Role of COPD in a case of fatal Aspergillus niger tracheobronchitis

A man with chronic obstructive pulmonary disease (COPD) in his mid-60s was admitted for respiratory failure due to multifocal, necrotising pneumonia. Despite initial improvement with antimicrobial therapy, the patient developed hemoptysis and progressive infiltrates. Subsequent fungal cultures from his bronchoalveolar lavage were positive for Aspergillus niger and treatment with voriconazole was added for suspected invasive pulmonary aspergillosis (IPA). A repeat bronchoscopy revealed cobblestone lesions with mucosal friability throughout the lower trachea and bilateral mainstem bronchi. Endobronchial biopsy showed septated hyphae confirming the diagnosis of IPA. Despite appropriate therapy, the patient declined further and passed away on hospital day 11. Invasive infections with A. niger are infrequent, with a paucity of data on clinical course and outcomes. Our case adds to the current body of literature regarding the potential virulence of this species in patients with COPD.

Bacterial pneumonia infection in pregnancy

Bacterial pneumonia in pregnancy is the most common fatal non-obstetrical infection and is associated with poorer maternal and fetal outcomes. Risk factors include normal physiological and anatomic changes that occur during pregnancy. In this review, we will discuss the etiological pathogens of bacterial pneumonias in pregnancy and its common complications, including both maternal and fetal outcomes. We will also review the diagnosis and management of bacterial pneumonia in the outpatient and inpatient setting and highlight the major pregnancy and lactation considerations when choosing antibiotic therapies.

A Case Series of Secondary Spontaneous Pneumomediastinum and Pneumothorax in Severe COVID-19 Pneumonia

Introduction

Pneumomediastinum and pneumothorax are uncommon complications in COVID-19 patients. The exact prevalence, etiology, and outcomes are not well known. We report a case series of patients in our institution with COVID-19 related pneumomediastinum and pneumothorax and address these questions.

Methods

We conducted a single-center retrospective chart review of patients admitted at our institution with a positive polymerase chain reaction (PCR) confirming the diagnosis of COVID-19. A cohort of 500 potential study candidates was identified, of whom eight were investigated. Demographic data, hospital course, patient co-morbidities, and outcome data were collected.

Results

Eight patients were included in our study who were identified as having an event (i.e., pneumomediastinum and/or pneumothorax) during the specified timeframe. Overall, 62% of patients were on high-flow nasal cannula with an average FiO₂ of >70%. The average oxygen saturation//fraction of inspired oxygen (SpO₂/FiO₂) ratio leading up to an event was 113.7286 (range: 101.11-130.66), and all of the patients not on mechanical ventilation met the criteria for acute respiratory distress syndrome (ARDS) based on the Kigali definition with SpO₂/FiO₂ < 315. The three patients who developed an event while requiring mechanical ventilation both had PaO₂/FiO₂ < 100, consistent with severe ARDS at the time of an event. The mean time in days, counted from the day of hospital admission until an event, was 10 days (range: 3-23 days). None of the cases had documented pulmonary parenchymal disease prior to developing COVID-19. To the best of our knowledge, these events were not iatrogenic in nature.

Conclusion

Secondary spontaneous pneumomediastinum and pneumothorax are rare albeit well-documented phenomena in hospitalized patients with COVID-19 infection. Interestingly, the majority of patients in our study were on high-flow nasal cannula at the time of an event. The majority of previously published data on this topic are on those who required positive pressure ventilation; however, there have been more recent papers that also describe these events in non-mechanically ventilated patients. The exact pathophysiology remains unknown, but it is likely multifactorial, and additional studies are needed to further evaluate this phenomenon.

Cystic Fibrosis and Sleep Circadian Rhythms

Cystic fibrosis (CF) is due to a mutation in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which leads to unusual water and chloride secretion across epithelial surfaces. The lungs are responsible for most morbidity, though other organs are frequently affected. Sleep abnormalities have long been recognized in CF. Abnormal ventilation and oxygenation, sinus disease, deconditioning due to muscle weakness and recurrent infections, and inflammation have been thought to play a role in sleep disorders in CF. However, there is evidence that CFTR gene dysregulation can affect circadian rhythms in CF. Early recognition and treatment of circadian rhythms may improve outcomes in CF.

Validity of cardiovascular magnetic resonance in pre- and post-operative evaluation of pulmonary arteries and ventricular functions in pediatric conotruncal anomalies

Background

The aim of this work is to evaluate the validity of magnetic resonance (MR) imaging in assessment of pulmonary arteries and ventricular functions with conotruncal anomalies in the pediatric population.

