Nurse Care Management for Opioid Use Disorder Treatment: The PROUD Cluster Randomized Clinical Trial

Importance

Few primary care (PC) practices treat patients with medications for opioid use disorder (OUD) despite availability of effective treatments.

Objective

To assess whether implementation of the Massachusetts model of nurse care management for OUD in PC increases OUD treatment with buprenorphine or extended-release injectable naltrexone and secondarily decreases acute care utilization.

Design, Setting, and Participants

The Primary Care Opioid Use Disorders Treatment (PROUD) trial was a mixed-methods, implementation-effectiveness cluster randomized clinical trial conducted in 6 diverse health systems across 5 US states (New York, Florida, Michigan, Texas, and Washington). Two PC clinics in each system were randomized to intervention or usual care (UC) stratified by system (5 systems were notified on February 28, 2018, and 1 system with delayed data use agreement on August 31, 2018). Data were obtained from electronic health records and insurance claims. An implementation monitoring team collected qualitative data. Primary care patients were included if they were 16 to 90 years old and visited a participating clinic from up to 3 years before a system's randomization date through 2 years after.

Intervention

The PROUD intervention included 3 components: (1) salary for a full-time OUD nurse care manager; (2) training and technical assistance for nurse care managers; and (3) 3 or more PC clinicians agreeing to prescribe buprenorphine.

Main Outcomes and Measures

The primary outcome was a clinic-level measure of patient-years of OUD treatment (buprenorphine or extended-release injectable naltrexone) per 10 000 PC patients during the 2 years postrandomization (follow-up). The secondary outcome, among patients with OUD prerandomization, was a patient-level measure of the number of days of acute care utilization during follow-up.

Results

During the baseline period, a total of 130 623 patients were seen in intervention clinics (mean [SD] age, 48.6 [17.7] years; 59.7% female), and 159 459 patients were seen in UC clinics (mean [SD] age, 47.2 [17.5] years; 63.0% female). Intervention clinics provided 8.2 (95% CI, 5.4-∞) more patient-years of OUD treatment per 10 000 PC patients compared with UC clinics (P = .002). Most of the benefit accrued in 2 health systems and in patients new to clinics (5.8 [95% CI, 1.3-∞] more patient-years) or newly treated for OUD postrandomization (8.3 [95% CI, 4.3-∞] more patient-years). Qualitative data indicated that keys to successful implementation included broad commitment to treat OUD in PC from system leaders and PC teams, full financial coverage for OUD treatment, and straightforward pathways for patients to access nurse care managers. Acute care utilization did not differ between intervention and UC clinics (relative rate, 1.16; 95% CI, 0.47-2.92; P = .70).

Conclusions and Relevance

The PROUD cluster randomized clinical trial intervention meaningfully increased PC OUD treatment, albeit unevenly across health systems; however, it did not decrease acute care utilization among patients with OUD.

Trial Registration

ClinicalTrials.gov Identifier: NCT03407638.

Combined nicotine patch with gum versus nicotine patch alone in smoking cessation in Hong Kong primary care clinics: a randomised controlled trial

Background

The prevalence of daily cigarette smoking has dropped to 10% in Hong Kong (HK) in 2017, however, smoking still kills 5700 persons per year. Studies suggest that abstinence rates are higher with combined NRT than single NRT, although local data on safety and benefits of combined NRT are lacking. The aim of this study is to compare the effectiveness of combined NRT with single NRT among HK Chinese.

Methods

This is a one-year, two-arm, parallel randomised trial. Five hundred sixty smokers, who smoked ≥10 cigarettes/day for ≥1 year, were randomized to combined and single NRT. Combined NRT group received counseling and nicotine patch & gum. Single NRT group received counselling and nicotine patch. Primary outcome was abstinence rate measured as self-reported 7-day point prevalence with CO validated at 52 weeks. Secondary outcomes included smoking abstinence rates at 4, 12, & 26 weeks. Crude odds ratio and p-value were reported from logistic regression without adjustment; for trend analysis, adjusted odds ratio (AOR) and p-value were reported from Generalized Estimating Equation (GEE) (controlling for time). All AORs were adjusted for age, sex, baseline CO and clusters.

