A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Costs of care for Crohn's disease following the introduction of infliximab: a single-centre UK experience

BACKGROUND

Infliximab is effective for induction and maintenance of remission in patients with Crohn's disease. There are few data, however, examining effect of infliximab therapy on management costs of Crohn's disease.

AIM

To assess Crohn's disease-related costs of care and resource use in a single-centre cohort of patients with Crohn's disease 12 months pre- and post-infliximab therapy.

METHODS

Data on 100 consecutive patients receiving infliximab were collected. Crohn's disease-related resource use was collected 12 months pre- and post-infliximab. National Health Service reference costs were applied to these data and the total Crohn's disease-related health service costs per patient were calculated (£UK). The cost of infliximab therapy was not included in our analysis.

RESULTS

Cost savings were demonstrated in all areas of Crohn's disease-related resource use following infliximab therapy. Mean total Crohn's disease-related cost reduction, 12 months following commencement of infliximab therapy, was £2750 per patient. Mean costs at 12 months post-infliximab in responders were lower than in nonresponders (£1656 vs. £3608, P = 0.02). The number of hospitalizations was reduced. Requirements for examination under anaesthesia were also significantly decreased.

CONCLUSION

Infliximab use resulted in Crohn's disease-related cost savings and hospital resource use, although this was not sufficient to cover the cost of therapy.

Changing pattern of organ donation at a single center: are potential brain dead donors being lost to donation after cardiac death?

Donation after cardiac death (DCD) has proven effective at increasing the availability of organs for transplantation.We performed a retrospective examination of Massachusetts General Hospital (MGH) records of all 201 donors from 1/1/98 to the 11/2008, including 54 DCD, 115 DBD and 32 DCD candidates that did not progress to donation (DCD-dnp). Comparing three time periods, era 1 (01/98-12/02), era 2 (01/03-12/05) and era 3 (01/06-11/08), DCD’s comprised 14.8,48.4% and 60% of donors, respectively (p = 0.002). A significant increase in the incidence of cardiovascular/cerebrovascular as cause of death was evident in era 3 versus eras 1 and 2; 74% versus 57.1% (p<0.001),as was a corresponding decrease in the incidence of traumatic death. Interestingly, we noted an increase in utilization of aggressive neurological management over time, especially in the DCD group.We detected significant changes in the make-up of the donor pool over the past decade. That the changes in diagnosis over time did not differ between DCD and DBD groups suggests this difference is not responsible for the increase in DCD rates. Instead, we suggest that changes in clinical practice, especially in management of patients with severe brain injury may account for the increased proportion of DCD.

Mycophenolate mofetil therapy for refractory inflammatory bowel disease

BACKGROUND

Mycophenolate mofetil (MMF) is an immunomodulatory drug, and its use in inflammatory bowel disease has previously been reported. The aim of this study was to review the Leeds Colitis Clinic experience of the safety and efficacy of MMF in treating patients with refractory Crohn's disease (CD) and ulcerative colitis (UC). This is an extension of a previously published study from our center with a longer follow-up period and approximately twice the number of patients.

METHODS

A retrospective analysis was performed of the records of all patients treated with MMF for inflammatory bowel disease over a 5-year period.

RESULTS

Of 70 patients identified, 67 had previously been treated with azathioprine unsuccessfully. Seventeen of the 70 patients had been successfully maintained in remission with MMF for an average duration of 33 months. Treatment with MMF was discontinued for 53 patients, 17 because of side effects and 36 because they had not responded to the treatment.

CONCLUSIONS

In our series, 17 patients (24.3%) had a sustained steroid-free remission with MMF therapy. Nineteen patients (27%) experienced side effects, of which 17 (24.3% of the total group) had to discontinue therapy. An additional 36 (51.4%) required an escalation in medical therapy or surgery because of failure of the MMF therapy. MMF may have a role in the treatment of refractory inflammatory bowel disease, especially in patients who have previously failed standard therapies such as azathioprine.

