Temporal change in urban fish biodiversity-Gains, losses, and drivers of change

Our aim was to examine temporal change in alpha and beta diversity of freshwater fish communities in rivers that have urbanized over the same period to understand the influence of changes in land use and river connectivity on community change. We used biological (2001-2018), land use (2000-2015), and connectivity data (1987-2017) from Toronto, Ontario, Canada. We used linear mixed effects models to determine the strength of upstream land use, connectivity, and their changes over time to explain temporal change in alpha and beta diversity indices. We examined beta diversity using the temporal beta diversity index (TBI) to assess site-specific community change. The TBI was partitioned into gains and losses, and species-specific changes in abundance were assessed using paired t-tests. There were more gains than losses across the study sites as measured by TBI. We found little to no significant differences in species-specific abundances at aggregated spatial scales (study region, watershed, stream order). We found different relationships between landscape and connectivity variables with the biodiversity indices tested; however, almost all estimated confidence intervals overlapped with zero and had low goodness-of-fit. More fish biodiversity gains than losses were found across the study region, as measured by TBI. We found TBI to be a useful indicator of change as it identifies key sites to further investigate. We found two high value TBI sites gained non-native species, and one site shifted from a cool-water to warm-water species dominated community, both of which have management implications. Upstream catchment land use and connectivity had poor explanatory power for change in the measured biodiversity indices. Ultimately, such spatial-temporal datasets are invaluable and can reveal trends in biodiversity useful for environmental management when considering competing interests involved with urban sprawl in the ongoing "Decade on Restoration."

Digital Endpoints for Assessing Instrumental Activities of Daily Living in Mild Cognitive Impairment: Systematic Review

BACKGROUND

Subtle impairments in instrumental activities of daily living (IADLs) can be a key predictor of disease progression and are considered central to functional independence. Mild cognitive impairment (MCI) is a syndrome associated with significant changes in cognitive function and mild impairment in complex functional abilities. The early detection of functional decline through the identification of IADL impairments can aid early intervention strategies. Digital health technology is an objective method of capturing IADL-related behaviors. However, it is unclear how these IADL-related behaviors have been digitally assessed in the literature and what differences can be observed between MCI and normal aging.

OBJECTIVE

This review aimed to identify the digital methods and metrics used to assess IADL-related behaviors in people with MCI and report any statistically significant differences in digital endpoints between MCI and normal aging and how these digital endpoints change over time.

METHODS

A total of 16,099 articles were identified from 8 databases (CINAHL, Embase, MEDLINE, ProQuest, PsycINFO, PubMed, Web of Science, and Scopus), out of which 15 were included in this review. The included studies must have used continuous remote digital measures to assess IADL-related behaviors in adults characterized as having MCI by clinical diagnosis or assessment. This review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

Ambient technology was the most commonly used digital method to assess IADL-related behaviors in the included studies (14/15, 93%), with passive infrared motion sensors (5/15, 33%) and contact sensors (5/15, 33%) being the most prevalent types of methods. Digital technologies were used to assess IADL-related behaviors across 5 domains: activities outside of the home, everyday technology use, household and personal management, medication management, and orientation. Other recognized domains-culturally specific tasks and socialization and communication-were not assessed. Of the 79 metrics recorded among 11 types of technologies, 65 (82%) were used only once. There were inconsistent findings around differences in digital IADL endpoints across the cognitive spectrum, with limited longitudinal assessment of how they changed over time.

CONCLUSIONS

Despite the broad range of metrics and methods used to digitally assess IADL-related behaviors in people with MCI, several IADLs relevant to functional decline were not studied. Measuring multiple IADL-related digital endpoints could offer more value than the measurement of discrete IADL outcomes alone to observe functional decline. Key recommendations include the development of suitable core metrics relevant to IADL-related behaviors that are based on clinically meaningful outcomes to aid the standardization and further validation of digital technologies against existing IADL measures. Increased longitudinal monitoring is necessary to capture changes in digital IADL endpoints over time in people with MCI.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022326861; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=326861.

A longitudinal examination of perinatal testosterone, estradiol and vitamin D as predictors of handedness outcomes in childhood and adolescence

The developmental origins of handedness remain elusive, though very early emergence suggests individual differences manifesting in utero could play an important role. Prenatal testosterone and Vitamin D exposure are considered, yet findings and interpretations remain equivocal. We examined n = 767 offspring from a population-based pregnancy cohort (The Raine Study) for whom early biological data and childhood/adolescent handedness data were available. We tested whether 18-week maternal circulatory Vitamin D (25[OH]D), and testosterone and estradiol from umbilical cord blood sampled at birth predicted variance in direction of hand preference (right/left), along with right- and left-hand speed, and the strength and direction of relative hand skill as measured by a finger-tapping task completed at 10 (Y10) and/or 16 (Y16) years. Although higher concentrations of Vitamin D predicted more leftward and less lateralized (regardless of direction) relative hand skill profiles, taken as a whole, statistically significant findings typically did not replicate across time-point (Y10/Y16) or sex (male/female) and were rarely detected across different (bivariate/multivariate) levels of analysis. Considering the number of statistical tests and generally inconsistent findings, our results suggest that perinatal testosterone and estradiol contribute minimally, if at all, to subsequent variance in handedness. Vitamin D, however, may be of interest in future studies.

Prevalence of non-tuberculous mycobacteria among previously treated TB patients in the Gulf of Guinea, Africa

Objective

Differentiation between non-tuberculous mycobacteria (NTM) and Mycobacterium tuberculosis complex (MTBC) is crucial for case management with the appropriate antimycobacterials. This study was undertaken in three West and Central African countries to understand NTM associated with pulmonary tuberculosis in the sub-region.

Methods

A collection of 503 isolates (158 from Cameroon, 202 from Nigeria and 143 from Ghana) obtained from solid and liquid cultures were analysed. The isolates were tested for drug susceptibility, and MTBC were confirmed using IS6110. All IS6110-negative isolates were identified by 65-kilodalton heat shock protein (hsp65) gene amplification, DNA sequencing and BLAST analysis.

Results

Overall, the prevalence of NTM was 16/503 (3.2%), distributed as 2/202 (1%) in Nigeria, 2/158 (1.3%) in Cameroon and 12/143 (8.4%) in Ghana. The main NTM isolates included 5/16 (31.3%) M. fortuitum, 2/16 (12.5%) M. intracellulare and 2/16 (12.5%) M. engbaekii. Eight (57.1%) of the 14 previously treated patients harboured NTM (odds ratio 0.21, 95% confidence interval 0.06-0.77; P=0.021). Three multi-drug-resistant strains were identified: M. engbaekii, M. fortuitum and M. intracellulare.

Conclusion

NTM were mainly found among individuals with unsuccessful treatment. This highlights the need for mycobacterial species differentiation using rapid molecular tools for appropriate case management, as most are resistant to routine first-line antimycobacterials.

