A pilot randomized controlled trial of dexamphetamine in patients with chronic fatigue syndrome

This study determined whether dexamphetamine improved symptoms and quality of life in patients with chronic fatigue syndrome. The setting was a specialized clinic within a tertiary referral hospital. This was a 6-week parallel-group, placebo-controlled trial with random allocation. There was a 2-week dose-adjustment phase and a 4-week stable treatment period. Outcome measures were the Fatigue Severity Scale, the Medical Outcomes Study 36-item Short-Form Health Survey, and two patient-determined outcomes. Ten patients were randomly assigned to dexamphetamine, and 10 were assigned to placebo. Fatigue Severity Scale scores improved in nine of 10 dexamphetamine and four of 10 placebo patients. The change in mean score was statistically significant. There were large but statistically nonsignificant changes in scores for the Short-Form Health Survey domains vitality and physical functioning. Dexamphetamine may be useful in the management of chronic fatigue syndrome; a larger and longer trial is justified by these results.

Improving medical diagnoses by understanding how they are made

While a correct diagnosis is essential to appropriate patient management, scant attention is paid to the processes by which medical diagnoses are arrived at. While mismanagement may arise from a lack of relevant knowledge or the misuse of available data, this is probably uncommon. In many cases in which diagnistic errors occur, an initial faulty triggering of an inappropriate hypothesis is followed by a premature closure, excluding the search for further data that might be relevant to the diagnostic process. Often this is followed by anchoring, so that even when additional relevant data becomes available, the new information is ignored, and the original, faulty diagnosis is retained. Disturbingly, these errors may not be a reflection of lack of training or experience, and must be guarded against by even the most senior clinicians. Perhaps a systematic review of diagnostic accuracy should become a routine part of institutional quality assurance programmes.

Development of the Drosophila tracheal system occurs by a series of morphologically distinct but genetically coupled branching events

The tracheal (respiratory) system of Drosophila melanogaster is a branched network of epithelial tubes that ramifies throughout the body and transports oxygen to the tissues. It forms by a series of sequential branching events in each hemisegment from T2 to A8. Here we present a cellular and initial genetic analysis of the branching process. We show that although branching is sequential it is not iterative. The three levels of branching that we distinguish involve different cellular mechanisms of tube formation. Primary branches are multicellular tubes that arise by cell migration and intercalation; secondary branches are unicellular tubes formed by individual tracheal cells; terminal branches are subcellular tubes formed within long cytoplasmic extensions. Each level of branching is accompanied by expression of a different set of enhancer trap markers. These sets of markers are sequentially activated in progressively restricted domains and ultimately individual tracheal cells that are actively forming new branches. A clonal analysis demonstrates that branching fates are not assigned to tracheal cells until after cell division ceases and branching begins. We further show that the breathless FGF receptor, a tracheal gene required for primary branching, is also required to activate expression of markers involved in secondary branching and that the pointed ETS-domain transcription factor is required for secondary branching and also to activate expression of terminal branch markers. The combined morphological, marker expression and genetic data support a model in which successive branching events are mechanistically and genetically distinct but coupled through the action of a tracheal gene regulatory hierarchy.

Hospital administrators' tolerance of staff needlestick injuries

OBJECTIVE

To survey hospital administrators regarding their opinions of an acceptable frequency of staff needlestick injury and the frequency that would prompt additional preventive action.

DESIGN

A simple anonymous questionnaire sent to 960 administrators with one reminder. Data were collected regarding hospital size and community role, whether human immunodeficiency virus (HIV)-infected patients had ever been treated, presence of an infection control practitioner, estimation of the proportion of staff vaccinated against hepatitis B, and opinions as to the acceptable frequency of needlestick accidents and the accident frequency, requiring additional action.

SETTING

240 public hospitals in New South Wales, Australia.

PARTICIPANTS

The executive officers, directors of medical services, directors of nursing, and safety officers of the hospitals surveyed.