Effect of a saponin-based surfactant and aging time on ruminal degradability of flaked corn grain dry matter and starch

The objectives of this study were to investigate the effect of a saponin-based surfactant, Grain Prep surfactant (GP), and hot flake aging time on starch characteristics and ruminal DM and starch degradability of steam-flaked corn grain. In 2 experiments, the moisture content of incoming corn was automatically adjusted using the Grain Prep Auto Delivery System to 19.8% (Exp. 1) and 18.5% (Exp. 2). The application rate of GP was 22 mg/kg (as-is basis). Control corn was treated with water alone. Processed corn in Exp. 2 was stored in insulated containers for 0, 4, 8, or 16 h. Flaked corn samples were incubated in the rumen of lactating dairy cows for 0, 2, 4, 6, 16, or 24 h. In Exp. 1, GP increased, compared with the control, the soluble fraction and effective degradability (ED) of DM by 17.2 and 8.6%, respectively. The ED of cornstarch was increased by 6.7%. In Exp. 2, the concentration of soluble DM and starch were increased by GP by 15 and 24% compared with the control. The ED of DM and starch were also increased by 3 and 4%, respectively. No differences in gelatinization temperatures were observed due to treatment, except that GP-treated grain had a slightly greater mean gelatinization enthalpy in Exp. 2. In a pilot study, DM degradability parameters were not affected by germination of the corn kernels. Aging of the hot flakes for up to 16 h resulted in a quadratic decrease in DM and starch ruminal degradability. The aging process affected starch gelatinization enthalpy values of flaked grain in a manner opposite to that observed for ruminal DM and starch degradation. This phenomenon was most likely explained by increased starch intramolecular associations or crystallinity associated with starch annealing, or both. This study confirmed our previous observations that Grain Prep surfactant increases flaked corn DM and starch degradability in the rumen. Because the rate of degradation was not affected by the surfactant, the increase in degradability was attributed mainly to increases in DM and starch solubility.

The marrow cell continuum: stochastic determinism

Traditional models of hematopoiesis have been hierarchical in nature. Over the past 10 years, we have developed data indicating that hematopoiesis is regulated in a continuum with deterministic and stochastic components. We have shown that the most primitive stem cells, as represented by lineage negative rhodamine(low) Hoechst(low) murine marrow cells are continuously or intermittently cycling as determined by in vivo BrdU labeling. When marrow stem cells are induced to transit cell cycle by in vitro exposure to cytokines, either IL-3, IL-6, IL-11, and steel factor or thrombopoietin, FLT3 ligand, and steel factor, they progress through cycle in a highly synchronized fashion. We have determined that when the stem cells progress through a cytokine stimulated cell cycle the homing, engraftment, adhesion protein, global gene expression, and hematopoietic differentiation phenotypes all change in a reversible fashion. This has led to the continuum model, in which, with cycle transit, chromatin is continually changing altering open transcription areas and providing a continually changing landscape of transcriptional opportunity. More recently, we have extended the changing differentiation profiles to differentiation into lung cells and found that non-hematopoietic differentiation also shows cycle related reversibly modulation. These observations all together support a continuum model of stem cell regulation in which the phenotype of the marrow stem cells is continually and reversibly changing over time.

Differentiation hotspots: the deterioration of hierarchy and stochasm

The conception of the present-day model of hematopoiesis was begun by the work of Professor Ernst Neumann in the 19th century when he established that immature blood cells in the bone marrow migrate out into the blood vessels. Here was the birth of the hierarchical model of hematopoiesis. Jumping 135 years into the present day, recent data suggests that the stem cell regulation is not based on the classic hierarchical model, but instead more on a functional continuum. Presumptively, chromatin remodeling with cycle transit underlies changes in gene expression. This implies that the differentiative potential of primitive stem cells should also shift with cycle transit. This model proposes a less rigid system, at least in the early stem cell and progenitor compartments in which the functional characteristics of stem cells change as they go through cycle transit. We have shown that hematopoietic stem cells reversibly shift their engraftment phenotype with cytokine induced cell cycle transit. Other shifts include adhesion protein expression, cytokine receptor expression, gene expression, and progenitor phenotype. We have also found differentiation "hotspots", culture times (reflective of cell cycle state) at which stem cell differentiation was directed toward a specific lineage. This data inaugurates the end of a pure stochastic model. This work complements existing scientific work without discounting it and adds an additional dimension of complexity (or simplicity) to the process of hematopoiesis.

