosome replication, and drug sensitivities

DNA gyrase and topoisomerase IV are the two type II topoisomerases present in bacteria. Though clearly related, based on amino acid sequence similarity, they each play crucial, but distinct, roles in the cell. Gyrase is involved primarily in supporting nascent chain elongation during replication of the chromosome, whereas topoisomerase IV separates the topologically linked daughter chromosomes during the terminal stage of DNA replication. These different roles can be attributed to differences in the biochemical properties of the two enzymes. The biochemical activities, physiological roles, and drug sensitivities of the enzymes are reviewed.

Identification of dnaX as a high-copy suppressor of the conditional lethal and partition phenotypes of the parE10 allele

Termination of DNA replication, complete topological unlinking of the parental template DNA strands, partition of the daughter chromosomes, and cell division follow in an ordered and interdependent sequence during normal bacterial growth. In Escherichia coli, topoisomerase IV (Topo IV), encoded by parE and parC, is responsible for decatenation of the two newly formed chromosomes. In an effort to uncover the pathway of information flow between the macromolecular processes that describe these events, we identified dnaX, encoding the tau and gamma subunits of the DNA polymerase III holoenzyme, as a high-copy suppressor of the temperature-sensitive phenotype of the parE10 allele. We show that suppression derives from overexpression of the gamma, but not the tau, subunit of the holoenzyme and that the partition defect of parE10 cells is nearly completely reverted at the nonpermissive temperature as well. These observations suggest a possible association between Topo IV and the replication machinery.

Social interventions in the care of human immunodeficiency virus (HIV)-infected pregnant women

The incidence of infection with the human immunodeficiency virus (HIV) is increasing among women of childbearing age. Women now account for 18% of the total number of cases of the acquired immunodeficiency syndrome (AIDS), compared with 9% a decade ago. The medical care of pregnant HIV-infected women must take into account the high prevalence of substance abuse, preceded and often accompanied by significant levels of physical, emotional, and sexual trauma, and the concomitant stigmatization of these women in their families and communities. Pregnancy is often a time when women are motivated to make major positive behavioral and life-style changes. To do this, they need ongoing, multidisciplinary counseling and support, with recognition that progress may be intermittent and slow. The Special Prenatal Care Program at Bellevue Hospital is described to show the level of resource commitment that is needed as well as the nearly universal acceptance of voluntary HIV counseling and testing in these conditions. Trends in permanency planning for the children of HIV-infected women are described. Future research needs are outlined, including female-specific drug treatment and more effective contraceptive technology for both men and women.

A comparison of five methods of temperature measurement in febrile intensive care patients

BACKGROUND

A clinically useful temperature measurement method should correlate well with the body's core temperature. Although previous investigators have studied temperature readings from different sites in hypothermic and normothermic patients, none have compared methods specifically in febrile patients.

OBJECTIVE

To compare temperature measurement methods in febrile intensive care patients.

METHODS

Temperature readings were obtained in rapid sequence from an electronic thermometer for oral and axillary temperature, rectal probe, infrared ear thermometer on "core" setting, and pulmonary artery catheter, approximately every hour during the day and every 4 hours at night. The sample consisted of 13 patients with pulmonary artery catheters and with temperatures of at least 37.8 degrees C.

RESULTS

Rectal temperature correlated most closely with pulmonary artery temperature. Rectal temperature showed closest agreement with pulmonary artery temperature, followed by oral, ear-based, and axillary temperatures. Rectal and ear-based temperatures were most sensitive in detecting temperatures greater than 38.3 degrees C. Likelihood ratios for detecting hyperthermia were 5.32 for oral, 2.46 for rectal, and 1.97 for ear-based temperature. Rectal and ear-based temperatures had the lowest negative likelihood ratios, indicating the least chance of a false negative reading. Axillary temperature had a negative likelihood ratio of 0.86.

CONCLUSIONS

Rectal temperature measurement correlates most closely with core temperature. If the rectal site is contraindicated, oral or ear-based temperatures are acceptable. Axillary temperature does not correlate well with pulmonary artery temperature. These results underscore the importance of consistency in method when establishing temperature trends, and of awareness of method when interpreting clinical data.