RESULTS

The response rate was 50%. Administrators' opinions of acceptable accident frequency increased with hospital size and (independently of size) with experience with HIV-infected patients, and with the presence of a full-time infection control practitioner. Accident frequencies judged to require additional preventive action were higher than injury frequencies regarded as acceptable.

CONCLUSIONS

The hospital administrators surveyed accept staff needlestick injuries as inevitable, the more so in hospitals that have treated known HIV-infected patients and that have full-time infection control practitioners.

HIV--Australasian experience. Current status of HIV infection in Australasia

The HIV/AIDS pandemic continues to evolve in a volatile and heterogeneous fashion and is now best described as a series of different but related epidemics, all posing their own particular problems. The response to the first decade of the epidemic in Australasia has been effective in a number of ways, but much remains to be done. The problems raised by recent cases of transmission of HIV in a health care setting have yet to be resolved. The characteristics of the local epidemic are increasingly divergent from the overseas models used to date, necessitating a flexible and creative approach tailored to the particular characteristics and needs of the local communities.

A 19F-NMR study of the membrane-binding region of D-lactate dehydrogenase of Escherichia coli

D-Lactate dehydrogenase (D-LDH) is a membrane-associated respiratory enzyme of Escherichia coli. The protein is composed of 571 amino acid residues with a flavin adenine dinucleotide (FAD) cofactor, has a molecular weight of approximately 65,000, and requires lipids or detergents for full activity. We used NMR spectroscopy to investigate the structure of D-LDH and its interaction with phospholipids. We incorporated 5-fluorotryptophan (5F-Trp) into the native enzyme, which contains five tryptophan residues, and into mutant enzymes, where a sixth tryptophan is substituted into a specific site by oligonucleotide-directed mutagenesis, and studied the 5F-Trp-labeled enzymes using 19F-NMR spectroscopy. In this way, information was obtained about the local environment at each native and substituted tryptophan site. Using a nitroxide spin-labeled fatty acid, which broadens the resonance from any residue within 15 A, we have established that the membrane-binding area of the protein includes the region between Tyr 228 and Phe 369, but is not continuous within this region. This conclusion is strengthened by the results of 19F-NMR spectroscopy of wild-type enzyme labeled with fluorotyrosine or fluorophenylalanine in the presence and absence of a nitroxide spin-labeled fatty acid. These experiments indicate that 9-10 Phe and 3-4 Tyr residues are located near the lipid phase.

Biotypes of Haemophilus parainfluenzae from the respiratory secretions in chronic bronchitis

A total of 2401 isolates of Haemophilus parainfluenzae was isolated from respiratory secretions of 36 healthy adults and 128 patients with chronic bronchitis over a period of 1 year. The isolates were allocated to eight biotypes, by their production of indole, urease and ornithine decarboxylase. Biotypes I and II constituted most of the isolates of H. parainfluenzae from the oropharynx of controls (75%) and chronic bronchitics (c. 90%). Among the patients, there was no difference in the isolation rate between oropharyngeal swabs and sputum specimens. Biotypes III, IV, VI, VII and VIII were isolated less frequently, as was a new taxon defined here as biotype V which does not produce indole, urease or ornithine decarboxylase. Biotype III was isolated significantly less frequently from cases of chronic bronchitis than from controls, whereas biotype II was isolated somewhat more frequently from the patients, especially during acute episodes.

Wheat dust-associated respiratory disease in a farming community

Sixty-six volunteers who considered themselves to have wheat dust-related respiratory disease, were reviewed from a farming community. A spectrum of disease was described ranging from a mild allergic rhinitis limited to periods of wheat dust exposure through to perennial asthma in which wheat dust was but one of several precipitating factors. Approximately half of those with asthma had symptoms limited to times of wheat dust exposure. Results of a limited survey of farmers showed patterns of symptoms similar to those in the volunteer group. Most subjects were atopic with elevated IgE levels, and had positive skin prick tests to environmental allergens. All but one of 65 subjects tested had a positive RAST test to wheat dust antigen. It is concluded that wheat dust associated respiratory tract disease is a significant problem in Australian farming communities, that a particular pattern of asthma can be described, and that IgE mediated reactions contribute to this disease pattern.