Results

Between March 2018 and December 2019, 42 patients ranging in age from 6 months to 18 years and diagnosed with conotruncal anomalies by echocardiographic examination were submitted for cardiac MRI followed by assessment of their morphological (intra- and extra-cardiac anatomy) and functional parameters. The most common conotruncal anomaly was tetralogy of Fallot which represented 45% of the cases. Cardiac magnetic resonance (CMR) compared to echocardiography showed 46% agreement in the assessment of right ventricular volumes and function. There was only 37% agreement between echocardiography and MRI in delineation of MAPCAS.

Conclusion

CMR provides a powerful tool, giving anatomical and physiological information that echocardiography and catheterization alone cannot provide in conotruncal anomalies.

Sleep Disordered Breathing in Adults with Cerebral Palsy: What Do We Know So Far?

As advances in medicine continue to extend the lifespan of patients with cerebral palsy (CP), emphasis must be placed on evaluating patients for chronic health issues common in the general adult population. Sleep-disordered breathing (SDB) affects a large number of otherwise healthy adults and is even more common in individuals with disability. SDB includes the following subtypes: obstructive sleep apnea, central sleep apnea, and sleep-related hypoventilation/hypoxemia. SDB consequences include poor daytime functioning from sleepiness and an increased risk of cardiovascular morbidity and mortality. There is a paucity of data available in the literature about the association between SDB and CP in the adult population. More research is needed to understand the true prevalence and management strategies of SDB in patients with CP. This review focuses on three major subtypes of SDB: obstructive sleep apnea, central sleep apnea, and sleep-related hypoventilation/hypoxemia.

Associations between preoperative anaemia and hospital costs following major abdominal surgery: cohort study

Background

Determining the cost-effectiveness and sustainability of patient blood management programmes relies on quantifying the economic burden of preoperative anaemia. This retrospective cohort study aimed to evaluate the hospital costs attributable to preoperative anaemia in patients undergoing major abdominal surgery.

Methods

Patients who underwent major abdominal surgery between 2010 and 2018 were included. The association between preoperative patient haemoglobin (Hb) concentration and hospital costs was evaluated by curve estimation based on the least-square method. The in-hospital cost of index admission was calculated using an activity-based costing methodology. Multivariable regression analysis and propensity score matching were used to estimate the effects of Hb concentration on variables related directly to hospital costs.

Results

A total of 1286 patients were included. The median overall cost was US $18 476 (i.q.r.13 784–27 880), and 568 patients (44.2 per cent) had a Hb level below 13.0 g/dl. Patients with a preoperative Hb level below 9.0 g/dl had total hospital costs that were 50.6 (95 per cent c.i. 14.1 to 98.9) per cent higher than those for patients with a preoperative Hb level of 9.0–13.0 g/dl (P < 0.001), 72.5 (30.6 to 128.0) per cent higher than costs for patients with a Hb concentration of 13.1–15.0 g/dl (P < 0.001), and 62.4 (21.8 to 116.7) per cent higher than those for patients with a Hb level greater than 15.0 g/dl (P < 0.001). Multivariable general linear modelling showed that packed red blood cell (PRBC) transfusions were a principal cost driver in patients with a Hb concentration below 9.0 g/dl.

Conclusion

Patients with the lowest Hb concentration incurred the highest hospital costs, which were strongly associated with increased PRBC transfusions. Costs and possible complications may be decreased by treating preoperative anaemia, particularly more severe anaemia.

Ocean-wide genomic variation in Gray's beaked whales, Mesoplodon grayi

The deep oceans of the Southern Hemisphere are home to several elusive and poorly studied marine megafauna. In the absence of robust observational data for these species, genetic data can aid inferences on population connectivity, demography and ecology. A previous investigation of genetic diversity and population structure in Gray's beaked whale (Mesoplodon grayi) from Western Australia and New Zealand found high levels of mtDNA diversity, no geographic structure and stable demographic history. To further investigate phylogeographic and demographic patterns across their range, we generated complete mitochondrial and partial nuclear genomes of 16 of the individuals previously analysed and included additional samples from South Africa (n = 2) and South Australia (n = 4), greatly expanding the spatial range of genomic data for the species. Gray's beaked whales are highly elusive and rarely observed, and our data represents a unique and geographically broad dataset. We find relatively high levels of diversity in the mitochondrial genome, despite an absence of population structure at the mitochondrial and nuclear level. Demographic analyses suggest these whales existed at stable levels over at least the past 1.1 million years, with an approximately twofold increase in female effective population size approximately 250 thousand years ago, coinciding with a period of increased Southern Ocean productivity, sea surface temperature and a potential expansion of suitable habitat. Our results suggest that Gray's beaked whales are likely to be resilient to near-future ecosystem changes, facilitating their conservation. Our study demonstrates the utility of low-effort shotgun sequencing in providing ecological information on highly elusive species.