Tolerance induction by costimulator blockade in 100 cGy treated hosts with varying degrees of genetic disparity

Long-term multilineage allochimerism can be obtained in H2-mismatched B6.SJL to BALB/c transplants with host irradiation of 100 cGy, donor spleen cell pre-exposure and costimulator blockade with anti-CD40 ligand (CD40L) antibody. We evaluated this allochimerism approach in murine marrow transplants with different degrees of major histocompatibility complexe (MHC) mismatching; these include: (1) H2-mismatched transplant H2Kk to H2Kb, (2) full haplo-identical transplant H2Kbd to H2Kbk, (3) a partial haplo-identical transplant H2Kd to H2Kbd and (4) an MHC class II mismatch. Levels of chimerism increased up to 12 weeks and then stayed relatively stable up to 1 year after transplant. At 18 weeks post-transplant, the H2-mismatched, haplo-identical, partial haplo-identical and class II-mismatch transplants evidenced 17.9+/-4.4, 40.7+/-0.9, 25.1+/-4.19 and 33.7+/-3.5% donor chimerism, respectively. Dropping the anti-CD40 antibody treatment and spleen cells or changing the schedule of antibody to one injection, in haplo-identical or full-mismatched transplants resulted in no donor-derived chimerism. On the other hand, these still resulted in minor chimerism in class II-mismatched transplants. Lineage analysis of peripheral blood at 6 and 12 months post-transplant demonstrated a significant shift toward increased chimeric lymphocytes and decreased chimeric granulocytes in the full H2 as compared with haplo-identical or class II transplants. Transplantation with anti-CD40L antibody eliminated both graft-versus-leukemia and graft-versus-host disease (GVHD) and delayed lymphocyte infusion did not rescue animals from fatal leukemia. In conclusion, under the conditions of our tolerization regimen, a haplo transplant gives higher engraftment levels than a full H2 mismatch, and despite lower engraftment levels, a class II-mismatched transplant can be successfully accomplished with only 100 cGy and no CD40L blockade.

Effects of moisture, roller setting, and saponin-based surfactant on barley processing, ruminal degradation of barley, and growth performance by feedlot steers

Two experiments were conducted to study the effects of six processing techniques for barley grain in a 3 x 2 factorial arrangement of grain conditions and roller settings on ruminal degradation of the grain (Exp. 1) and on growth performance by 138 feedlot steers (n = 23 per treatment; Exp. 2). Dry barley (11% moisture, D barley), barley tempered to 20% moisture (M barley), and barley tempered with 60 mL/t of surfactant-based tempering agent (GrainPrep, Agrichem, Inc., Anoka, MN; MS barley), were each rolled at two roller settings selected from preliminary tests. The settings selected for the study were RD, the roller position that had yielded optimally processed D barley, and RMS, the setting that had yielded optimally processed MS barley. Setting RMS was tighter than RD. Barley rolled at the RMS setting was more extensively processed (i.e., had a lower [P < 0.001] processing index, PI), had lighter (P < 0.001) volume weight, thinner (P < 0.001) kernels, and fewer (P < 0.001) whole kernels compared with setting RD. Tempering did not affect (P > 0.05) PI, percentage of whole kernels, or kernel thickness at either roller setting. The processing characteristics of tempered barley were unaffected (P > 0.05) by surfactant. The extent of in situ DM disappearance (ISDMD) was higher (P < 0.01) in grain rolled at setting RMS compared with RD. At both roller settings, tempering reduced (P < 0.05) ISDMD between 4 and 24 h of ruminal incubation. Steers fed RMS-rolled barley had lower (P < 0.001) DMI, slightly lower (P = 0.084) ADG, but increased (P < 0.05) gain:feed (G:F) compared with steers fed RD-rolled barley. Tempering did not affect (P > 0.05) ADG, DMI, or G:F during backgrounding, but improved (P < 0.01) these variables during finishing. Surfactant improved (P < 0.05) G:F but not DMI or ADG. The improvement in G:F was most pronounced when setting RMS was used. The optimal PI values calculated from performance data were numerically greater for the backgrounding diet than for the finishing diet. Steers fed M or MS barley had heavier (P < 0.01) hot carcasses and thicker (P < 0.05) fat cover but lower (P < 0.05) dressing percentages than steers fed D. When the feed barley was rolled at setting RMS, steers fed MS barley produced heavier (P < 0.05) carcasses than those fed M. Tempering with or without surfactant increased performance by feedlot steers compared with not tempering. Diet composition and degree of barley processing mediated this effect.