Results

Abstinence rates at 4, 12, 26 and 52 weeks were all higher in the combined NRT group (35.8, 21.9, 16.8, 20.1%) compared with the single NRT group (28, 16.8, 11.2, 14.3%). At 4 weeks, combined NRT group was more likely to quit smoking (OR 1.43, 95% CI, 1.00 to 2.05) than the single NRT group. From GEE analysis, combined NRT group had a significantly higher abstinence rate (23.6%) than the single NRT group (17.6%) across repeated measures at all-time points. Combined NRT group was more likely to quit smoking (OR 1.43, 95% CI, 1.15 to 1.77). No significant difference in the side effect profile was detected between groups.

Conclusions

Smokers given 8 weeks of combined NRT were more likely to quit smoking at 4, 12, 26 and 52 weeks compared with single NRT. Combined NRT was as well tolerated as single NRT and it should be further promoted in our community.

Trial registration

NCT03836560 from ClinicalTrial.gov, 9 Feb 2019.

Pain and Pain Management in a Hong Kong Emergency Department

Background

The prevalence of pain is high in emergency departments (ED), according to previous studies. There is little information on the epidemiology of pain in Hong Kong EDs. This study aimed to explore the epidemiology of pain in a single academic ED in Hong Kong, and to evaluate the pain management policy in the ED.

Methods

Retrospective case review study with explicit record review of ED clinical records; records obtained by means of systematic sampling of a seven-consecutive-day period attendance. Data on the prevalence and location of pain, waiting time for drugs for pain relief, and pain drug prescription rates were obtained. Descriptive data analysis was performed.

Results

A total of 494 ED clinical records were reviewed. The prevalence of pain was 60.7% (300/494) during the study period. 72.3% (217/300) of patient attendances with pain had duration of pain not exceeding three days; 79.0% (237/300) of them were classified as ‘semi-urgent’ or ‘non-urgent’. 41.7% (125/300) of patients suffering from pain were given drugs for pain relief. The median time for patients to receive analgesic drugs was 56.0 (IQR 25.0-104.5) minutes after registration. Pain assessment using a numerical rating scale was positively associated with drug prescriptions for pain relief.

Conclusion

The prevalence of pain in ED patients was high, and comparable with the figures from studies in other EDs. Patients attending with pain had to wait more than 60 minutes for drugs for pain relief on average. (Hong Kong j.emerg.med. 2011;18:406-411)

Continuous positive airway pressure-associated cutaneous amoebiasis in an immunosuppressed patient

Organisms of the genus Acanthamoeba are environmentally ubiquitous and colonizers of the oral mucosa in humans. While largely asymptomatic in healthy persons, Acanthamoeba infection can cause disseminated disease with poor prognosis in immunosuppressed populations. Here we report a unique case of cutaneous amoebiasis associated with continuous positive airway pressure use in an immunosuppressed patient.

Emerging pathogen in immunocompromised hosts: Exophiala dermatitidis mycosis in graft-versus-host disease

Infection with the dematiaceous environmental fungus Exophiala, an emerging pathogen in immunocompromised individuals, poses a diagnostic and therapeutic challenge. Herein, we report the first Exophiala dermatitidis fungemia case, to our knowledge, in an allogeneic hematopoietic stem cell transplant patient with graft-versus-host disease, expanding the clinical setting where Exophiala species mycosis should be suspected.

Use of electroacupuncture to accelerate the antidepressant action of selective serotonin reuptake inhibitors: a single-blind, randomised, controlled study

1. Patients treated with dense cranial electroacupuncture stimulation (DCEAS) had a significantly greater reduction in the 17-item Hamilton Rating Scale for Depression scores and clinically significant response to treatment than those having sham acupuncture (19.4% vs.8.8%). 2. Neither sham acupuncture nor DCEAS had effects on the platelet serotonin system. 3. In the early phase of selective serotonin reuptake inhibitor treatment for depressed patients, DCEAS could be used as an additional therapy. 4. Neurobiological mechanisms responsible for DCEAS effects warrant further investigation using neuroimaging.