Managing Fungal Infections in Cystic Fibrosis Patients: Challenges in Clinical Practice

Cystic Fibrosis (CF) is an autosomal recessive disease characterized by a mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. Impairment of the CFTR protein in the respiratory tract results in the formation of thick mucus, development of inflammation, destruction of bronchial tissue, and development of bacterial or fungal infections over time. CF patients are commonly colonized and/or infected with fungal organisms, Candida albicans or Aspergillus fumigatus, with prevalence rates ranging from 5% to 78% in the literature. Risk factors for acquiring fungal organisms include older age, coinfection with Pseudomonas aeruginosa, prolonged use of oral and inhaled antibiotics, and lower forced expiratory volume (FEV₁). There are limited data available to differentiate between contamination, colonization, and active infection. Furthermore, the pathogenicity of colonization is variable in the literature as some studies report a decline in lung function associated with fungal colonization whereas others showed no difference. Limited data are available for the eradication of fungal colonization and the treatment of active invasive aspergillosis in adult CF patients. In this review article, we discuss the challenges in clinical practice and current literature available for laboratory findings, clinical diagnosis, and treatment options for fungal infections in adult CF patients.

3D reconstructions, 4D imaging and postprocessing with CT in musculoskeletal disorders: Past, present and future

Three-dimensional (3D) imaging and post processing are common tasks used daily in many disciplines. The purpose of this article is to review the new postprocessing tools available. Although 3D imaging can be applied to all anatomical regions and used with all imaging techniques, its most varied and relevant applications are found with computed tomography (CT) data in musculoskeletal imaging. These new applications include global illumination rendering (GIR), unfolded rib reformations, subtracted CT angiography for bone analysis, dynamic studies, temporal subtraction and image fusion. In all of these tasks, registration and segmentation are two basic processes that affect the quality of the results. GIR simulates the complete interaction of photons with the scanned object, providing photorealistic volume rendering. Reformations to unfold the rib cage allow more accurate and faster diagnosis of rib lesions. Dynamic CT can be applied to cinematic joint evaluations a well as to perfusion and angiographic studies. Finally, more traditional techniques, such as minimum intensity projection, might find new applications for bone evaluation with the advent of ultra-high-resolution CT scanners. These tools can be used synergistically to provide morphologic, topographic and functional information and increase the versatility of CT.

Determinants of bilevel therapy in the management of obstructive sleep apnea

BACKGROUND

The aim of this study was to investigate potential patient or polysomnogram (PSG) characteristics that can help determine who might benefit from bilevel positive airway pressure (BPAP) in the treatment of uncomplicated OSA.

STUDY DESIGN

This was a single center, retrospective, observational study in which 19 patients who met our inclusion criteria for BPAP were matched to 40 patients in the control group. Data on patient baseline characteristics as well as PSG results were analyzed.

RESULTS

Baseline patient and PSG characteristics were similar with the exception of shorter sleep time in the BPAP group, 290 min compared with 351 min (p = 0.005). Analysis of oxygen saturations revealed that the percent of total sleep time (TST) spent below 90% (SpO₂ < 90%) was statistically higher in BPAP group (mean 21.4% ± 23.6%) compared with CPAP (mean 9.1% ± 11.1%, p = 0.045). For every 5% increase in TST at SpO₂ < 90%, there is a 28% increase in the odds of BPAP prescription (OR = 1.276, 95%CI 1.029, 1.582, p = 0.027), and for every 10% increase, there is an increase of 63% (OR 1.627, 95%CI 1.058-2.502). The Hosmer-Lemeshow goodness-of-fit test revealed a good fit (p = 0.23). The AUC was 0.7.

CONCLUSION

There is an association between duration of hypoxemia on the PSG and the likelihood of requiring BPAP for the treatment of uncomplicated OSA. More research is needed to understand the best patient-centered therapy when initiating PAP in the management of OSA.