The marrow stem cell: the continuum

The marrow hematopoietic stem cell is currently being redefined as to all aspects of its phenotype and its total differentiation capacity. This redefinition now includes its plasticity as to production of nonhematopoietic and hematopoietic cell types, the determinants of its in vivo engraftment potential and its expression of stem cell functional characteristics.

Marrow stem cell potential within a continuum

On the basis of our studies of the fluctuation of the hematopoietic stem cell phenotype with cell cycle trnsit, we hypothesize that the ability of marrow stem cells to convert to nonhematopoietic cells will also vary at different points in the cell cycle. The new biology of stem cells has an impact on many fields including developmental biology and stem cell biology and the clinical potential is enormous.

The role of neuroimaging in selecting treatments for patients with acute stroke

The armamentarium available for treating acute stroke patients is growing as clinical trials show benefit of intravenous thrombolysis, intra-arterial clot lysis, and antiplatelet agents. Patients with dissection or severe atheromatous stenosis of major cerebrovascular vessels are commonly treated with anticoagulation to prevent recurrent artery-to-artery embolus or arterial thrombosis. These advances in acute stroke treatments demand an accurate means to quickly identify those patients most likely to benefit (or not benefit) from a specific therapy. Fortunately, advances in imaging cerebrovascular lesions, decreased brain perfusion, and even ischemic tissue injury now make it possible to consider tailoring therapy to the individual patient's cerebrovascular problem. Experience and controlled clinical data in this endeavor is meager. Here we describe the ability of various emergency neuroimaging tools to provide information on the state of brain blood flow, metabolism, and vascular anatomy. Most importantly, we present the rationale and limited available evidence relevant to how the neuroimaging information might be used to select optimal treatments for individual patients.

Evaluation of the effect of an AIDS prevention program on high school students' sexual risk-taking behavior

The study evaluated the effects of an AIDS prevention program on 179 high school students' sexual risk-taking behavior. Young actors role modeled behaviors to reduce the risk of AIDS. Sexual risk-taking behavior was assessed prior to and 3 months after attending the program. The pre-test mean sexual risk-taking score was 1.8 (SD = 3.5) with 0 to 30 as the potential range. There were significant differences between pre- and post-test sexual risk-taking behavior for the low-risk group (< or = 1.8), Wilcoxon (127) = -4.5, p = .000, and high-risk group (> 1.8), Wilcoxon (52) = -2.2, p = .03. Findings suggest support for role modeling strategies in decreasing sexual risk-taking behavior among high school students.

Comparison of the amplified Mycobacterium tuberculosis (MTB) direct test, Amplicor MTB PCR, and IS6110-PCR for detection of MTB in respiratory specimens

Several nucleic acid amplification techniques (NAAT) have been developed for rapid and direct detection of Mycobacterium tuberculosis (MTB) from clinical specimens. This study compared the performances of the Gen-Probe Amplified MTB Direct Test (AMDT), Roche Amplicor MTB PCR test, and an IS6110-PCR assay with acid-fast smear and culture in the detection of MTB from 428 respiratory specimens from 259 patients. Patients' charts were reviewed for clinical correlation. Of 98 specimens that were clinically positive for MTB, acid-fast smear was positive in 50% of cases, culture in 93%, IS6110-PCR in 83%, AMDT in 84%, and Amplicor MTB PCR in 80%. Of 337 specimens that were negative for MTB, 117 (35%) were positive for nontuberculous mycobacteria. Specificities were as follows: smear, 89%; culture, 100%; IS6110-PCR, 99%; AMDT, 98%; and Amplicor MTB PCR, 96%. The accuracies of the tests were 80%, 98%, 96%, and 92%, respectively. MTB culture-positive specimens that were smear-negative were detected by AMDT and IS6110-PCR in 77% of cases and by Amplicor MTB PCR in 70%. NAAT was less sensitive than was culture for detection of MTB, but all these techniques had acceptable accuracy and were completed within hours. NAAT may be useful for rapid screening of respiratory specimens to distinguish MTB from nontuberculous mycobacteria infection in order to isolate patients.