Evaluation of a selective medium for the isolation and differentiation of Haemophilus influenzae and Haemophilus parainfluenzae from the respiratory tract of chronic bronchitics

Respiratory tract specimens from chronic bronchitic patients were cultured for Haemophilus species on conventional chocolate agar and a modified sucrose medium in order to determine the accuracy of the new medium in differentiating Haemophilus influenzae from Haemophilus parainfluenzae strains. Haemophilus influenzae biotypes II and III and Haemophilus parainfluenzae biotypes I and II were found to be the predominant strains isolated from the respiratory tract. The modified sucrose medium was found to be a rapid and reliable means of differentiating Haemophilus influenzae from Haemophilus parainfluenzae by sucrose fermentation, on initial isolation.

Bacterial colonisation of the respiratory tract in chronic bronchitis

One hundred and nine subjects with chronic bronchitis were studied prior to winter and without clinical infection, to determine baseline patterns of bacterial colonisation. Qualitative analysis of cultures of oropharyngeal swabs showed little difference from age matched normal controls (17) except for growth of small numbers of Gram negative coliforms in the chronic bronchitic group. Quantitation of bacteria colonising the oropharynx showed small numbers (mean of 10(5) cfu/ml), with no particular bacteria dominating. Haemophilus influenzae was present in 7.3% of throat swabs from chronic bronchitic patients, but the organism was always less than 10% of the total count. Quantitation of bacteria in sputum showed significantly higher numbers (mean 10(7) cfu/ml). H. influenzae was detected in 25.7% of available specimens, and when present constituted greater than 90% of the total count. Biotyping of H. influenzae isolates demonstrated a separate colonisation of the upper and lower respiratory tracts.

Nasal histamine challenges in symptomatic allergic rhinitis

Twenty subjects (seven with perennial allergic rhinitis, seven with symptomatic seasonal allergic rhinitis, and six normal control subjects) underwent assessment of nasal sensitivity to histamine. Nasal resistance was measured by posterior rhinometry under control conditions and after log incremental doses of histamine solution pipetted into the nose (0.5 to 5000 micrograms). Allergic subjects exhibited a twofold rise of nasal resistance with doses of 0.5, 5, or 50 micrograms of histamine, whereas the nasal resistance in normal subjects remained unchanged until 500 or 5000 micrograms of histamine had been administered. Nasal reactivity to histamine was not correlated with symptoms on the day of testing but was correlated with the number of positive wheals to skin prick testing. It was concluded that nasal resistance is more sensitive to histamine in subjects with allergic rhinitis than in normal control subjects and that this difference may be used as the basis of a diagnostic test.

Kaposi's sarcoma of the palate in a patient with AIDS: an unusual presentation

Kaposi's sarcoma formerly a rare tumour in the western world, is now found frequently in homosexual patients with the Acquired Immune Deficiency Syndrome. A common site of occurrence is the mouth. The characteristic intra-oral appearance of the lesion is of a flat or raised pigmented lesion. An intra-oral Kaposi's sarcoma which was not pigmented and which presented as a painless, soft swelling on the hard palate is reported. The unusual appearance of the lesion is described and the importance of accurate diagnosis of intra-oral lesions in patients with the Acquired Immune Deficiency Syndrome is emphasized.

Biotyping respiratory Haemophilus species with the microbact system

The biochemical characteristics of 114 respiratory Haemophilus isolates were examined by the Minitek and Microbact systems. The Microbact system was easy to use and read, although some of the less important reactions (glucose and xylose) were difficult to interpret on occasions. On the basis of the 3 crucial reactions--indole production, ornithine decarboxylase and urease activity--discrepancies between the two systems were minor. Given careful standardization of techniques the Microbact system is a suitable alternative to established techniques for the biotyping of H. influenzae and H. parainfluenzae.