Developments in imaging methods used in hip arthroplasty: A diagnostic algorithm

BACKGROUND

Several imaging modalities can be used to diagnose complications of hip prosthesis placement. Despite progress in these imaging techniques, there are, as yet, no guidelines as to their respective indications.

METHODS

We formed a panel of experts in fields related to prosthesis imaging (radiology, nuclear medicine, orthopedic surgery) and conducted a review of the literature to determine the value of each modality for diagnosing complications following hip replacement.

RESULTS

Few recent studies have investigated the benefits related to the use of the latest technical developments, and studies comparing different methods are extremely rare.

CONCLUSIONS

We have developed a diagnostic tree based on the characteristics of each imaging technique and recommend its use. Computed topography was found to be the most versatile and cost-effective imaging solution and therefore a key tool for diagnosing the complications of hip replacement surgery.

Subchondral linear hyperintensity of the femoral head: MR imaging findings and associations with femoro-acetabular joint pathology

PURPOSE

The goal of this study was to evaluate the associations between linear hyperintensity in the subchondral bone of the femoral head on T2-weighted MR imaging and structural bone lesions.

MATERIAL AND METHODS

The MR imaging examinations of 63 patients (66 hips) that showed a bone marrow edema pattern (BMEP) of the hip were retrospectively evaluated (study group). The study group comprised 43 men and 20 women, with a mean age of 55.3 years±16.9 (SD) (range: 19-84 years). A control group of 61 patients (77 hips) without BMEP of the hip on MR imaging was created. The control group comprised 30 men and 31 women, with a mean age of 53.1 years±15.6 (SD) (range: 25-83 years). The presence of linear abnormalities of the subchondral bone on T2-weighted fat-saturated sequences (TR/TE=4220-4340/42-45ms) was evaluated and MR imaging findings were correlated with structural femoro-acetabular pathology (advanced chondropathy, osteonecrosis, subchondral insufficiency fractures and macroscopic fractures) and with pain duration.

RESULTS

A linear hyperintensity in the subchondral bone on T2-weighted MR imaging was found in 43/66 hips with areas of BMEP (65.1%) and in 3/77 hips without BMEP (3.8%). Subchondral linear hyperintensity was seen in 15/16 (93.7%) hips with a subchondral insufficiency fracture. Among the 16 hips with an ARCO stage III osteonecrosis, 13 (76.9%) presented BMEP associated with a subchondral linear hyperintensity. BMEP was present in 6/8 hips with ARCO stage IV osteonecrosis; however, only two hips (25%) exhibited subchondral linear hyperintensities. Finally, 77.7% of patients with subchondral linear hyperintensities presented with acute or subacute hip pain (P<0.0001).

CONCLUSION

Femoral head subchondral linear hyperintensity on T2-weighted MR imaging is common and is associated with acute subchondral bone damage.

Operator dependent factors implicated in failure of non-invasive positive pressure ventilation (NIPPV) for respiratory failure

BACKGROUND

Non-invasive Positive Pressure Ventilation (NIPPV) is employed for the management of acute respiratory failure and studies have shown that it can prevent the need for endotracheal intubation, mechanical ventilation and associated complications. Given limited studies evaluating the factors, other than those related patient or underlying disease severity, that may lead to NIPPV failure, we performed this study to gain insight into current practices in terms of utilization of NIPPV and operator dependent factors that may possibly contribute to failure of NIPPV.

METHOD

After institutional board review approval a retrospective chart review was performed of consecutive patients who were initiated on and failed NIPPV between January 2009 and December 2009. Data was recorded regarding baseline demographics, admission diagnosis, indications for NIPPV, presence of contraindications, type of NIPPV and initial settings, ABG analysis before and after initiation, whether a titration of the settings was performed or not, operator related factors that may have contributed to failure of NIPPV and clinical outcomes.

RESULTS

Among 1095 patients screened, 111 failed NIPPV. The mean age was 60 years with 59% males. The most frequent indication for initiating NIPPV was COPD exacerbation (N = 27) followed by pneumonia (N = 26). CPAP was used in 5(6%) patients. Median inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP) setting were 10 and 5 cm of H₂ O respectively. Three most common reasons for failure were an inappropriate indication (33%), Progression of underlying disease (30%) and lack of titration (23%). Overall mortality was 22%. Mortality was higher when NIPPV failure was seen among patients with an inappropriate indication or an overlooked contraindication compared to those with an appropriate indication (27% vs 17%).