418 cases of laparoscopic colorectal resections: a single-institution experience and literature review

INTRODUCTION

Evidence from randomised controlled trials has shown that laparoscopic colon and rectal cancer resection not only confers short-term benefits but also does not differ considerably in terms of its long-term oncological outcomes, as compared with open surgery.

METHODS

All laparoscopic colon and rectal resections performed between January 2005 and December 2007 were included. Patient records were reviewed from a prospective database and the relevant clinical data was obtained, with a subgroup analysis of cancer procedures performed.

RESULTS

418 patients (247 male), median age 63 years (range 24 to 88), underwent laparoscopic resection of the colon and rectum. The median Body Mass Index (BMI) was 22.5 (range 13.5 to 39.3). The majority of the procedures were performed for malignant disease (81.3 percent) and the most common procedure was anterior resection (79.4 percent). The median duration of surgery was 135 minutes (range 65 to 330), with conversions to open surgery in 44 patients (10.5 percent). Complications occurred in 78 patients (18.7 percent), including anastomotic leaks in five (1.20 percent). The median length of hospital stay was five days (range 3 to 90) and the median follow-up was 19 months (range 1 to 46). In the 340 patients with malignant disease, the median number of lymph nodes harvested was 13 (range 5 to 48), and at the latest review, 230 patients (67.6 percent) were disease-free, with locoregional recurrence in 2.9 percent and systemic recurrence in 10 percent.

CONCLUSION

To date, this is the largest series of laparoscopic colorectal resections reported locally, and our results show that it is safe, feasible and produces favourable results.

Microbial succession of glycogen accumulating organisms in an anaerobic-aerobic membrane bioreactor with no phosphorus removal

The succession of glycogen accumulating organisms (GAOs) has been observed in an acetate-fed, anaerobic-aerobic sequencing membrane bioreactor (MBR) operated for 260 days without enhanced biological phosphorus removal (EBPR) activity. Semi-quantitative fluorescence in situ hybridization results showed that a gammaproteobacterial lineage GB frequently observed in EBPR processes was initially the numerically dominant species (50-66% of total cells) of the GAO in the MBR from day 1 to day 38. During this period, succession of two different subgroups of group GB was also observed. On day 85 onward, a population shift from GB group to 'Defluvicoccus'-related tetrad-forming organisms (TFO) occurred. This microbial succession was suspected to be related to the applied operating conditions (long hydraulic retention time and long solid residence time) which favored the proliferation of 'Defluvicoccus'-related TFO rather than the GB group. Application of terminal restriction fragment length polymorphism on selected samples further revealed that the microbial diversity of the seeding sludge as determined by the number of terminal restriction fragments was higher than that of sludge samples taken after day 85.

Proliferation of glycogen accumulating organisms induced by Fe(III) dosing in a domestic wastewater treatment plant

To meet the effluent requirements given for the sensitive receiving body, the Southpest Wastewater Treatment Plant of Budapest, Hungary uses a combined activated sludge-biofilter system with chemical precipitation for P removal. Causes of the proliferation of glycogen accumulating organisms (GAOs) observed in the unaerated/oxic activated sludge unit of this system were investigated both in full-scale and in lab-scale experiments combined with a detailed analysis of the microbial communities. Concentration profile measurements throughout the 8-stage activated sludge unit indicated anaerobic conditions in the first two unaerated reactors and low orthophosphate level (< 1 mg l(-1)) in all of the stages that could not be attributed to the influent quality, but to Fe (III)-dosing to the returned activated sludge. Microbiological analysis revealed the presence of GAOs from the GB group in the Gammaproteobacteria and occasionally tetrad-forming organisms from Actinobacteria, and the absence of Rhodocyclus-related polyphosphate accumulating organisms (PAOs) in the activated sludge samples. Comparative lab-scale studies carried out in two identically arranged UCT-systems with staged anoxic reactors also confirmed that Fe (III)-dosing may result in phosphorus deficiency of the microbial niche, leading to the suppression of growth and EBPR activity of PAOs and to the proliferation of GAOs.