A simple model for the evolution of temperature-dependent sex determination explains the temperature sensitivity of embryonic mortality in imperiled reptiles

A common reptile conservation strategy involves artificial incubation of embryos and release of hatchlings or juveniles into wild populations. Temperature-dependent sex determination (TSD) occurs in most chelonians, permitting conservation managers to bias sex ratios towards females by incubating embryos at high temperatures, ultimately allowing the introduction of more egg-bearing individuals into populations. Here, we revisit classic sex allocation theory and hypothesize that TSD evolved in some reptile groups (specifically, chelonians and crocodilians) because male fitness is more sensitive to condition (general health, vigor) than female fitness. It follows that males benefit more than females from incubation environments that confer high-quality phenotypes, and hence high-condition individuals. We predict that female-producing temperatures, which comprise relatively high incubation temperatures in chelonians and crocodilians, are relatively stressful for embryos and subsequent life stages. We synthesize data from 28 studies to investigate how constant temperature incubation affects embryonic mortality in chelonians with TSD. We find several lines of evidence suggesting that warm, female-producing temperatures are more stressful than cool, male-producing temperatures. Further, we find some evidence that pivotal temperatures (TPiv, the temperature that produces a 1:1 sex ratio) may exhibit a correlated evolution with embryonic thermal tolerance. If patterns of temperature-sensitive embryonic mortality are also indicative of chronic thermal stress that occurs post-hatching, then conservation programs may benefit from incubating eggs close to species-specific TPivs, thus avoiding high-temperature incubation. Indeed, our models predict that, on average, a sex ratio of >75% females can generally be achieved by incubating eggs only 1°C above TPiv. Of equal importance, we provide insight into the enigmatic evolution of TSD in chelonians, by providing support to the hypothesis that TSD evolution is related to the quality of the phenotype conferred by incubation temperature, with males produced in high-quality incubation environments.

Analysis of common genetic variation and rare CNVs in the Australian Autism Biobank

BACKGROUND

Autism spectrum disorder (ASD) is a complex neurodevelopmental condition whose biological basis is yet to be elucidated. The Australian Autism Biobank (AAB) is an initiative of the Cooperative Research Centre for Living with Autism (Autism CRC) to establish an Australian resource of biospecimens, phenotypes and genomic data for research on autism.

METHODS

Genome-wide single-nucleotide polymorphism genotypes were available for 2,477 individuals (after quality control) from 546 families (436 complete), including 886 participants aged 2 to 17 years with diagnosed (n = 871) or suspected (n = 15) ASD, 218 siblings without ASD, 1,256 parents, and 117 unrelated children without an ASD diagnosis. The genetic data were used to confirm familial relationships and assign ancestry, which was majority European (n = 1,964 European individuals). We generated polygenic scores (PGS) for ASD, IQ, chronotype and height in the subset of Europeans, and in 3,490 unrelated ancestry-matched participants from the UK Biobank. We tested for group differences for each PGS, and performed prediction analyses for related phenotypes in the AAB. We called copy-number variants (CNVs) in all participants, and intersected these with high-confidence ASD- and intellectual disability (ID)-associated CNVs and genes from the public domain.

RESULTS

The ASD (p = 6.1e-13), sibling (p = 4.9e-3) and unrelated (p = 3.0e-3) groups had significantly higher ASD PGS than UK Biobank controls, whereas this was not the case for height-a control trait. The IQ PGS was a significant predictor of measured IQ in undiagnosed children (r = 0.24, p = 2.1e-3) and parents (r = 0.17, p = 8.0e-7; 4.0% of variance), but not the ASD group. Chronotype PGS predicted sleep disturbances within the ASD group (r = 0.13, p = 1.9e-3; 1.3% of variance). In the CNV analysis, we identified 13 individuals with CNVs overlapping ASD/ID-associated CNVs, and 12 with CNVs overlapping ASD/ID/developmental delay-associated genes identified on the basis of de novo variants.

LIMITATIONS

This dataset is modest in size, and the publicly-available genome-wide-association-study (GWAS) summary statistics used to calculate PGS for ASD and other traits are relatively underpowered.

CONCLUSIONS

We report on common genetic variation and rare CNVs within the AAB. Prediction analyses using currently available GWAS summary statistics are largely consistent with expected relationships based on published studies. As the size of publicly-available GWAS summary statistics grows, the phenotypic depth of the AAB dataset will provide many opportunities for analyses of autism profiles and co-occurring conditions, including when integrated with other omics datasets generated from AAB biospecimens (blood, urine, stool, hair).

Salty summertime streams—road salt contaminated watersheds and estimates of the proportion of impacted species

Road salt runoff is a leading cause of secondary freshwater salinization in north temperate climates. Increased chloride concentrations in freshwater can be toxic and lead to changes in organismal behavior, lethality, biotic homogenization, and altered food webs. High chloride concentrations have been reported for winter months in urban centers, as road density is highest in cities. However, summer chloride conditions are not typically studied as road salt is not actively applied outside of winter months, yet summer is when many taxa reproduce and are most sensitive to chloride. In our study, we test the spatial variability of summer chloride conditions across four watersheds in Toronto, Canada. We find 89% of 214 sampled sites exceeded the federal chronic exposure guidelines for chloride, and 13% exceeded the federal acute guidelines. Through a model linking concentration to cumulative proportion of impacted species, we estimate 34% of sites show in excess of one-quarter of all species may be impacted by their site-specific chloride concentrations, with up to two-thirds of species impacted at some sites. Our results suggest that even presumed low seasons for chloride show concentrations sufficient to cause significant negative impacts to aquatic communities.

Psychometric Evaluation of an Australian Version of the Vocational Index for Adults with Autism

Background

Autistic individuals are underrepresented in employment and postsecondary education. Research is hampered by a lack of psychometrically valid instruments that can be used to assess the vocational activities of autistic people. This study examined the psychometric properties of an Australian modified version of the Vocational Index for Adults with Autism (M-VIAA), an assessment of vocational independence.

Methods

Participants were 105 autistic and 106 nonautistic young adults aged 17-26 years recruited from the longitudinal Study of Australian School Leavers with Autism. We examined psychometric properties of the M-VIAA by (1) comparing scores between autistic and nonautistic participants, (2) examining convergent validity with daily living skills, and (3) divergent validity with autistic traits. We explored change over time by comparing baseline and 24-month follow-up scores in autistic participants.

Results

We found vocational independence to be significantly higher in nonautistic participants compared with autistic participants. We did not find a significant relationship between daily living skills and the M-VIAA. There was a small but significant relationship between the M-VIAA and autistic traits. Scores on the M-VIAA remained stable over time for a subsample of autistic participants.

Conclusions

The present study provides preliminary support for the M-VIAA with some limitations. Support for construct validity was mixed with support for concurrent and discriminant, but not convergent validity. We suggest that the M-VIAA may not capture the full complexity of vocational challenges faced by autistic people. Future research should build on the structure of the VIAA while ensuring applicability across cultures and contexts, as well as ensuring the richness of vocational activities of autistic people is captured.