A comparison of five methods of temperature measurement in febrile intensive care patients

BACKGROUND: A clinically useful temperature measurement method should correlate well with the body's core temperature. Although previous investigators have studied temperature readings from different sites in hypothermic and normothermic patients, none have compared methods specifically in febrile patients. OBJECTIVE: To compare temperature measurement methods in febrile intensive care patients. METHODS: Temperature readings were obtained in rapid sequence from an electronic thermometer for oral and axillary temperature, rectal probe, infrared ear thermometer on "core" setting, and pulmonary artery catheter, approximately every hour during the day and every 4 hours at night. The sample consisted of 13 patients with pulmonary artery catheters and with temperatures of at least 37.8 degrees C. RESULTS: Rectal temperature correlated most closely with pulmonary artery temperature. Rectal temperature showed closest agreement with pulmonary artery temperature, followed by oral, ear-based, and axillary temperatures. Rectal and ear-based temperatures were most sensitive in detecting temperatures greater than 38.3 degrees C. Likelihood ratios for detecting hyperthermia were 5.32 for oral, 2.46 for rectal, and 1.97 for ear-based temperature. Rectal and ear-based temperatures had the lowest negative likelihood ratios, indicating the least chance of a false negative reading. Axillary temperature had a negative likelihood ratio of 0.86. CONCLUSIONS: Rectal temperature measurement correlates most closely with core temperature. If the rectal site is contraindicated, oral or ear-based temperatures are acceptable. Axillary temperature does not correlate well with pulmonary artery temperature. These results underscore the importance of consistency in method when establishing temperature trends, and of awareness of method when interpreting clinical data.

Stomal seeding of head and neck cancer by percutaneous endoscopic gastrostomy tube placement

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tubes have replaced nasogastric tubes and Stamm gastrostomy tubes as a preferred means of feeding for patients with head and neck cancers, as recommended by the results of large series. A patient with stomal seeding of squamous cell carcinoma of the upper aerodigestive tract by PEG placement was reported. A review of literature was performed.

METHODS

A Medline search of implantation of squamous cell carcinoma from the upper aerodigestive tract to PEG exit site since the introduction of PEG was performed.

RESULTS

Two reports of implantation of squamous cell carcinoma of the upper aerodigestive tract to PEG exit site were found. Both patients and our patient were staged T4.

CONCLUSIONS

Implantation of squamous cell carcinoma from the upper aerodigestive tract to the PEG exit site is a rare and late complication. Its prevalence is not known. For patients with a significant amount of squamous cell carcinoma in the upper aerodigestive tract, we recommend Stamm gastrostomy over PEG insertion by the pull technique. There is no report of such late complication by the push technique.

Orphans of the HIV epidemic: unmet needs in six US cities

In the United States, an estimated 72,000-125,000 children and adolescents will lose their mothers to AIDS by the year 2000. Six cities have been particularly hard hit: New York City, Newark, Miami, San Juan, Los Angeles, and Washington, DC. The most urgent unmet needs for children, their families and new guardians are for mental health services, including bereavement counselling; transitional services to help overcome the loss of AIDS-related benefits following the parent's death; legal services; housing supports, and appropriate evaluations and referrals by juvenile justice and school staff to community-based services. Professional staff need additional training and support. Public policies and legal standards should stress a preference for maintaining children in their extended families, broadly defined, whenever possible. Much more needs to be done to improve the lives and futures of these youth.

Ethics, epidemiology, and women's health

Ethical issues arise throughout the conduct of epidemiologic studies, in the processes of determining the study question, designing the protocol, and implementing the study. There also is an ethical dimension when studies are not done, for example, in studies of the effect of drugs and chemicals on male reproductive capacity. Harm as well as risk must be considered in the conduct of epidemiologic studies. The ethical principles that govern research, while independently justifiable, may come into conflict. Principles that govern research also may conflict with those that predominate in clinical practice. An example is the current controversy over unblinding anonymous, newborn human immunodeficiency virus seroprevalence studies to identify potentially infected infants. As women's health becomes more prominent on the research agenda, the resolution of these conflicts will become a complex challenge to epidemiologists, ethicists, clinicians, and the communities they serve.

Bull's-eyes and halos: useful MR discriminators of osseous metastases

To evaluate the presence of (a) a focus of high signal intensity in the center of an osseous lesion (bull's-eye) as a negative discriminator for metastasis and (b) a rim of high signal intensity around an osseous lesion (halo) as a positive discriminator, a retrospective study was performed in 47 patients with osseous lesions suspect for metastatic disease who underwent magnetic resonance (MR) imaging of the pelvis. The findings in 17 patients with proved osseous metastasis were compared with those in 30 patients not believed to have metastatic disease; T1- and T2-weighted MR images were evaluated. The bull's-eye sign was found to be a specific indicator of normal hematopoietic marrow (sensitivity, 95%; specificity, 99.5%). The halo sign and diffuse signal hyperintensity were a strong indicator of metastatic disease (sensitivity, 75%; specificity, 99.5%). These results suggest that use of the bull's-eye sign as a discriminator of benign disease and use of the halo sign as a discriminator of metastasis help characterize suspect areas of marrow lesions.