The use of hemi-imagery for studying brain asymmetries in image generation

To learn if there are brain asymmetries for image generation we asked 50 right-handed normal subjects to image one-half of an object and to report which half (right or left) they saw. We found that these subjects were more likely to image the right half of objects than the left. We also found that right hemi-imagers demonstrated a greater degree of right-handedness than did left hemi-imagers. Our results suggest that in strongly right-handed subjects the left hemisphere is more adept at object image generation than is the right hemisphere.

Personal history, training, and worksite as predictors of back pain of nurses

Back pain among nurses is a common problem. Prior studies of this problem have been based on cross-sectional or retrospective data. This 18-month prospective study involving nurses newly graduated from nursing school investigated personal, worksite, and training factors associated with future risk of back pain. Each nurse underwent a preliminary interview and periodic follow-ups to identify those with back injuries. Contingency tables and logistic regression analyses demonstrated that prior significant back pain episodes (evidenced by previous job changes because of back pain, frequent medication use, etc.) were associated with increased future risk. Training at nursing school or on the job did not have a protective effect. This pilot study therefore suggests factors useful in placement and counseling of new nurses and indicates the need for further implementation of mechanical lift assist device use.

Work-related symptoms and checkstand configuration: an experimental study

Supermarket checkers are known to be at risk of upper-extremity cumulative trauma disorders. Forty-two experienced checkers checked a standard "market basket" of items on an experimental checkstand. The counter height could be adjusted (high = 35.5, low = 31.5 inches), and the pre-scan queuing area length (between conveyor belt and laser scanner) could be set to "near" or "far" lengths. Each subject scanned under the high-near, high-far, low-near, and low-far conditions in random order. Seven ordinal symptom scales were used to describe comfort. Analysis showed that both counter height and queuing length had significant effects on symptoms. Furthermore, the height of the subject affected the degree and direction of the impact of the checkstand configuration differences. The study suggests that optimization of design may be experimentally evaluated, that modification of postural as well as frequency loading may be beneficial, and that adjustability for the individual may be advisable.

N-acetyl-beta-D-glucosaminidase test for screening milk samples for subclinical mastitis

The use of the N-acetyl-beta-D-glucosaminidase (NAGase) test for detecting subclinical mastitis was investigated in surveys of milk samples from 20 farms. A milk sample was considered to be mastitic if it had a milk cell count above 400,000 cells/ml, and the NAGase test results were graded accordingly. The test gave an average of 16.6 per cent false positives and 2.0 per cent false negatives per herd. It was concluded that the NAGase test could be used as a rapid screening method for selecting suspect samples for further analysis by standard methods.

Examination of milk samples from experimentally infected heifers by an N-acetyl-beta-D-glucosaminidase test and an antigen-capture ELISA

Milk samples collected from normal and experimentally infected quarters of five heifers throughout their first lactation were examined by bacterial culture, milk cell count (MCC), N-acetyl-beta-D-glucosaminidase (NAGase) test and a monoclonal antibody based antigen-capture ELISA. The results were analysed according to the presence (mastitis positive) or absence (mastitis negative) of bacteria on culture, and the numbers of false negative and false positive results of the other three tests defined in relation to this. Similar numbers of false negative results were observed with the MCC (20), NAGase (18) and ELISA (13). False positive results due to the physiological factors present in early lactation were evident in the MCC, prominent in the NAGase test and absent from the ELISA. The major difference in false positive results associated with experimental infection between the three tests was the more rapid return to negative values of the ELISA following resolution of infection, compared with MCC and NAGase.

Hematogenous dissemination of Mycobacterium tuberculosis in patients with AIDS

Proof of hematogenous dissemination of Mycobacterium tuberculosis was initially reported in the early 1900s and was noted to be most frequent in patients with miliary tuberculosis. More recently, M. tuberculosis bacteremia has been reported in human immunodeficiency virus (HIV)-infected patients. We describe 13 adult HIV-infected patients in whom hematogenous M. tuberculosis dissemination was evident. Although for most patients whose bone marrow aspirate cultures yielded M. tuberculosis a chest roentgenogram revealed a miliary pattern, roentgenograms for those with M. tuberculosis bacteremia usually revealed evidence of lobar or diffuse infiltrates. Most patients with M. tuberculosis bacteremia had other risk factors for M. tuberculosis, and many had a rapid death, suggesting acute fulminant infection. Our own experience suggests that there are various syndromes associated with hematogenous dissemination in patients infected with M. tuberculosis.