Lay summary

Why was this study done?: Despite the urgent need to improve employment and other vocational outcomes of autistic people, there are few instruments that measure the range of vocational independence demonstrated by these individuals. The Vocational Index for Adults with Autism (VIAA) is an instrument that identifies the common vocational activities that autistic people engage in following high school. There is a need, however, for researchers to examine the usefulness of the instrument and its applicability in countries outside the United States.What was the purpose of this study?: The goal of this study was to evaluate a modified version of the VIAA (M-VIAA) in a group of autistic people from Australia.What did the researchers do?: We examined responses to the M-VIAA in 211 autistic and nonautistic young adults. We compared the M-VIAA with participant's daily living skills and level of autistic traits, as well as any change in scores over time.What were the results of the study?: Vocational independence was higher in nonautistic participants than in autistic participants. Vocational independence was not related to daily living skills; however, it was related to autistic traits. Over 2 years, scores on the M-VIAA did not change a lot for the autistic participants.What do these findings add to what was already known?: Our study provides some initial support for the M-VIAA in a non-US-based population. However, we also identified that the instrument may not represent the full range of challenges nor the richness of vocational activities experienced by autistic individuals in postsecondary vocational settings.What are potential weaknesses in the study?: The M-VIAA provides limited information about the richness of postsecondary vocational and education activities that autistic individuals may be engaged in. Because few individuals reported having an intellectual disability, we are unable to say how our results might apply to these individuals. Because we modified the instrument for use in Australia, our results may not apply to different countries or to the original version of the instrument.How will these findings help autistic adults now or in the future?: Our study provides preliminary support for the Australian version of the VIAA but suggests that it could be improved to better reflect the richness and range of vocational challenges experienced by autistic people. Our findings therefore identify areas for improvement for assessing the vocational activities and independence of autistic people.

Study protocol for the Australian autism biobank: an international resource to advance autism discovery research

BACKGROUND

The phenotypic and genetic heterogeneity of autism spectrum disorder (ASD) presents considerable challenges in understanding etiological pathways, selecting effective therapies, providing genetic counselling, and predicting clinical outcomes. With advances in genetic and biological research alongside rapid-pace technological innovations, there is an increasing imperative to access large, representative, and diverse cohorts to advance knowledge of ASD. To date, there has not been any single collective effort towards a similar resource in Australia, which has its own unique ethnic and cultural diversity. The Australian Autism Biobank was initiated by the Cooperative Research Centre for Living with Autism (Autism CRC) to establish a large-scale repository of biological samples and detailed clinical information about children diagnosed with ASD to facilitate future discovery research.

METHODS

The primary group of participants were children with a confirmed diagnosis of ASD, aged between 2 and 17 years, recruited through four sites in Australia. No exclusion criteria regarding language level, cognitive ability, or comorbid conditions were applied to ensure a representative cohort was recruited. Both biological parents and siblings were invited to participate, along with children without a diagnosis of ASD, and children who had been queried for an ASD diagnosis but did not meet diagnostic criteria. All children completed cognitive assessments, with probands and parents completing additional assessments measuring ASD symptomatology. Parents completed questionnaires about their child's medical history and early development. Physical measurements and biological samples (blood, stool, urine, and hair) were collected from children, and physical measurements and blood samples were collected from parents. Samples were sent to a central processing site and placed into long-term storage.

DISCUSSION

The establishment of this biobank is a valuable international resource incorporating detailed clinical and biological information that will help accelerate the pace of ASD discovery research. Recruitment into this study has also supported the feasibility of large-scale biological sample collection in children diagnosed with ASD with comprehensive phenotyping across a wide range of ages, intellectual abilities, and levels of adaptive functioning. This biological and clinical resource will be open to data access requests from national and international researchers to support future discovery research that will benefit the autistic community.

Acute phase proteins and IP-10 as triage tests for the diagnosis of tuberculosis: systematic review and meta-analysis

OBJECTIVES

We examined the data reported in studies for diagnostic purposes and to discuss whether their intended use could be extended to triage, as rule-in or rule-out tests to select individuals who should undergo further confirmatory tests.

METHODS

We searched Scopus, PubMed and Web of Science with the terms 'acute phase proteins,' 'IP-10,' 'tuberculosis,' 'screening' and 'diagnosis,' extracted the sensitivity and specificity of the biomarkers and explored methodologic differences to explain performance variations. Summary estimates were calculated using random-effects models for overall pooled accuracy. The hierarchical summary receiver operating characteristic model was used for meta-analysis.

RESULTS

We identified 14, four and one studies for C-reactive protein (CRP), interferon γ-induced protein 10 (IP-10) and alpha-1-acid glycoprotein (AGP). The pooled CRP sensitivity/specificity (95% confidence interval) was 89% (80-96) and 57% (36-65). Sensitivity/specificity were higher in high-tuberculosis-burden countries (90%/64%), HIV-infected individuals (91%/61%) and community-based studies (90%/62%). IP-10 sensitivity/specificity in TB vs. non-TB studies was 85%/63% and in TB and HIV coinfected vs. other lung conditions 94%/21%. However, IP-10 studies included diverse populations and a high risk of bias, resulting in very low-quality evidence. AGP had 86%/93% sensitivity/specificity.

CONCLUSIONS

Few studies have evaluated CRP, IP-10 and AGP for the triage of symptomatic patients. Their high sensitivity and moderate specificity warrant further prospective studies exploring whether their combined use could optimize performance.

Successful AV Fistula Creation does not Lead to Higher Catheter Use: The Experience by the Northwest Renal Network 16 Vascular access Quality Improvement Program. Four Years follow-up

Background

In 2002, the Center for Medicare and Medicaid Services (CMS) required all 18 Renal Networks to participate in a Vascular Access Quality Improvement Program (QIP). The Northwest Renal Network (NWRN 16) chose to increase arteriovenous fistula (AVF) use. NWRN 16 hypothesized that strategies which targeted the improvement of AVF rate and the reduction of catheter use were the same. In December 2001, 44.2% of hemodialysis (HD) patients in the NWRN 16 received HD using an AVF which met the Dialysis Outcome Quality Initiative (K/DOQI) 40% AVF guideline for prevalent patients. However, 43% of HD facilities (2869 patients) had less than 40% of AVF and higher HD catheter rates than the average Network catheter rates (25.0 vs. 20.3%). To address the needs of underperforming facilities, NWRN 16 provided education and tools for their vascular access decision makers to promote AVF creation and catheter reduction.

Methods

In 2002, NWRN 16 sponsored four regional workshops targeted at nephrologists, vascular surgeons, HD nurses, and interventional radiologists.

Results

Percentage of AVFs in use in invited facilities increased from 31.3% pre-intervention to 56.2% at 4 yrs: 78% increase (99% confidence interval: 77.8% to 81.5%). Percentage of catheters increased from 25% to 25.8%: 3.2% change over 4 yrs (99% confidence interval: 2.5% to 4%).