A case-control study of deaths from asthma

A population based case control-study was initiated in 1981 to identify risk factors for death from asthma. Over a two year period all deaths in the Auckland population possibly due to asthma, in people less than 60 years of age, were investigated. From the 47 people who died from asthma 44 who had useful reversibility of airways obstruction (records showing greater than 20% variability of peak flow or a history indicating equivalent variability of shortness of breath) before death were selected as cases for the study. Both hospital and community based controls were used. The cases were more likely than were the community controls to have had severe disease, a hospital admission or visits to a hospital emergency department in the previous year (odds ratios 4.4, 16.0, 8.5 respectively). The asthmatic patients who died were more likely than either group of controls to have had a previous life threatening asthma attack. Poor management of the disease and poor compliance on the part of the patient increased the risk of death. In addition, use of three or more types of asthma drug within the past year was associated with an increased risk of dying that was independent of disease severity. Of interest was a similarity between asthmatic patients admitted to hospital and those who died. Nevertheless, a history of a previous life threatening attack and a recent admission to hospital identified a group at high risk.

Deaths from asthma in New Zealand

We report the first complete population based study of childhood deaths due to asthma. All deaths ascribed to asthma in New Zealand children aged 0-14 were investigated as part of a two year national study of mortality from asthma. The 16 children who died from asthma all developed asthma by the age of 4; 15 had a family history of asthma, and 12 had associated atopic disorders. Disturbed pyschosocial relationships were evident in eight families. Seven children died in less than three hours from the onset of their final attack. All children died outside hospital. Mortality from asthma in Maori children (3.14 per 100 000) was five times that of European children. With hindsight, factors which if avoided could have led to a different outcome were identified in eleven cases. The circumstances surrounding these deaths were similar to those described for adults with asthma; this study, however, underlines the importance of parental care and knowledge in the management of children with asthma. Inadequate long term medical care, underassessment of severity by family and doctors, failure of the family to call for help when required, and inadequate responses of medical services contributed to the fatalities. Excess beta2 sympathomimetic dosage or overreliance on home nebulisers were uncommon. Most childhood deaths from asthma should be prevented by increased family awareness, better assessment of severity, improved long term treatment, and rapid access to emergency medical care.

Management of acute asthma attacks in Auckland A & E departments

Many asthmatics in the Auckland area use hospital accident and emergency (A & E) departments as the primary source of treatment during acute asthmatic attacks. A review of A & E records has revealed important variations in the standard of care they receive, and highlights the need for further education of A & E officers.

Asthma mortality in New Zealand: a two year national study

The epidemic of deaths from bronchial asthma in New Zealand was investigated by a two-year national review of all deaths of persons under 70 years where "asthma" appeared in part I of a death certificate or in a coroner's report of cause of death. Information about the patients, the characteristics and management of their asthma and the circumstances of the fatal episode was obtained by interviewing relatives and general practitioners and perusal of hospital records. The reviewing panel of the asthma task force of the Medical Research Council considered 271 of the 342 deaths studied were due to asthma. A high national asthma mortality rate (5.1 per 100 000) was confirmed, with rates for Maoris (18.9) and Pacific Islanders (9.4) considerably higher than that for Europeans (3.4 per 100 000). After standardising for age and ethnic groups, there remained a threefold variation in mortality rates among health districts suggesting regional differences in prevalence, severity or management of asthma. No single cause for these high mortality rates was found. One-quarter of the deaths occurred in patients who had had previous life threatening attacks. Excessive use of bronchodilator drugs did not account for the high mortality rates, but inappropriate prolonged use of a home nebuliser may have delayed institution of other therapy in a few cases.