High-temperature creep rupture of low alloy ferritic steel butt-welded pipes subjected to combined internal pressure and end loadings

Constitutive equations are reviewed and presented for low alloy ferritic steels which undergo creep deformation and damage at high temperatures; and, a thermodynamic framework is provided for the deformation rate potentials used in the equations. Finite element continuum damage mechanics studies have been carried out using these constitutive equations on butt-welded low alloy ferritic steel pipes subjected to combined internal pressure and axial loads at 590 and 620 degrees C. Two dominant modes of failure have been identified: firstly, fusion boundary failure at high stresses; and, secondly, Type IV failure at low stresses. The stress level at which the switch in failure mechanism takes place has been found to be associated with the relative creep resistance and lifetimes, over a wide range of uniaxial stresses, for parent, heat affected zone, Type IV and weld materials. The equi-biaxial stress loading condition (mean diameter stress equal to the axial stress) has been confirmed to be the worst loading condition. For this condition, simple design formulae are proposed for both 590 and 620 degrees C.

Are BMI and other anthropometric measures appropriate as indices for obesity? A study in an Asian population

We have examined the relationships between percentage of body fat (PBF) and risk factors for cardiovascular disease and insulin resistance and how good body mass index (BMI) and other anthropometric measures are as indices of obesity. High PBF levels were associated with increased risk of cardiovascular disease and insulin resistance. The World Health Organization BMI of 30 kg/m(2) for obesity has low sensitivity, 6.7% and 13.4% for men and women, respectively. For every obese man and woman identified, 6.7 and 1.76 times nonobese men and women, respectively, will be misclassified as obese. With the locally established BMI cutoff point for obesity of 27 kg/m(2) for men and 25 kg/m(2) for women, the sensitivity was improved to 46.7% and 60.8%, respectively. For every obese man and woman identified, 3.76 and 1.64 times nonobese men and women, respectively, will be misclassified as obese. None of the other anthropometric indices was better than the locally established BMIs. We showed that the BMIs for obesity for our local men and women are different. These BMIs were most precise among all indices studied. However, they still lead to high false-positive rates. For more effective management of the problem of obesity, we need to develop more precise, simple, and cost-effective methods for the measurement of PBF.

The combined oral contraceptive pill in women over age forty

INTRODUCTION

By the age of 35 years, most women would have completed their families and contraception then becomes an important consideration. In the next one or two decades, other health concerns such as osteoporosis, dysfunctional uterine bleeding, ovarian, endometrial, colorectal and breast cancers and cardiovascular diseases will assume prominence in the lives of women. We review the role of the combined oral contraceptive (OC) pill in the older woman in the context of these important health concerns.

METHODS

A Medline search was made for possible interaction between OC use and the above conditions. An important criteria for citation was publication in a high impact factor journal; furthermore to represent the wider context from which there issues derive we choose, whenever appropriate, general journal with wide readership including, but not limited to the Lancet or New England Journal of Medicine; we also choose studies published in journals of other medical disciplines instead of purely gynaecological journals to reflect the multidisciplinary impact of the combined OC pills.

RESULTS

Combined OC retards bone demineralisation which could translate clinically to a reduction in postmenopausal osteoporotic fractures; it affords good menstrual cyclicity and alleviation of perimenopausal vasomotor symptoms; it offers chemoporophylaxis against epithelial ovarian cancers and endometrial cancers. There is evidence that it could be protective against colorectal cancers. The combined OC may attenuate the disease progression of rheumatoid arthritis and reduces the risk of ectopic pregnancy and pelvic inflammatory disease. In an older woman who does not smoke and is in good health, the excess risk of stroke, myocardial infarcts and venous thromboembolism is minimal, if at all, as is the risk of breast neoplasm. In women with proven human papilomavirus infection of the cervix who are using OCs, regular cervical screening is especially important.