CONCLUSIONS

Excluding progression of underlying disease, operator dependent factors linked to NIPPV failure are; inappropriate indication, lack of adequate titration and an overlooked contraindication. Inappropriate utilization of NIPPV in respiratory failure is associated with higher mortality.

Quantitative comparison of structure and dynamics of elastin following three isolation schemes by 13C solid state NMR and MALDI mass spectrometry

Methods for isolating elastin from fat, collagen, and muscle, commonly used in the design of artificial elastin based biomaterials, rely on exposing tissue to harsh pH levels and temperatures that usually denature many proteins. At present, a quantitative measurement of the modifications to elastin following isolation from other extracellular matrix constituents has not been reported. Using magic angle spinning (13)C NMR spectroscopy and relaxation methodologies, we have measured the modification in structure and dynamics following three known purification protocols. Our experimental data reveal that the (13)C spectra of the hydrated samples appear remarkably similar across the various purification methods. Subtle differences in the half maximum widths were observed in the backbone carbonyl suggesting possible structural heterogeneity across the different methods of purification. Additionally, small differences in the relative signal intensities were observed between purified samples. Lyophilizing the samples results in a reduction of backbone motion and reveals additional differences across the purification methods studied. These differences were most notable in the alanine motifs indicating possible changes in cross-linking or structural rigidity. The measured correlation times of glycine and proline moieties are observed to also vary considerably across the different purification methods, which may be related to peptide bond cleavage. Lastly, the relative concentration of desmosine cross-links in the samples quantified by MALDI mass spectrometry is reported.

Sleep disorders in pregnancy

Sleep disturbances are common in pregnancy and may be influenced by a multitude of factors. Pregnancy physiology may predispose to sleep disruption but may also result in worsening of some underlying sleep disorders, and the de novo development of others. Apart from sleep disordered breathing, the impact of sleep disorders on pregnancy, fetal, and neonatal outcomes is poorly understood. In this article, we review the literature and discuss available data pertaining to the most common sleep disorders in perinatal women. These include restless legs syndrome, insomnia, circadian pattern disturbances, narcolepsy, and sleep-disordered breathing.

[Ptosis secondary to cavernous sinus meningioma]

INTRODUCTION

Meningiomas of the cavernous sinus are often the cause of neuro-ophthalmologic manifestations. Fifty percent of affected patients present with ptosis. We report a case of ptosis acquired during the first year of life due to oculomotor nerve palsy secondary to a cavernous sinus meningioma. We then discuss the causes of third cranial nerve palsy and treatment options for ptosis associated with CN III palsy.

OBSERVATION

A fifteen-year-old female patient presented with ptosis due to a third cranial nerve palsy appearing within the first year of life. Magnetic resonance imaging (MRI) revealed a cavernous sinus meningioma. The ptosis was treated by frontalis suspension using autologous temporalis fascia. The meningioma required regular follow-up.

DISCUSSION

Ptosis due to third cranial nerve palsy is rare in children. The most common etiologies are congenital and represent 33 to 40% of cases in various studies. Other etiologies are traumatic, tumoral, vascular and infectious. The cause needs to be found by imaging over the entire course of the nerve. Cavernous sinus meningioma is one cause of third cranial nerve palsy. The surgical treatment of ptosis due to third cranial nerve palsy is levator resection or frontalis suspension with a strip of fascia lata or temporalis fascia.

Effects of acute intermittent hypoxia on glucose metabolism in awake healthy volunteers

Accumulating evidence suggests that obstructive sleep apnea is associated with alterations in glucose metabolism. Although the pathophysiology of metabolic dysfunction in obstructive sleep apnea is not well understood, studies of murine models indicate that intermittent hypoxemia has an important contribution. However, corroborating data on the metabolic effects of intermittent hypoxia on glucose metabolism in humans are not available. Thus the primary aim of this study was to characterize the acute effects of intermittent hypoxia on glucose metabolism. Thirteen healthy volunteers were subjected to 5 h of intermittent hypoxia or normoxia during wakefulness in a randomized order on two separate days. The intravenous glucose tolerance test (IVGTT) was used to assess insulin-dependent and insulin-independent measures of glucose disposal. The IVGTT data were analyzed using the minimal model to determine insulin sensitivity (S(I)) and glucose effectiveness (S(G)). Drops in oxyhemoglobin saturation were induced during wakefulness at an average rate of 24.3 events/h. Compared with the normoxia condition, intermittent hypoxia was associated with a decrease in S(I) [4.1 vs. 3.4 (mU/l)(-1).min(-1); P = 0.0179] and S(G) (1.9 vs. 1.3 min(-1)x10(-2), P = 0.0065). Despite worsening insulin sensitivity with intermittent hypoxia, pancreatic insulin secretion was comparable between the two conditions. Heart rate variability analysis showed the intermittent hypoxia was associated with a shift in sympathovagal balance toward an increase in sympathetic nervous system activity. The average R-R interval on the electrocardiogram was 919.0 ms during the normoxia condition and 874.4 ms during the intermittent hypoxia condition (P < 0.04). Serum cortisol levels after intermittent hypoxia and normoxia were similar. Hypoxic stress in obstructive sleep apnea may increase the predisposition for metabolic dysfunction by impairing insulin sensitivity, glucose effectiveness, and insulin secretion.