Application of a monoclonal antibody-based enzyme-linked immunosorbent assay for detection of an inflammatory response antigen in subclinical mastitic milk samples

A monoclonal antibody to a 23.5-kDa bovine inflammatory antigen present in high levels in mastitic milk has been used in an antigen-capture enzyme-linked immunosorbent assay (ELISA) to screen milk samples from herds of cattle for subclinical mastitis. The results from 20 herds with a total of 2,612 quarter samples are presented. Good correlation was observed between the ELISA level and the milk cell count (MCC). The results demonstrated an average of 5% false negatives (1.8% associated with isolates of Staphylococcus aureus and/or Streptococcus spp.) and 7.7% false positives for each herd in relation to mastitic (greater than 400,000 cells per ml) or nonmastitic (less than 400,000 cells per ml) MCCs.

Artificial intelligence-assisted occupational lung disease diagnosis

An artificial intelligence expert-based system for facilitating the clinical recognition of occupational and environmental factors in lung disease has been developed in a pilot fashion. It utilizes a knowledge representation scheme to capture relevant clinical knowledge into structures about specific objects (jobs, diseases, etc) and pairwise relations between objects. Quantifiers describe both the closeness of association and risk, as well as the degree of belief in the validity of a fact. An independent inference engine utilizes the knowledge, combining likelihoods and uncertainties to achieve estimates of likelihood factors for specific paths from work to illness. The system creates a series of "paths," linking work activities to disease outcomes. One path links a single period of work to a single possible disease outcome. In a preliminary trial, the number of "paths" from job to possible disease averaged 18 per subject in a general population and averaged 25 per subject in an asthmatic population. Artificial intelligence methods hold promise in the future to facilitate diagnosis in pulmonary and occupational medicine.

Comparison of the PREMIER cryptococcal antigen enzyme immunoassay and the latex agglutination assay for detection of cryptococcal antigens

A new enzyme immunoassay (EIA), PREMIER Cryptococcal Antigen, was compared with latex agglutination (LA) for the detection and quantitation of circulating capsular polysaccharide antigen from Cryptococcus neoformans. The clinical evaluation of PREMIER EIA as a screening assay, including 475 specimens with 120 LA and EIA positives, resulted in 99% sensitivity and 97% specificity. The clinical specimens included sera and cerebrospinal fluids as well as 10 rheumatoid factor-positive and 20 anti-nuclear antibody-positive serum samples. This monoclonal antibody-based assay detects serotypes A to D at 0.63, 0.63, 7.8, and 62 ng/ml, respectively. With three different known positive specimens, the assay was found to yield coefficients of variation of 2 to 12% for intra- and interassay comparisons of precision and reproducibility. The primary use for semiquantitative values derived with the LA or EIA is to follow the course of disease and monitor drug therapies. The present data suggest that the PREMIER EIA will be a valuable method for this purpose. We conclude that the PREMIER Cryptococcal Antigen EIA provides a rapid, convenient, and reliable antigen detection method for screening and semiquantitative determination of antigen levels.

Spectrum of Cryptococcus neoformans infection in 68 patients infected with human immunodeficiency virus

Sixty-eight patients infected with human immunodeficiency virus (HIV) and Cryptococcus neoformans who presented to three major medical centers in New Orleans, Louisiana, were studied retrospectively. In patients with meningitis the most common presenting symptoms were fever and headache. Those without central nervous system involvement generally had an isolated pulmonary infection due to C. neoformans and presented with cough and dyspnea. CSF parameters were abnormal in 41% of patients, and the India ink preparation was positive in 88% of patients with cultures of CSF positive for C. neoformans. The overall median survival time for the 47 patients who died was 5 months, with a range of 0-22 months. Of the 27 patients who received maintenance therapy with amphotericin B, two (7%) relapsed. The only factors found to be associated with a poor prognosis were abnormal computed tomography of the head and altered mental status on presentation. C. neoformans infections in HIV-infected patients remain difficult to treat and have a poor prognosis.