CONCLUSION

The non-contraceptive health benefits of the combined OCs justify its usage in the healthy older woman.

Effective suppression of vancomycin-resistant Enterococcus species in asymptomatic gastrointestinal carriers by a novel glycolipodepsipeptide, ramoplanin

Nosocomial bloodstream infections due to vancomycin-resistant enterococci (VRE) are associated with increased morbidity rates, mortality rates, and hospitalization costs. Gastrointestinal carriage of VRE is an important risk factor for subsequent infections. This 3-arm, phase II, double-blinded, randomized, multicenter, placebo-controlled study evaluated the safety and efficacy of oral ramoplanin (a novel, nonabsorbed glycolipodepsipeptide) versus placebo for suppression of gastrointestinal VRE colonization. Sixty-eight patients who were colonized with VRE were enrolled and received 2 daily doses of ramoplanin (100 mg or 400 mg) or placebo orally for 7 days. The primary end point was the proportion of persons per group from whom VRE were not recovered (VRE-free) on days 7, 14, and 21 after screening. After treatment, VRE-free status was as follows: day 7, none of the 20 patients in the placebo group, and 17 of 21 (P<.001) and 18 of 20 (P<.001) in the 100-mg and 400-mg ramoplanin groups, respectively; on day 14, 2 of 20 patients in the placebo group, and 6 of 21 (P=.134) and 7 of 17 (P=.028), in the 100-mg and 400-mg ramoplanin groups, respectively. By day 21, there were no differences between treatment groups. Adverse events were similar for all treatment groups. Ramoplanin was safe and effective in temporarily suppressing gastrointestinal VRE carriage.

National and regional assessment of the antibacterial soap market: a step toward determining the impact of prevalent antibacterial soaps

BACKGROUND

Consumer antibacterial soaps contain triclosan or triclocarban. No scientific data have been published to suggest that the use of antibacterial agents in household products prevents infection, and triclosan resistance mechanisms have recently been identified. Little data are available regarding the prevalence of antibacterial agents contained in consumer soaps.

METHODS

In a physician-performed survey of 23 stores in 10 states from December 1999 to April 2000, investigators determined the number of national brand liquid and bar soaps and percent of each containing antibacterial agents sold at national chain, regional grocery, and Internet stores.

RESULTS

Antibacterial agents were present in 76% of liquid soaps and 29% of bar soaps available nationally. There were no differences found between national, regional, and Internet stores.

CONCLUSION

Overall, 45% of surveyed soaps contain antibacterial agents. With limited documented benefits and experimental laboratory evidence suggesting possible adverse effects on the emergence of antimicrobial resistance, consumer antibacterial use of this magnitude should be questioned.

Bartonella henselae neuroretinitis in cat scratch disease. Diagnosis, management, and sequelae

OBJECTIVE

This study aimed to report the long-term outcomes of patients treated with an antibiotic drug combination for Bartonella henselae neuroretinitis.

DESIGN

The study design was a retrospective case series.

PARTICIPANTS

Seven consecutive patients with neuroretinitis and cat scratch disease participated.

INTERVENTIONS

Patients underwent medical and ophthalmic evaluations. Blood cultures were obtained, and B. henselae antibody titers were measured. Tuberculosis, Lyme, toxoplasmosis, syphilis, and sarcoidosis were excluded. Patients received oral doxycycline 100 mg and rifampin 300 mg twice daily for 4 to 6 weeks and were observed for an average of 16 months (range, 10-24 months). Formal electrophysiologic testing was performed in three patients after resolution of neuroretinitis.

MAIN OUTCOME MEASURES

The changes in ocular inflammation and visual function associated with treatment were recorded. Follow-up examinations and electrophysiologic testing documented sequelae.