Death from asthma in Auckland: circumstances and validation of causes

New Zealand has experienced an epidemic of asthma deaths since 1977 with mortality rates of over 3.0/100 000 for people aged 5-34 years, more than three times the rate of comparable countries. To examine the reasons for this high mortality rate all deaths from asthma in people under 70 years in the Auckland region in 1981-82 were investigated. A total of 84 possible cases were studied and the validity of death certificates was found to be excellent for people under the age of 50 years. Fifty-three cases had usefully reversible asthma at the time of death and the mortality rate was almost four times higher in Pacific Islanders than in caucasians, with the Maori rate being intermediate. Sixty-seven percent (35) of the deaths in people with usefully reversible asthma occurred at home. In only 40% of cases had the patient reached some form of medical care. No deaths occurred in the patients admitted to hospital with the diagnosis of asthma during this period.

Decrease in mitogen responsiveness of mononuclear cells from peripheral blood after epinephrine administration in humans

A single subcutaneous injection of 0.2 mg epinephrine into healthy human subjects caused a transient lymphocytosis in peripheral blood. Mononuclear cells (MNC), isolated at various times after epinephrine administration, were cultured in the presence of mitogens. The blastogenic responses to pokeweed mitogen (PWM) and phytohemagglutinin (PHA) were significantly reduced for up to 60 min post-epinephrine (p less than 0.05); the response to concanavalin A (Con A) was reduced in the 15-min samples only. All responses returned to pre-injection levels by 120 min post-injection. Removal of adherent monocytes from MNC isolates before culture did not restore normal mitogen responsiveness. When MNC were cultured in the absence of mitogens, there was no difference in survival between pre- and post-epinephrine samples. Incubation of untreated MNC for 2 hr or 18 hr in vitro with various concentrations of epinephrine (10(-5) to 10(-1) mg/ml) had no effect upon the subsequent blastogenic response to mitogens. Other workers have reported that epinephrine administration causes alterations in the composition of the circulating lymphocyte pool. Taken together, these data suggest that the reduction in mitogen responsiveness after epinephrine is the result of changes in the distribution of lymphocyte subclasses in peripheral blood.

Decrease in mitogen responsiveness of mononuclear cells from peripheral blood after epinephrine administration in humans

A single subcutaneous injection of 0.2 mg epinephrine into healthy human subjects caused a transient lymphocytosis in peripheral blood. Mononuclear cells (MNC), isolated at various times after epinephrine administration, were cultured in the presence of mitogens. The blastogenic responses to pokeweed mitogen (PWM) and phytohemagglutinin (PHA) were significantly reduced for up to 60 min post-epinephrine (p less than 0.05); the response to concanavalin A (Con A) was reduced in the 15-min samples only. All responses returned to pre-injection levels by 120 min post-injection. Removal of adherent monocytes from MNC isolates before culture did not restore normal mitogen responsiveness. When MNC were cultured in the absence of mitogens, there was no difference in survival between pre- and post-epinephrine samples. Incubation of untreated MNC for 2 hr or 18 hr in vitro with various concentrations of epinephrine (10(-5) to 10(-1) mg/ml) had no effect upon the subsequent blastogenic response to mitogens. Other workers have reported that epinephrine administration causes alterations in the composition of the circulating lymphocyte pool. Taken together, these data suggest that the reduction in mitogen responsiveness after epinephrine is the result of changes in the distribution of lymphocyte subclasses in peripheral blood.