Bone metabolism in children with asthma treated with inhaled beclomethasone dipropionate

Previous studies have shown that inhaled corticosteroids can affect bone metabolism in adults. A study to assess the effect of inhaled beclomethasone, 300 to 800 micrograms/day for at least 6 months (mean 25 months), was therefore undertaken in children. In part 1 of the study, 18 children with asthma, aged 4 to 17 years (mean 10.1 years), were compared with an age- and sex-matched group of children with asthma not treated with corticosteroids. In part 2, eight more pairs were compared. Comparisons were also made with 61 healthy children. Bone mineral density measured by radiographic absorptiometry, and bone mineral content measured by single-photon absorptiometry and by dual-energy x-ray absorptiometry, showed no significant differences. Serum levels of calcium, magnesium, zinc, total alkaline phosphatase, bone specific alkaline phosphatase, parathyroid hormone, 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D also showed no differences. The activity of tartrate-resistant acid phosphatase, a marker of bone resorption, was significantly lower in the beclomethasone group than in both the asthma control and the normal control groups, but urine calcium excretion did not differ. Patients with asthma had lower serum osteocalcin and higher serum copper levels than control subjects without asthma, but treatment with beclomethasone did not affect these values. We conclude that inhaled beclomethasone (up to 800 micrograms/day) does not reduce bone mineralization or increase bone resorption. Effects on bone formation were difficult to assess because asthma per se caused a significant reduction in osteocalcin, a sensitive marker of bone formation.

Estimates of the number of motherless youth orphaned by AIDS in the United States

OBJECTIVE

To estimate the number of youth in the United States who have been or will be left motherless by the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic, in order to project the need for family supports, age-appropriate foster and congregate care, and mental health and social services.

DESIGN

Orphans are defined as youth whose mothers (the usual caregiving parent) die of HIV/AIDS-related causes. A mathematical model was constructed to estimate the number of such motherless youth. Cumulative fertility rates were applied to the number of reported AIDS deaths (1981 through 1990) and projected deaths (1991 through 1995) of adult women less than 50 years old. The results were adjusted for underreporting of HIV/AIDS-related mortality, pediatric AIDS deaths, infant mortality, ethnic and racial variation in fertility, and decreased fertility associated with late-stage HIV disease. Estimates were made for the number who were children (less than 13 years of age), adolescents (13 to 17 years of age), or young adults (18 years of age or older) at the time of their mothers' death.

RESULTS

By the end of 1995, maternal deaths caused by the HIV/AIDS epidemic will have orphaned an estimated 24,600 children and 21,000 adolescents in the United States; unless the course of the epidemic changes dramatically, by the year 2000, the overall number of motherless children and adolescents will exceed 80,000. In 1991, an estimated 13% of US children and 9% of adolescents whose mothers died of all causes were children of women who died of HIV/AIDS-related diseases. These proportions will surpass 17% and 12%, respectively, by 1995. The vast majority of these motherless youth will come from poor communities of color.

CONCLUSIONS

A large and rapidly growing number of American youth are being orphaned by the HIV/AIDS epidemic. Unless increased attention and resources are devoted to this vulnerable population, a social catastrophe is unavoidable.

Clinical observations of nebulized flunisolide in infants and young children with asthma and bronchopulmonary dysplasia

Severe bronchopulmonary dysplasia (BPD) is frequently associated with asthma. The combination is often severe enough to necessitate corticosteroid therapy. There are no commercially available nebulizer solutions of corticosteroids for use in infants and young children. Seven infants and small children with very severe BPD and asthma aged 6-24 months, were treated with flunisolide, 187-250 micrograms q.i.d. in the form of nasal spray delivered by nebulizer. After treatment for 2.5-20 months, four patients showed clinical improvement, one initially improved but later deteriorated and died of cardiac failure, and two patients showed no improvement and died within 3 months. The number of days of hospitalization was significantly reduced from 8.4/month to 2.5/month (P less than 0.05). No side-effects were detected and it was felt that the three patients who died, did so as a consequence of very severe BPD and its cardiac consequences. The suspension remained stable for 80 min when mixed with normal saline, cromolyn sodium, albuterol, or acetylcysteine. It is concluded that nebulized flunisolide is a potentially useful treatment for infants and young children with asthma and BPD.

Renal infarction associated with an extraadrenal pheochromocytoma

A patient with an abdominal extraadrenal pheochromocytoma showed computed tomography findings of renal infarction. Selective angiography of the affected kidney showed no evidence of arterial occlusion or emboli. We postulate that the renal infarcts were caused by reversible severe vasospasm associated with high systemic blood levels of norepinephrine and angiotensin II.