Conclusion

The success of Network 16's AVF interventions demonstrates the effectiveness of Network education promoting multidisciplinary teamwork, and innovative strategies to increase dramatically AVF use without substantial increase in catheter use.

Successful Multidisciplinary Interventions for Arterio-Venous Fistula Creation by the Pacific Northwest Renal Network 16 Vascular access Quality Improvement Program

Background

In December 2001, 44.2% of hemodialysis (HD) patients in the Northwest Renal Network (NWRN 16) received dialysis using an arteriovenous fistula (AVF). Substantial differences were noted in percentages of patients with AVF, ranging from 5% to 90% of the facility population, suggesting wide variation in physician practice patterns within the Network. To address the needs of facilities having <40% AVF, NWRN 16 provided education and tools for their vascular access decision-makers to promote AVF creation.

Methods

In 2002, the Network sponsored 4 regional workshops targeted to nephrologists, vascular surgeons, dialysis nurses, and interventional radiologists.

Results

46 facilities (43% of all Network facilities) had <40% AVF in use in December, 2001, dialyzing 2940 patients (Invited Units). Percent AVF in use in all the Invited Facilities increased from 31.3% pre-intervention to 39.8% at 1 year (p<0.001 vs pre) to 56.2% at four years: 79.8% increase in the prevalent AVF rate over a four-year period (95% confidence interval: 77.8% to 81.7%).

Conclusion

Low prevalent AVF rates in many NWRN 16 facilities may have resulted from differences in physician practice patterns. The success of Network 16 AVF Intervention demonstrates the effectiveness of Network education promoting multidisciplinary teamwork, innovative strategies to increase AVF rates among dialysis patients.

Are patients with pulmonary tuberculosis who are identified through active case finding in the community different than those identified in healthcare facilities?

The lack of healthcare access contributes to large numbers of tuberculosis (TB) cases being missed and has led to renewed interest in outreach approaches to increase detection. It is however unclear whether outreach activities increase case detection or merely identify patients before they attend health facilities. We compared adults with cough of >2 weeks' duration recruited in health facilities (1202 participants) or in urban slums (2828 participants) in Nigeria. Participants provided demographic and clinical information and were screened using smear microscopy. The characteristics of smear-positive and smear-negative individuals were compared stratified by place of enrolment. Two hundred nine health facility participants (17.4%) and 485 community-based participants (16.9%) were smear positive for pulmonary TB. Community-based smear-positive cases were older (mean age, 36.3 vs. 31.8 years), had longer cough duration (10.3 vs. 6.8 weeks) and longer duration of weight loss (4.6 vs. 3.6 weeks) than facility-based cases; and they complained more of fever (87.4% vs. 74.6%), chest pain (89.0% vs. 67.0%) and anorexia (79.5% vs. 55.5%). Community smear-negative participants were older (mean, 39.4 vs. 34.0 years), were more likely to have symptoms and were more likely to have symptoms of longer duration than smear-negative facility-based participants. Patients with pulmonary TB identified in the community had more symptoms and longer duration of illness than facility-based patients, which appeared to be due to factors differentially affecting access to healthcare. Community-based activities targeted at urban slum populations may identify a different TB case population than that accessing stationary services.

Resistance to first-line tuberculosis drugs in three cities of Nigeria

OBJECTIVES

To determine the levels of resistance to first-line tuberculosis drugs in three cities in three geopolitical zones in Nigeria.

METHODS

A total of 527 smear-positive sputum samples from Abuja, Ibadan and Nnewi were cultured on BACTEC- MGIT 960. Drug susceptibility tests (DST) for streptomycin, isoniazid, rifampicin and ethambutol were performed on 428 culture-positive samples on BACTEC-MGIT960.

RESULTS

Eight per cent of the specimens cultured were multi-drug-resistant Mycobacterium tuberculosis (MDR-TB) with varying levels of resistance to individual and multiple first-line drugs. MDR was strongly associated with previous treatment: 5% of new and 19% of previously treated patients had MDR-TB (OR 4.1 (95% CI 1.9-8.8), P = 0.001) and with young adult age: 63% of patients with and 38% without MDR-TB were 25-34 years old (P = 0.01). HIV status was documented in 71%. There was no association between MDR-TB and HIV coinfection (P = 0.9) and gender (P > 0.2 for both).

CONCLUSIONS

MDR-TB is an emerging problem in Nigeria. Developing good quality drug susceptibility test facilities, routine monitoring of drug susceptibility and improved health systems for the delivery of and adherence to first- and second-line treatment are imperative to solve this problem.

Pilot study on multidrug resistant tuberculosis in Nigeria

BACKGROUND

Drug resistant tuberculosis (TB) has lately emerged and it represents a serious public health problem. We set out to determine drug resistance among TB patients.

METHODS

Using automated BACTEC cultures, multidrug resistant-tuberculosis (MDR-TB) was investigated in 117 diagnosed cases in Abuja, Nigeria.

RESULTS

Ten (31%) of 32 culture-positive patients were resistant to at least one and four (13%) to all of the four drugs tested. No association between drug resistance and human immunodeficiency virus (HIV) infection was found.

CONCLUSIONS

MDR-TB is present in Nigeria and larger studies are urgently required. TB clinical management and control efforts should be improved.

Successful AV fistula creation does not lead to higher catheter use: the experience by the Northwest Renal Network 16 Vascular Access Quality Improvement Program. Four years follow-up

BACKGROUND

In 2002, the Center for Medicare and Medicaid Services (CMS) required all 18 Renal Networks to participate in a Vascular Access Quality Improvement Program (QIP). The Northwest Renal Network (NWRN 16) chose to increase arteriovenous fistula (AVF) use. NWRN 16 hypothesized that strategies which targeted the improvement of AVF rate and the reduction of catheter use were the same. In December 2001, 44.2% of hemodialysis (HD) patients in the NWRN 16 received HD using an AVF which met the Dialysis Outcome Quality Initiative (K/DOQI) 40% AVF guideline for prevalent patients. However, 43% of HD facilities (2869 patients) had less than 40% of AVF and higher HD catheter rates than the average Network catheter rates (25.0 vs. 20.3%). To address the needs of underperforming facilities, NWRN 16 provided education and tools for their vascular access decision makers to promote AVF creation and catheter reduction.

METHODS

In 2002, NWRN 16 sponsored four regional workshops targeted at nephrologists, vascular surgeons, HD nurses, and interventional radiologists.

RESULTS

Percentage of AVFs in use in invited facilities increased from 31.3% pre-intervention to 56.2% at 4 yrs: 78% increase (99% confidence interval: 77.8% to 81.5%). Percentage of catheters increased from 25% to 25.8%: 3.2% change over 4 yrs (99% confidence interval: 2.5% to 4%).

CONCLUSION

The success of Network 16's AVF interventions demonstrates the effectiveness of Network education promoting multidisciplinary teamwork, and innovative strategies to increase dramatically AVF use without substantial increase in catheter use.