Effects of acute intermittent hypoxia on glucose metabolism in awake healthy volunteers

Accumulating evidence suggests that obstructive sleep apnea is associated with alterations in glucose metabolism. Although the pathophysiology of metabolic dysfunction in obstructive sleep apnea is not well understood, studies of murine models indicate that intermittent hypoxemia has an important contribution. However, corroborating data on the metabolic effects of intermittent hypoxia on glucose metabolism in humans are not available. Thus the primary aim of this study was to characterize the acute effects of intermittent hypoxia on glucose metabolism. Thirteen healthy volunteers were subjected to 5 h of intermittent hypoxia or normoxia during wakefulness in a randomized order on two separate days. The intravenous glucose tolerance test (IVGTT) was used to assess insulin-dependent and insulin-independent measures of glucose disposal. The IVGTT data were analyzed using the minimal model to determine insulin sensitivity (S(I)) and glucose effectiveness (S(G)). Drops in oxyhemoglobin saturation were induced during wakefulness at an average rate of 24.3 events/h. Compared with the normoxia condition, intermittent hypoxia was associated with a decrease in S(I) [4.1 vs. 3.4 (mU/l)(-1).min(-1); P = 0.0179] and S(G) (1.9 vs. 1.3 min(-1)x10(-2), P = 0.0065). Despite worsening insulin sensitivity with intermittent hypoxia, pancreatic insulin secretion was comparable between the two conditions. Heart rate variability analysis showed the intermittent hypoxia was associated with a shift in sympathovagal balance toward an increase in sympathetic nervous system activity. The average R-R interval on the electrocardiogram was 919.0 ms during the normoxia condition and 874.4 ms during the intermittent hypoxia condition (P < 0.04). Serum cortisol levels after intermittent hypoxia and normoxia were similar. Hypoxic stress in obstructive sleep apnea may increase the predisposition for metabolic dysfunction by impairing insulin sensitivity, glucose effectiveness, and insulin secretion.

Induction of autoantibodies during prolonged treatment with infliximab

OBJECTIVE

To determine the frequency and correlates of autoantibody formation in patients with rheumatic diseases treated with infliximab in a routine clinical setting.

METHODS

All patients receiving at least 5 infusions of infliximab, and with anticipated continuation, were prospectively evaluated for the development of the following antibodies: antinuclear antibody (ANA), anti-DNA, anti-Sm, anti-RNP, anti-SSA and anti-SSB. Correlates with pharmacologic treatments, response to infliximab, and adverse events were assessed.

RESULTS

Seventy-six percent of 42 patients receiving prolonged treatment with infliximab developed new autoantibodies, and these persisted in 57%. The most common new autoantibody was ANA in 45%, followed by anti-DNA in 33%, anti-Sm in 31%, and anti-RNP in 29%. New autoantibody formation was associated with both a greater number of infusions (p = 0.015) and a higher total dose of infliximab infused (p = 0.047). No other treatment, disease characteristic, or loss of efficacy to infliximab discriminated between those developing antibodies compared to those without new antibody formation. No patient developed clinical signs of a new connective tissue disease.

CONCLUSION

Autoantibody formation is seen commonly in patients receiving prolonged treatment with infliximab. Concomitant immunosuppressive treatments did not preclude the formation of antibodies. The clinical significance of antibody formation remains to be determined.