New X-linked syndrome with seizures, acquired micrencephaly, and agenesis of the corpus callosum

We report on 4 generations in a family with 3 living males, 3 males who died in infancy, and 3 females with neurologic impairment and agenesis of the corpus callosum (ACC). Manifestations in the surviving males include severe acquired micrencephaly, mental retardation, limb contractures, scoliosis, tapered digits with hyperconvex nails, a characteristic face with large eyes, prominent supraorbital ridges, synophris, optic atrophy, broad alveolar ridges and seizures. Urologic anomalies include renal dysplasia, cryptorchidism, and hypospadias. Two affected females were less severely impaired and continued to be socially responsive as adults, but had spastic quadriplegia and seizures. One obligate heterozygote was retarded with emotional problems while another obligate carrier female and her daughter were clinically normal. Pedigree analysis suggested X-linked inheritance with variable expression in females. These findings are inconsistent with the well-described X-linked conditions with ACC including FG syndrome and Aicairdi syndrome. ACC has not been described in Coffin-Lowry syndrome, a condition with similar clinical findings, which also demonstrates marked variability of expression in carrier females. In order to assist in carrier determination, brain imaging studies and DNA linkage analysis of the affected relatives was performed. We found a spectrum of agenesis of the corpus callosum with the most severe manifestations in the most severely affected males. DNA analysis using a series of X-linked probes suggests linkage with a LOD score of 1.26 at theta = 0 to a region between p 11.3 and p 21.3.

Familial pheochromocytomas with unusual associations

Pheochromocytoma occurs in a familial pattern in approximately 10% of patients. Although most familial pheochromocytomas are an expression of the genetic abnormality of neuroectodermal dysplasia or the genetic syndrome of multiple endocrine neoplasia, some familial pheochromocytomas occur without associated disease. Two patients with familial pheochromocytoma are described. One had an extraadrenal tumor, producing severe renal artery stenosis and in whose family pheochromocytomas were found in three successive generations. A second had multiple pheochromocytomas associated with von Hippel-Lindau disease and a family member with multiple endocrine neoplasia type 2. The combinations and permutations of these genetic entities form discrete syndromes, with other peculiar interrelationships, pathologically related to an aberration in the migration, growth, and differentiation of the neural crest cells, and emphasizing their common neuroectodermal origin. The unique features that characterize the familial pheochromocytomas and cause diagnostic and therapeutic challenges are reviewed.

Children in HIV/AIDS clinical trials: still vulnerable after all these years

“All things considered, I chose what was best for my children, or what I thought was best…” confessed Jean- Jacques Rousseau in 1782. What more can one expect from a parent or a professional entrusted with decisions about children? What Rousseau thought was “best” for each of his five infants, however, was to dispatch them to foundling homes in Paris, without even keeping a record of their birthdates, thus leaving them to an unknown but probably dismal fate.

Acting from moral and often legal obligations to protect vulnerable persons from harm and to enhance their welfare, adults daily make decisions about and for children. Professionals and policy makers fulfill their social responsibilities by creating and implementing policies and practices that enable children's caregivers to fulfill these same goals.

What's in a name? The policy implications of the CDC definition of AIDS

Disease classification systems and surveillance definitions are ordinarily tools for medical professionals, not matters for political debate and patient advocacy. It is hard to imagine a protest march complaining about the classification system for colon cancer. But when it comes to AIDS, nothing is ordinary.

The Centers for Disease Control's (CDC) case definition of AIDS is used by public health officials, researchers, clinicians, hospital administrators, disability specialists, insurance administrators, health economists, legislators, social workers, policy makers, and the media. It has influenced the way the HIV epidemic is perceived, managed, and funded.

It is not surprising, then, that the CDC definition of AIDS and its proposed revision is currently the subject of intense scrutiny. The case definition has transcended epidemiology to become a symbol for the inadequacies of the U.S. government's response to the HIV epidemic, and a particular symbol for the failure to address the needs of HIV-infected women.

Primary macronodular hepatic tuberculosis: US and CT appearances

Tuberculosis of the liver is uncommon except in association with miliary dissemination. Although hepatic involvement by tuberculosis tends to be diffuse, the macronodular or pseudotumor forms are rare. In addition, reports of actual imaging of tuberculous liver involvement are rare. A 5-year-old boy with a febrile illness due to macronodular hepatic tuberculosis, demonstrated by abdominal computed tomography (CT), and diagnosed by liver biopsy is presented.