Sex differences in the clinical presentation of urban Nigerian patients with pulmonary tuberculosis

BACKGROUND

Differences in clinical presentation of tuberculosis (TB) have been reported in different age groups, gender and in different parts of the world. Study of gender differences in clinical presentation of patients will assist in targeting those at higher risk and ensure successful TB control planning.

OBJECTIVE

To describe the differences in clinical presentation and risk factors for TB in male and female Nigerian patients with pulmonary tuberculosis (PTB).

METHODS

Patients with cough of more than three weeks duration attending hospitals in Abuja, Nigeria were interviewed with a structured questionnaire. After clinical examination, sputum samples were examined by smear microscopy and one sample was cultured. Haematological examination, serum chemistries, HIV serology, and chest X-ray evaluation were also evaluated.

RESULTS

Of 1186 patients who had sputum culture, 731 (62%) were positive for TB: 437 (60%) males and 394 (40%) females. The mean (SD) age of males was significantly greater than that of females, 34 (11) vs. 31 (12) years, rp = 0.001. Male patients were more likely to be employed and better educated than women. More men than women smoked cigarettes. Women were more likely to be co-infected with HIV and less likely to be smear-positive than men. Male patients had more severe radiological disease.

CONCLUSION

More men than women appear to present with TB at hospitals in Abuja. Male patients were older and are more likely to have smear-positive TB, whereas, female patients were more likely to be co-infected with HIV.

Same-day smears in the diagnosis of tuberculosis

OBJECTIVE

To assess the feasibility of completing the diagnosis of tuberculosis (TB) in 1 day by collecting only on-the-spot specimens.

METHODS

Individuals with suspected TB attending district hospitals in Abuja submitted three sputum samples for routine diagnosis (the standard approach). One additional sample was collected 1 h after the first sputum (the same-day approach). One sputum sample was cultured. Blood samples were tested for HIV.

RESULTS

Two hundred and twenty-four patients with chronic cough had 135/672 (20%) positive on-the-spot smears and 47/224 (21%) positive morning smears. The same-day and internationally recommended approaches identified 44 and 45 of the 78 patients with positive cultures, respectively. 106/194 (55%) patients were HIV positive. Only 9-11% of their smears were positive compared with 30-32% for HIV negatives (P < 0.01).

CONCLUSION

It could be possible to diagnose TB in a single day by examining two spot specimens, but the feasibility needs to be confirmed on a larger scale.

Influences of secondary disturbances on lodgepole pine stand development in Rocky Mountain National Park

Although high-severity fire is the primary type of disturbance shaping the structure of lodgepole pine (Pinus contorta) stands in the southern Rocky Mountains, many post-fire stands are also affected by blowdown, low-severity surface fires, and/or outbreaks of mountain pine beetle (MPB; Dendroctonus ponderosae). The ecological effects of these secondary disturbances are poorly understood but are potentially important in the context of managing for ecological restoration and fire hazard mitigation. We investigated the effects of blowdown, surface fires, and MPB outbreaks on demographic processes in post-fire lodgepole pine stands in Rocky Mountain National Park, Colorado, USA. We used dendroecological methods to reconstruct stand characteristics prior to and following secondary disturbances for paired stands with and without secondary disturbances. Surface fire events do not kill canopy trees or trigger pulses of recruitment and as such do not have detectable influences on stand development. In contrast, both MPB and blowdown kill canopy trees and trigger pulses of tree regeneration of lodgepole pine and subalpine fir (Abies lasiocarpa). The amount and species composition of post-disturbance regeneration is dependent on the severity of the disturbance and on the time since stand initiation. Secondary disturbances of higher severity (i.e., killing >50% of the canopy trees) that occur in younger post-fire stands favor new establishment of lodgepole pine. In contrast, secondary disturbances of lower severity in older stands (>250 years) trigger a pulse of establishment of subalpine fir. The results of this study demonstrate that the high tree densities characteristic of lodgepole pine stands in the southern Rockies (southern Wyoming to northern New Mexico) are the result of dense regeneration following stand-replacing fires and that surface fires had little or no thinning effect on tree densities. Thus, current high stand densities in the study area are not the result of suppression of surface fires. Moreover, the strong pulses of regeneration following forest thinning by MPB and blowdowns imply that, depending on the degree of thinning, thinning prescriptions to reduce fuels in the lodgepole pine forest type may have the unintended consequence of increasing ladder fuels 15-20 years following treatments.

Short-term bleach digestion of sputum in the diagnosis of pulmonary tuberculosis in patients co-infected with HIV

The bleach digestion of sputum may improve the yield of smear microscopy but has not been validated in patients with HIV. Therefore we assessed the performance of bleach-digested smear microscopy among patients with HIV. One thousand three hundred and twenty one patients with chronic cough submitted three sputum samples for direct smear microscopy and were offered HIV tests. One sample was selected for a bleach-digested smear and another one was cultured. Patients were classified as having 'definite' (>or=2 positive smears), 'very likely' (smear-negative, culture- positive), 'less likely' (one smear-positive, culture-negative) and 'unlikely' (smear and culture negative) tuberculosis (TB). In all, 566/1045 (54%) patients were HIV positive and 731/1186 (62%) were culture positive. The digested smears were positive in 123/125 (98%) 'definite', 4/118 (3%) 'very likely' and 1/174 'unlikely' TB patients with HIV and in 125/127 (98%) 'definite', 2/74 (3%) 'very likely', 4/4 'less likely' and 2/127 'unlikely' TB without HIV. Three direct smears identified 252 (57%) and one digested smear 254 (57%) of the 444 patients with 'definite' or 'very likely' TB. One bleach-digested smear performed similarly to three direct smears. Both methods were less sensitive in HIV-positive patients. Further studies are needed to compare the performance of the two methods under operational conditions.

Successful multidisciplinary interventions for arterio-venous fistula creation by the Pacific Northwest Renal Network 16 vascular access quality improvement program

BACKGROUND

In December 2001, 44.2% of hemodialysis (HD) patients in the Northwest Renal Network (NWRN 16) received dialysis using an arteriovenous fistula (AVF). Substantial differences were noted in percentages of patients with AVF, ranging from 5% to 90% of the facility population, suggesting wide variation in physician practice patterns within the Network. To address the needs of facilities having < 40% AVF, NWRN 16 provided education and tools for their vascular access decision-makers to promote AVF creation.

METHODS

In 2002, the Network sponsored 4 regional workshops targeted to nephrologists, vascular surgeons, dialysis nurses, and interventional radiologists.

RESULTS

46 facilities (43% of all Network facilities) had <40% AVF in use in December, 2001, dialyzing 2940 patients (Invited Units). Percent AVF in use in all the Invited Facilities increased from 31.3% pre-intervention to 39.8% at 1 year (p<0.001 vs pre) to 56.2% at four years: 79.8% increase in the prevalent AVF rate over a four-year period (95% confidence interval: 77.8% to 81.7%).