Spirituality for nurses and their practice

This descriptive study compared the inclusion of spirituality in the practice of two groups of nurses: nurses prepared in parish nursing (PN) and nurses not specifically prepared in spiritual care (NonPN). The Spirituality in Nursing Care tool was used to determine sources of spiritual strength and spiritual experiences of the respondents, the application of spirituality in their practice, and the interventions and indicators they used in determining the need for spiritual assistance. Random sampling using U.S. postal codes selected 600 members from a national mailing list of nurses prepared in parish nursing and 600 similarly selected nurses not prepared in parish nursing. A total of 645 questionnaires were returned with complete data. The following question was asked: How do nurses prepared in providing spiritual care (PN) compare to nurses not similarly prepared (NonPN) in terms of: (a) personal sources of spiritual strength, (b) spiritual experiences, (c) application of spirituality in their practice, (d) identification of indicators of spiritual needs in their clients, and (e) interventions used to meet the spiritual needs of their clients? The findings indicate there are differences in how PN and NonPN groups of nurses respond to spirituality of self and their use of spirituality in clinical practice. It is suggested that parish nurses take the lead to further study spirituality and the indicators and appropriate interventions, and identify patient outcomes when spiritual needs are addressed by nurses in providing "holistic nursing practice."

Intensive training of phonological skills in progressive aphasia: a model of brain plasticity in neurodegenerative disease

Three patients with a typical syndrome of nonfluent primary progressive aphasia (Mesulam's syndrome) were trained daily with a remediation protocol including auditory exercises specifically designed to involve several aspects of phonological processing, a domain known to be specifically affected in the condition. The speech content of the exercises was based on the temporal theory of phonological processes according to which increasing the duration of formant transition should facilitate phoneme discrimination and phoneomic awareness. Significantly improved performance on the trained tasks was demonstrated in the three patients. Improvement further generalized to other tasks such as nonword repetition and reading. We conclude that such results (1) argue for using intensive focused therapy of language impairment in neurodegenerative disorders, (2) may constitute a good model of brain plasticity in neurodegenerative disorders in general, and (3) support theories of phonological processing emphasizing temporal features of the auditory signal.

Effect of ventral tegmental 6-hydroxydopamine lesions on the locomotor stimulant action of nicotine in rats

Convergent evidence suggests that the locomotor stimulant effect of nicotine is mediated by nicotinic receptors located on mesolimbic dopaminergic neurons. However, 6-hydroxydopamine lesions of the ventral tegmental area, resulting in substantial depletion of nucleus accumbens dopamine, were recently reported to have no effect on nicotine-induced locomotion. The present study sought to re-examine this issue. Rats received bilateral infusions of 6-hydroxydopamine or vehicle into the ventral tegmental area. Starting 3 weeks later, locomotor activity was tested after subcutaneous injection of saline, nicotine (0.4 mg/kg base), amphetamine (0.5 mg/kg) or scopolamine (0.5 mg/kg). In lesioned animals, the locomotor stimulant effects of nicotine and amphetamine were greatly reduced, whereas saline and scopolamine-induced activity was scarcely affected. Dopamine denervation was assessed by autoradiography, using [125I]RTI-55 to label plasmalemmal dopamine transporters. Labelling was reduced in nucleus accumbens core and shell and in the ventral tegmental area (by 87, 81 and 70%, respectively), and in nigrostriatal areas (52-77%). The locomotor stimulant effects of nicotine and amphetamine were correlated with residual [125I]RTI-55 labelling in mesolimbic and nigrostriatal regions (r=0.6-0.8). The present results provide further evidence that the locomotor stimulant effect of nicotine is dependent on the integrity of ascending dopamine neurons.

Persistent nicotinic blockade by chlorisondamine of noradrenergic neurons in rat brain and cultured PC12 cells