Mortality from asthma: a new epidemic in New Zealand

Trends in mortality attributed to asthma in the 5-34-year age group were examined in New Zealand, Australia, England and Wales, the United States, Canada, and West Germany for the years 1959-79. An epidemic of deaths from asthma occurred in the mid-1960s in New Zealand, Australia, and England and Wales but not in the other countries. In Australia and England and Wales the death rate quickly returned to pre-epidemic levels, but in New Zealand the decline in mortality was slow, and by 1974 the death rate was still almost double the pre-epidemic level. Of great concern was an abrupt increase in reported deaths from asthma in New Zealand after 1976 with the mortality rate during 1977-9 being greater than during the previous epidemic. In contrast, asthma mortality had remained relatively stable in the other populations.The new epidemic in New Zealand was investigated and appeared to be real. It could not be explained by changes in the classification of deaths from asthma, inaccuracies in death certification, or changes in diagnostic fashions. The most likely explanation appeared to be related to the management of asthma in New Zealand, and this is being investigated.

Has the change to beta-agonists combined with oral theophylline increased cases of fatal asthma?

An apparent increase in young people dying suddenly from acute asthma has been noted in the past 2 years in Auckland. 22 fatal cases were reviewed. Prescribing habits for asthma therapy have been changing in New Zealand, with a considerable increase in the use of oral theophylline drugs, particularly sustained-release preparations, which in many patients have replaced inhaled steroids and cromoglycate. It is suggested that there may be an additive toxicity between theophylline and inhaled beta 2-agonists at high doses which produces cardiac arrest. Also when regular symptomatic treatment with bronchodilators replaces inhaled steroids or cromoglycate the patient's perception of an asthma crisis may be delayed.

Immune complex detection in arterial and venous blood: a preliminary study

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Transfer factor and hepatitis B: a double blind study

A prospective, double blind placebo-controlled trial was carried out on twenty-nine patients with hepatitis B. Thirteen received transfer factor and sixteen placebo. There were no significant differences between the two groups in any clinical or laboratory measurements made, although a rapid early reduction of serum aspartate transaminase levels by transfer factor is possible. Similarly, no significant changes were delineated by the in vitro measurements of lymphocyte function. Transfer factor did not alter the natural course of hepatitis B.

Antinuclear antibodies in patients receiving non-practolol beta-blockers

Antinuclear antibodies (ANA) were found in 54 (7.0%) out of 767 treated hypertensive patients compared with 59 (2.4%) out of 2470 healthy controls. Inclusion of a non-practolol beta-blocker in the treatment regimen did not significantly affect the incidence of ANA. ANA was found in significantly more patients being treated with methyldopa (13.0%) than patients receiving other hypotensive agents (3.8%). Non-practolol beta-blockers in combination with methyldopa did not increase the incidence of ANA further.

Transfer factor therapy: clinical experience and the role of the E rosette assay

Transfer factor has been administered to 17 patients, most with infectious diseases of various kinds. In 12 patients the therapy was followed by a definite clinical improvement although in most cases conventional chemotherapy was given concomitantly. In all cases where clinical improvement followed the sheep red cell or E rosette assay showed low values initially, with an improvement following therapy. This test of T lymphocyte function may be useful both in predicting patients likely to respond to transfer factor, and in monitoring response to treatment. As no specific assay of transfer factor activity is available, an in vivo rise in E rosette formation following transfer factor administration serves as a crude indicator that the injected material has some biological activity.

T-lymphocyte colonies in malignant disease

T-lymphocyte colonies have been cultured in 106 subjects comprising healthy individuals and hospital inpatients as controls and patients with a wide variety of malignancies. Abnormal results were recorded in 89% of patients with malignant disease and in 23 of 24 patients with carcinomas (96%). This test may be valuable in research, and in diagnosis and monitoring of progress in malignant disease.

Practolol and the safety of other beta blockers

Recognition of the "occulomucocutaneous syndrome" related to practolol administration has caused the safety of other beta-blocking agents to come under close scrutiny. No satisfactory means of screening for at-risk patients is available. ANF estimation, has considerable limitations as both a screening and a diagnostic procedure. Patients with skin lesions alone may not be positive, while even advanced cases often show very low titres. There are important technical difficulties with the assay and interpretation of results is hindered by an increase in incidence of the antibody with age, in females, and in patients on a wide variety of other therapeutic agents.