CONCLUSION

Low prevalent AVF rates in many NWRN 16 facilities may have resulted from differences in physician practice patterns. The success of Network 16 AVF Intervention demonstrates the effectiveness of Network education promoting multidisciplinary teamwork, innovative strategies to increase AVF rates among dialysis patients.

Microbiological validation of smear microscopy after sputum digestion with bleach; a step closer to a one-stop diagnosis of pulmonary tuberculosis

BACKGROUND

Smear microscopy is relatively insensitive for the diagnosis of TB. The digestion of sputum with household bleach prior to smear preparation has been reported to improve its sensitivity. This method has not been validated.

METHODS

Seven hundred and fifty six patients with symptoms suggestive of pulmonary TB (PTB) were asked to submit 3 sputum specimens for direct microscopy. One specimen was selected at random for culture and another specimen was digested to prepare a further smear. The WHO case definition (>or=2 positive smears or one positive smear and positive culture) was used to compare the sensitivity and specificity of the smears.

FINDINGS

Four hundred and fifty five (60%) patients were culture-positive. Of these, 235 (31%) had "definite" PTB and 223 (29%) "very likely" PTB (smear-negative, culture-positive). The WHO case definition identified 51% (235/458) of the patients with "definite" or "very likely" PTB. One digested smear detected 219 (93%) of the 235 patients with "definite" PTB and 10 patients with "very likely" PTB (sensitivity (95%CI) 50% (45-55%); specificity 99% (97-100%)). The positive and negative predictive values for one digested smear were 98% (95-99%) and 56% (52-60%) respectively, which were not different (p>0.5) to the WHO case definition (100% and 57%, respectively).

INTERPRETATION

One bleach-digested smear is as sensitive and specific as the WHO case definition for the diagnosis of PTB.

Comparison of scanty AFB smears against culture in an area with high HIV prevalence

To verify among tuberculosis (TB) suspects attending hospitals in Abuja, Nigeria, if sputum smears graded as scanty are false-positive, sputum smears from 1068 patients were graded with the International Union Against Tuberculosis and Lung Disease classification. One specimen was cultured. Eight hundred and twenty-four (26%) smears were positive, 137 (4%) scanty and 2243 negative. Of 1068 cultures, 680 (64%) were positive. One hundred and thirty (95%) scanty and 809 (98%) positive smears were culture-positive. Twelve of 18 patients with a single scanty smear and 51 of 52 with > or = 2 scanty smears were culture-positive. Fewer than < 5% scanty results, < 1% of the patients treated for TB, are false-positive.

Becoming a success story: how boys who have molested children talk about treatment

This grounded theory study was designed to generate a mid-range theory of treatment from the perspective of boys who have molested children and undergone outpatient treatment. Data included information from seven boys' charts, their written responses to open-ended questions, and audio-taped interviews. The interviews generated a series of statements reflecting the boys' experiences in treatment, which were analysed by the constant comparative method. The basic social process of treatment was 'becoming a success story'. The structural elements of becoming a success story included relapse prevention, compliance and decision-making. The boys integrated these structural elements by talking to people they trusted, listening to what people said, and using what people said to help them do what was right. Becoming a success story took place in a context of family and community support. In its current form, this theory of treatment success can be used in practice to monitor progress through treatment.

Children's ibuprofen suspension for the acute treatment of pediatric migraine

OBJECTIVE

To compare the efficacy of a single over-the-counter dose (7.5 mg/kg, p.o.) of children's ibuprofen suspension vs. placebo for the acute treatment of pediatric migraine.

BACKGROUND

Migraine occurs in 4% of young children. There is a paucity of controlled clinical research in the treatment of childhood migraine and there are currently no approved drugs in the USA for treatment of migraine in children < or = 12 years of age. The purpose of this study is to assess the efficacy and tolerability of a single OTC dose of ibuprofen suspension for the acute treatment of childhood migraine.

METHODS

Prospective, double-blind, placebo-controlled, parallel group, randomized study of children 6-12 yrs with migraine (I.H.S.-R 1997) treating 1 attack with a 7.5 mg/kg liq. ibuprofen vs matching placebo. Efficacy measures: (1). Headache severity based upon a 4 pt scale (severe, mod., mild, no headache) at 30, 60, 90, 120, 180 and 240 minutes post dose, and (2). nausea, vomiting, and photo/phonophobia at 120 min. The 1 degrees endpoint was cumulative % of responders (severe or mod. headache reduced to mild or none) by 120 minutes. Secondary endpoints were headache recurrence within 4-24 hours and need for rescue medicines within 4 hours.

RESULTS

138 enrolled; 84 treated/completed diary. 45 active agent, 39 placebo. The 2 groups were comparable (active: placebo) - Ages: 9: 9.1, gender boy/girl - 1.25: 1.6, and diagnosis: migraine w/o aura - 86%: 79%. Concomitant use of prophylactic Rx: 24%: 10% (Table 3). Nausea was eliminated in 60% of the ibuprofen treated patients and 39% of the placebo group (p<0.001). Vomiting, photophobia and phonophobia had marginal, but not statistically significant, decreases at 2 hours. A striking gender difference was noted (Table 4): No AE's were reported.

CONCLUSION

Children's ibuprofen suspension at an OTC dose of 7.5 mg/kg is an effective and well-tolerated agent for pain relief in the acute treatment of childhood migraine, particularly in boys. There is a striking difference in gender response rates and placebo responder rates between girls and boys. The boys responded at a statistically significant rate, and girls failed to do so because of a very high placebo responder rate. Multi-center trials are recommended.

Pregnancy outcomes after laparoscopic myomectomy with ultrasonic energy and laparoscopic suturing of the endometrial cavity

STUDY OBJECTIVE

To evaluate pregnancy outcomes in women with laparoscopic removal of myomas that resulted in entry into the endometrial cavity and required laparoscopic repair of the endometrial cavity.

DESIGN

Retrospective chart review (Canadian Task Force classification II-2). SETTING; Private obstetrics-gynecology practice and departments of obstetrics and gynecology at two university-affiliated hospitals.

PATIENTS

Seven women with symptomatic uterine leiomyomata treated by laparoscopic myomectomy, who achieved pregnancy.

INTERVENTION

Laparoscopic dissection of myomas with the ultrasonic scalpel and laparoscopic suturing of the uterus with the Endo Stitch device in three layers.

MEASUREMENTS AND MAIN RESULTS

Indications for laparoscopic myomectomies were excessive bleeding and significant growth of uterine myomas. The size of myomas in all patients ranged from 12 to 2 cm. Average operating time was 232.8 minutes and average blood loss was 117.8 ml. The largest number of myomas removed from a single patient was nine. All procedures were performed on an outpatient basis and no complications occurred. All women easily achieved pregnancy and four were delivered at or near term by cesarean section. One delivered vaginally at 28 weeks secondary to uncontrolled premature labor, without uterine dehiscence. Two had elective terminations at 8 weeks.