Chlorisondamine (CHL) blocks behavioural responses to nicotine for several weeks or months in rats. Persistent blockade has also been demonstrated ex vivo, in assays of nicotine-evoked striatal dopamine release. Central administration of [3H]-CHL leads to long-term retention of radiolabel in nigrostriatal dopaminergic neurons and in few other cell groups. We investigated whether an analogous blockade also occurs in noradrenergic neurons in the brain and in cultured pheochromocytoma (PC12) cells, which have a similar noradrenergic phenotype. Administration of CHL (10 mg kg(-1) s.c. or 10 microg i.c.v.), 21 days prior, resulted in a near-total block of nicotine-evoked release of hippocampal [3H]-noradrenaline ([3H]-NA) from superfused rat synaptosomes; NMDA-evoked [3H]-NA release was unaffected. Three weeks after administration of [3H]-CHL (10 microg i.c.v.), preferential accumulation of radiolabel was observed in the locus coeruleus, which provides the entire noradrenergic innervation to hippocampus, as well as in previously noted structures. In rat pheochromocytoma (PC12) cells, nicotine evoked [3H]-NA release (EC50 approximately 30 microM). This effect was blocked by co-incubation with mecamylamine (10 microM) or CHL (1 microM) but was not affected by alpha-bungarotoxin. As in the hippocampus, the nicotinic agonist cytisine was at least as efficacious as nicotine. Acute exposure of PC12 cells to CHL 10 or 100 microM (but not 1 microM), followed by 90 min wash-out, almost completely blocked release evoked by 30 microM nicotine. More prolonged (24 h) exposure to CHL 100 microM (but not 1 or 10 microM), followed by 3 days of wash-out, partially inhibited release evoked by nicotine, leaving responses to high K+ unchanged. A significant (30%) reduction was also seen 5 days after exposure. We conclude that persistent nicotinic blockade by CHL is neither restricted to mesostriatal dopamine neurons, nor to the CNS, nor to neurons possessing the same nicotinic receptor pharmacology. In addition, the persistent blockade does not appear to result from an acute blocking action, but may be dependent upon intracellular accumulation of the antagonist.

Epidemic of pediatric deaths from acute renal failure caused by diethylene glycol poisoning. Acute Renal Failure Investigation Team

CONTEXT

Contaminated pharmaceutical products can result in substantial morbidity and mortality and should be included in the differential diagnosis of deaths of unknown origin.

OBJECTIVE

To investigate an outbreak of deaths among children from acute renal failure in Haiti to determine the etiology and institute control measures.

DESIGN

Case-control study, cohort study, and laboratory toxicologic evaluation.

SETTING

Pediatric population of Haiti.

PARTICIPANTS

Cases were defined as Haitian residents younger than 18 years with idiopathic anuria or severe oliguria for 24 hours or longer. Febrile hospitalized children without renal failure were enrolled as control subjects.

MAIN OUTCOME MEASURE

The odds of exposure to suspected etiologic agents among cases and controls.

RESULTS

We identified 109 cases of acute renal failure among children. The clinical syndrome included renal failure, hepatitis, pancreatitis, central nervous system impairment, coma, and death. Of 87 patients with follow-up information who remained in Haiti for treatment, 85 (98%) died; 3 (27%) of 11 patients transported to the United States for intensive care unit management died before hospital discharge. A locally manufactured acetaminophen syrup was highly associated with disease (odds ratio, 52.7; 95% confidence interval, 15.2-197.2). Diethylene glycol (DEG) was found in patients' bottles in a median concentration of 14.4%. The median estimated toxic dose of DEG was 1.34 mL/kg (range, 0.22-4.42 mL/kg). Glycerin, a raw material imported to Haiti and used in the acetaminophen formulation, was contaminated with 24% DEG.

CONCLUSIONS

An epidemic of severe systemic toxicity and deaths from DEG-contaminated acetaminophen syrup occurred in Haiti. Good manufacturing practice regulations should be used by all pharmaceutical manufacturers to prevent such tragedies.

Particle size does not affect the rate of intracellular routing for ligands internalized by non-adsorptive pinocytosis

The rate at which three different species of a fluid phase marker (horseradish peroxidase) reached the lysosomal compartment of mouse LM fibroblasts was compared. Initial observations suggested that the rate was a function of particle size. Adjustment of the concentrations of the various species of HRP to equal numbers of physical particles negated the apparent affect. Thus, particle size does not affect the intracellular routing of a ligand entering fibroblasts by non-adsorptive pinocytosis.

Nurse practitioners: reevaluation of the need for and willingness to hire by nurse administrators, nurse practitioners, and physicians

A survey of all nurse administrators and advanced practice nurses and a simple random sample survey of licensed physicians in Nevada were completed to reevaluate the perceived need for and willingness to hire nurse practitioners (NPs). The reevaluation was deemed necessary based on a similar survey that was completed by these authors in 1990. At that time significant questions were raised concerning the lack of understanding of the role of NPs in and their contribution to the health care team. The results of the study clearly indicate that the unique contributions of the NP to the health care team should be further publicized and clarified. In addition, for some physicians, a significant disparity continues to exist between the optimal, collaborative role and the more readily accepted dependent role of the NP. The family NP (FNP) continues to be the most desired specialty for those who hire NPs.