Risk of functional decline among well elders

Active lifestyles may delay the onset of the functional consequences of chronic disease, potentially increasing active life expectancy. We analyzed the Longitudinal Study of Aging (LSOA) to test the hypothesis that elders participation in an active lifestyle prevents loss of function. Focusing on the cohort aged 70-74 who reported being able to carry 25 lb, walk 1/4 mile, climb 10 steps and do heavy housework without help and without difficulty at baseline, decline was defined as no longer being able to perform these tasks independently and without difficulty 2 years later. Using multivariate logistic regression, results reveal that those who did not report regularly exercising or walking a mile were 1.5 times more likely to decline than those who did, controlling for reported medical conditions and demographic factors. Similar findings (with different models) were observed for both men and women. Findings suggest the potential value of programs oriented toward the primary prevention of functional decline.

Comparative trial of a two-dosage schedule of ketoconazole 2% cream for the treatment of tinea pedis

Sixty-two patients with mycologically confirmed tinea pedis received two different treatment regimens of ketoconazole 2% cream on a randomized double-blind basis for 1 month with weekly evaluations. A 4-week posttreatment follow-up permitted an assessment of recurrence or improvement. After 1 month of treatment, 90% of the patients treated once daily responded clinically, in comparison with 83% of those treated twice daily. The cure rate was 63% for the once-daily and 60% for the twice-daily group. This rate substantially improved at follow-up (77% and 73%, respectively). One patient from each group discontinued therapy for an adverse reaction. On the basis of both clinical and mycologic assessments, topical treatment with ketoconazole 2% cream was effective as a once-daily therapy.

Anaesthesia for Treacher Collins and Pierre Robin syndromes: a report of three cases

We present three patients with Treacher Collins or Pierre Robin syndromes who had historical and physical evidence of airway obstruction, difficulty feeding, and sleep disturbances. These preoperative findings correlated with difficult airway management intraoperatively. Based on this experience, we recommend that children with obstructive symptoms have laryngoscopy prior to anaesthetic induction. If the glottic opening is visualized, inhalational induction can proceed. If the glottic structures cannot be visualized, then the anaesthetist must choose between awake oral or nasal intubation, elective tracheostomy, or fiberoptic intubation. In all cases, a tracheostomy tray should be ready and a surgeon experienced in paediatric tracheostomy should be in attendance. After intubation, anaesthesia is best maintained with oxygen and a potent inhalational agent. Extubation should only be done with the patient fully awake and with emergency airway equipment immediately available. Postoperatively, these patients should be transferred to an intermediate care area or intensive care unit where they can be observed closely since delayed complications of airway obstruction are common in this group of patients.

Last days: a study of the quality of life of terminally ill cancer patients

Behavior of a number of Quality of Life measures gathered from two samples of terminal cancer patients over the last weeks of their lives are reported. Samples represent patients in the 26 hospices participating in a nationwide U.S. demonstration project and patients in the palliative care units of two Montreal hospitals. The U.S. data reported are quality of life measures made by a lay principal care person (PCP) or trained interviewer; the Montreal measures were made by both an attending doctor and an attending nurse. The general finding, as expected, is one of increasing deterioration in quality of life, with accelerated deterioration between 3 and 1 week of death. Pain follows a somewhat different pattern than other measures. More patients are in either of the extreme categories at an earlier point in time than found for other measures, and there are fewer changes as death is approached. Finally, about 20% of the patients do not fall into extremely low quality of life categories, even in the week prior to death.

Processed bovine cartilage: an improved biosynthetic implant for contour defects

Irradiated human cartilage has been found to be a superior implant material for correction of contour defects; however, availability problems have prevented this material from gaining wide acceptance. Implantation of processed irradiated bovine cartilage in primates and rabbits, as described here, provides strong evidence that this material performs like irradiated allograft cartilage antigenically and has certain cosmetic advantages over allograft cartilage. Our studies in primates have shown that there is no systemically measurable antibody-antigen reaction, either cellular or noncellular, to irradiated processed bovine cartilage. Neither primary nor second-set provocative implantations produced any measurable rejection. In rabbits, composite grafts of two pieces of irradiated bovine cartilage adjacent to each other were also well tolerated, with no measurable absorption and with capsule formation typical of a foreign body reaction to an inert object.