CONCLUSION

Laparoscopic suturing of the endometrial cavity in three layers does not prevent future pregnancies, and pregnancies can progress to term and in some cases be delivered vaginally without dehiscence. (J Am Assoc Gynecol Laparosc 8(1):129-136, 2001)

MEASURING Sexual Arousal

The impact of sexual offenses and abuse is incalculable, both on the victims themselves and the society responsible for protecting them. Identifying people who sexually offend against adults and children and preventing them from engaging in abusive behavior in the future requires valid and reliable methods that accurately identify the perpetrators' characteristics and measure treatment effectiveness. This article reviews the literature on penile plethysmography (PPG), a mechanism by which erectile response to deviant sexual stimuli can be measured.

Milieu management of traumatized youngsters

TOPIC

Traumatized youngsters are disproportionately represented in out-of-home treatment facilities. Conceptual models that guide treatment of traumatized youngsters are not well integrated with models that guide milieu management.

PURPOSE

To describe a milieu management approach for treatment of traumatized youngsters.

SOURCES

Clinical experience with hospital and residential treatment facilities and therapeutic foster homes, as well as literature support.

CONCLUSIONS

Familiar treatment strategies take on an additional meaning when they are implemented in the context of the children's histories of exposure to traumatic events.

Determinants of short- and long-term outcome in patients with respiratory failure caused by AIDS-related Pneumocystis carinii pneumonia

OBJECTIVES

To determine (1) predictors of in-hospital mortality and long-term survival in patients with acute respiratory failure (ARF) caused by acquired immunodeficiency syndrome-related Pneumocystis carinii pneumonia (PCP) and (2) long-term survival for patients with ARF relative to those without ARF.

METHODS

A retrospective medical chart review was conducted of all cases of PCP-related ARF for which the patient was admitted to the intensive care unit of a single tertiary care institution between 1991 and 1996. Data were extracted regarding physiologic scores, relevant laboratory values, and duration of previous maximal therapy with combined anti-PCP agents and corticosteroids at entry to the intensive care unit. Duration of survival was determined by Kaplan-Meier methods from date of first hospital admission and compared for patients with and without ARF.

RESULTS

There were 41 admissions to the intensive care unit among 39 patients, with 56.4% in-hospital mortality. Higher physiologic scores (Acute Physiology and Chronic Health Evaluation II [APACHE II], Acute Lung Injury, and modified Multisystem Organ Failure scores) were predictive of in-hospital mortality. Duration of previous maximal therapy also predicted in-hospital mortality (45% for patients with <5 days of previous maximal therapy vs 88% for those with > or =5 days of previous maximal therapy; P = .03). Combining physiologic scores and duration of previous maximal therapy enhanced prediction of in-hospital mortality. There was no difference in long-term survival between patients with PCP with ARF and those without ARF (P = .80), and baseline characteristics did not predict long-term survival.

CONCLUSIONS

In-hospital mortality of patients with acquired immunodeficiency syndrome-related PCP and ARF is predicted by duration of previous maximal therapy and physiologic scores, and their combination enhances predictive accuracy. Long-term survival of patients with ARF caused by PCP is comparable to that of patients with PCP who do not develop ARF, and determinants of in-hospital mortality do not predict long-term survival.

Prostate-specific antigen in vaginal fluid as a biologic marker of condom failure

Forty women participated in three clinic visits during which they were exposed to their partner's semen (10 microL, 100 microL, and 1 mL). At each visit they took vaginal fluid samples before exposure to their partner's semen, immediately after, and at 1, 24, and 48 h after exposure. PSA was measured with an enzyme-linked immunoassay. The mean PSA level for preexposure swabs ranged between 0.43 and 0.88 ng/mL. The mean PSA levels were 193 immediately after exposure to 10 microL, 472 after 100 microL, and 19,098 after 1 mL. The PSA levels declined within 1 h, and returned to background at 48 h. The findings confirm that our procedure is a sensitive and specific method for detecting recent semen exposure, and indicate that PSA levels depend on exposure intensity and time since exposure. Application of this method in condom efficacy studies provides objective evidence of condom failure that enhances the interpretation of self-report.

Idiopathic immune-mediated acquired von Willebrand's disease in a patient with angiodysplasia: demonstration of an unusual inhibitor causing a functional defect and rapid clearance of von Willebrand factor

A case of idiopathic immune-mediated von Willebrand's disease (AvWD) associated angiodysplasia and recurrent lower gastrointestinal bleeding is reported. Coagulation parameters at presentation were activated partial thromboplastin time of 41 sec, bleeding time >15 min, factor VIII procoagulant activity, 5%; von Willebrand factor antigen (WF:Ag) 5%, and vWF:ristocetirn cofactor activity 11% sodium dodecyl sulfate-agarose gel electrophoresis pattern of plasma vWF showed a pattern similar to type II vWD. An in vitro inhibitor against vWF in the immunoglobulin (Ig)G fraction of the patient's plasma was demonstrated vWF parameters showed a short-lived increase after 1-deamino-8-D-arginine vasopressin (DDAVP) administration. The patient's bleeding episodes were initially managed adequately with cryoprecipitate replacement therapy and DDAVP, to which she became refractory. No significant improvement was achieved following the institution of immunosuppressive therapy in the form of high-dose steroids and cyclophosphamide. She was then treated with intravenous immunoglobulin (IvIg) to which she showed an adequate response in terms of her clinical situation and her hemostatic parameters. The patient is on maintenance treatment with repeated courses of IvIg based on vWF parameter monitoring. To our knowledge, this is the third reported association between idiopathic immune-mediated AvWD and angiodysplasia.

Idiopathic immune-mediated acquired von Willebrand's disease in a patient with angiodysplasia: demonstration of an unusual inhibitor causing a functional defect and rapid clearance of von Willebrand factor

A case of idiopathic immune-mediated von Willebrand's disease (AvWD) associated angiodysplasia and recurrent lower gastrointestinal bleeding is reported. Coagulation parameters at presentation were activated partial thromboplastin time of 41 sec, bleeding time >15 min, factor VIII procoagulant activity, 5%; von Willebrand factor antigen (WF:Ag) 5%, and vWF:ristocetirn cofactor activity 11% sodium dodecyl sulfate-agarose gel electrophoresis pattern of plasma vWF showed a pattern similar to type II vWD. An in vitro inhibitor against vWF in the immunoglobulin (Ig)G fraction of the patient's plasma was demonstrated vWF parameters showed a short-lived increase after 1-deamino-8-D-arginine vasopressin (DDAVP) administration. The patient's bleeding episodes were initially managed adequately with cryoprecipitate replacement therapy and DDAVP, to which she became refractory. No significant improvement was achieved following the institution of immunosuppressive therapy in the form of high-dose steroids and cyclophosphamide. She was then treated with intravenous immunoglobulin (IvIg) to which she showed an adequate response in terms of her clinical situation and her hemostatic parameters. The patient is on maintenance treatment with repeated courses of IvIg based on vWF parameter monitoring. To our knowledge, this is the third reported association between idiopathic immune-mediated AvWD and angiodysplasia.

Adenocarcinoid of ileum and appendix, incidentally discovered during exploratory laparotomy for gastric MALT lymphoma, with subsequent diffuse prostatic metastases: report of a case with light, immunohistochemical, and electron microscopic studies

The diagnosis of adenocarcinoid (mucinous/goblet cell carcinoid) is usually unexpected by both clinicians and pathologists. We report here the case of a 74-year-old man with gastric lymphoma (B-cell MALToma) diagnosed by endoscopy, who was found on exploratory laparotomy also to have extensive intraabdominal involvement by adenocarcinoid, arising from the ileum and/or appendix. The patient died two years after diagnosis with bladder outlet and small bowel obstruction due to diffuse metastases. In addition to mucin positivity, immunohistochemical stains demonstrated the tumor to be positive for chromogranin, synaptophysin, serotonin, gastrin, and glucagon. Of histogenetic interest, some individual neoplastic cells appeared to be positive for both mucin and chromogranin, and this was confirmed by the electron microscopic finding of microvilli, intracytoplasmic mucin droplets, and neurosecretory granules involving the same neoplastic cells. This also appears to be the first reported case of adenocarcinoid associated with lymphoma and demonstration of histochemical/immunohistochemical and ultrastructural evidence of cellular components with dual mucinous adenocarcinoma and neuroendocrine features, and the second reported case to have prostatic metastases.

The incidence and spectrum of AIDS-defining illnesses in persons treated with antiretroviral drugs

The incidence and spectrum of primary AIDS-defining illnesses in human immunodeficiency virus-positive patients receiving antiretroviral drugs may have changed since the introduction of newer antiretroviral agents. We performed a retrospective analysis of patients enrolled in the British Columbia Drug Treatment Program who were ever prescribed antiretroviral drugs between 1 January 1994 and 31 December 1996. Rates were calculated on a 6-month basis. There were 344 AIDS cases diagnosed among 2,533 participants between 1994 and 1996. The incidence of primary AIDS diseases decreased from 1994 to 1996, with a sharp decline in 1995 and 1996. There was no statistically significant change in the incidence of primary AIDS diagnoses relative to one another, and Pneumocystis carinii pneumonia and Kaposi's sarcoma remain the most common AIDS index diagnoses. In patients receiving antiretroviral therapy in the modern era, the incidence of AIDS-defining illnesses has decreased substantially, but the spectrum of AIDS-defining illnesses remains unchanged.

Validation of the modified multisystem organ failure score as a predictor of mortality in patients with AIDS-related Pneumocystis carinii pneumonia and respiratory failure

STUDY OBJECTIVES

To validate a previously developed multisystem organ failure (MSOF) score with and without the addition of the lactate dehydrogenase (LDH) level as a predictor of survival to hospital discharge in patients with AIDS-related Pneumocystis carinii pneumonia (PCP) and acute respiratory failure (ARF).

DESIGN

Retrospective chart review between April 1, 1991, and September 30, 1996.

SETTING

University-affiliated tertiary care center in downtown Vancouver, British Columbia, Canada.

PATIENTS

All patients with PCP-related ARF admitted to the ICU of St. Paul's Hospital during the study period.

INTERVENTIONS

As putative prognostic instruments, data were extracted regarding the APACHE II (acute physiology and chronic health evaluation II), acute lung injury (ALI), AIDS, and modified MSOF scores, as well as LDH levels, at entry to the ICU. Patients were stratified based on an LDH level of < or > or = 2,000 U/L and this threshold was assessed in its predictability of outcome when added to each of the above scores. For APACHE II, the score was categorized in six groups and evaluated with and without inclusion of the LDH. Receiver operating characteristic curves were constructed for LDH and for each score with and without the LDH level to assess accuracy of prediction. The area under each curve was calculated and compared to estimate the statistical significance of observed differences.

MEASUREMENTS AND RESULTS

There were 40 admissions to the ICU of 38 patients with 52.5% mortality. The ALI and AIDS scores were not predictive of outcome. The modified MSOF and APACHE II scores were significant predictors of survival and the performance of both was enhanced by the addition of LDH.

CONCLUSIONS

Both the APACHE II and the modified MSOF scores were significant predictors of outcome in the patient population studied. These results validate the modified MSOF score as an effective predictor of survival to hospital discharge among patients with AIDS-related PCP who develop ARF and the performance of the score is enhanced by the addition of the LDH level.

Pulmonary metastasis from a benign giant-cell tumor of the hand: report of a case diagnosed by fine-needle aspiration cytology

We report on the fine-needle aspiration cytologic findings of a metastatic giant-cell tumor of the right long digit to the lungs. The patient had undergone curettage of his giant-cell tumor of the finger twice 2 yr before his last admission. The lesion recurred 9 mo later, and a Ray resection of the right long digit was performed. Recently, a routine follow-up chest X-ray disclosed pulmonary metastasis. The aspirate from the lung yielded a highly cellular double-cell population, composed of mononuclear stromal cells and an osteoclast-like giant-cell population. The rarity of this tumor and its metastatic potential can cause considerable difficulty in diagnosing this entity. Clinical data, radiologic findings, and cytologic features are important to reach the correct diagnosis. Fine-needle aspiration cytology is a reliable, relatively noninvasive, and cost-effective diagnostic tool in the diagnosis of visceral metastasis in giant-cell tumors.

Care of central venous catheters for total parenteral nutrition

This report summarizes data obtained via a mailed questionnaire from 129 Department of Veterans Affairs (VA) hospitals regarding current practices in the care of central venous catheters (CVCs) used for total parenteral nutrition (TPN). The size of VA hospitals' acute medical-surgical beds ranged from 14 to 1320 (median 168) beds. Over 6000 patients annually received CVCs for TPN. Hospitals reported using triple-lumen catheters most frequently as their CVC for TPN (80.3%). A povidone-iodine scrub was used to prepare the skin for CVC insertion by 72.6% of reporting hospitals. Sixty percent of hospitals used transparent polyurethane dressings. Care of CVCs varied among hospitals. Catheter-related infection and sepsis rates were within the national average, although < 50% of responding hospitals provided data on these outcomes. The results of this survey point to the need for a national standardized database relative to patients receiving TPN via a CVC.

Fine-needle aspiration diagnosis of extrapulmonary Pneumocystis carinii lymphadenitis in a human immunodeficiency virus positive patient

Extrapulmonary Pneumocystitis carinii is an uncommon and probably underdiagnosed complication of pulmonary P. carinii infections. We report the cytologic diagnosis of a case of P. carinii lymphadenitis which presented, without concurrent or historical pneumonitis, in a human immunodeficiency virus (HIV) positive patient who was taking aerosolized pentamidine. The diagnosis was suggested by abundant granular exudate on the cell block. Only scant, fragmented, irregular-shaped granular exudate was present on the direct smears and the Millipore filter preparation. The diagnosis was confirmed by special stains on the cell block.