RESULTS

Patients presented following cat exposure with fever, malaise, and blurred vision. Decreased visual acuity (ranging from 20/40 to counting fingers) frequently was associated with dyschromatopsia and afferent pupillary defects. Ophthalmoscopic analysis showed signs of neuroretinitis, including nerve fiber layer hemorrhages, cotton-wool spots, multiple discrete lesions in the deep retina, and stellate macular exudates. B. henselae infection was confirmed with positive blood cultures or elevated immunofluorescent antibody titers or both. Therapy appeared to promote resolution of neuroretinitis, restoration of visual acuity, and clearance of bacteremia. After 1 to 2 years, two eyes had residual disc pallor, afferent pupillary defects, retinal pigmentary changes, and mildly decreased visual acuity. Electrophysiologic studies showed that when compared to the fellow eye, affected eyes had subnormal contrast sensitivity, abnormal color vision, and abnormal visually evoked potentials. Conversely, electroretinograms were normal in all subjects.

CONCLUSIONS

B. henselae is a cause of neuroretinitis in cat scratch disease. Compared to historic cases, doxycycline and rifampin appeared to shorten the course of disease and hasten visual recovery. Long-term prognosis is good, but some individuals may acquire a mild postinfectious optic neuropathy.

Is there a need to treat hypokalaemia associated with intravenous salbutamol infusion?

OBJECTIVES

To investigate the evolution of metabolic effects associated with intravenous salbutamol infusion given together with 2 doses of intramuscular steroids in the treatment of preterm labour.

METHODS

Preterm labour was inhibited with an intravenous infusion of salbutamol in 8 women between 26 and 32(+6) weeks with normal singleton pregnancies. Serum glucose concentration, serum potassium, sodium and insulin concentrations, and total white cell count both during the infusion as well as post-therapy, were plotted against time.

RESULTS

Intravenous salbutamol infusion administered at a rate required to inhibit uterine contractions in preterm labour causes a rise in serum glucose and plasma insulin concentrations. The serum glucose and plasma insulin levels peaked soon after cessation of therapy and took 2-3 hours to come to pre-infusion levels. The decline in serum potassium concentration was gradual and plateaued after 2 hours. Once the salbutamol infusion was stopped the potassium levels were back to normal by 2 hours. There is an increase in total white cell count within an hour of the initiation of therapy.

CONCLUSION

There is no need to administer insulin for hyperglycaemia and/or potassium for hypokalaemia unless the patient is a known diabetic or when a patient needs immediate surgery.

Positron emission tomography in male violent offenders with schizophrenia

The FDG PET brain scans from 31 offenders with schizophrenia and schizoaffective disorder from a maximum security mental hospital were compared with those of normal controls (N = 6) in terms of relative FDG uptake in a range of regions covering frontal and temporal regions. The patient sample was divided into those who had a history of repetitive violent offending (RVO, N = 17) and those without a repetitive violent history (NRVO, N = 14) according to the violence rating of their pre-admission convictions. Reduced FDG uptake was noted at both the right and left anterior inferior temporal (R and L AIT) regions in NRVOs but only at LAIT in RVOs. NRVOs had significantly lower FDG uptake at RAIT than RVOs. The findings suggest that metabolic changes at AIT may be related to different patterns of violent offending in patients with schizophrenia.

Pulp management in dens evaginatus

A 12-yr-old Guamanian girl presented with seven premolars displaying dens evaginatus. The pulp of one tooth was necrotic secondary to fracture of the evagination. Calcium hydroxide treatment was used to induce closure of this root apex, and subsequent routine canal obturation resulted in clinical success. Three teeth had fractured evaginations and compromised coronal pulps, but the radicular pulp tissue was vital. Coronal calcium hydroxide pulpotomy procedures were performed, and root development continued on all three teeth. In one of these teeth, endodontic treatment was completed, and in the other two the radicular pulp remained vital. Three teeth had intact evaginations and vital pulps. In an attempt to protect these evaginations from trauma, composite reinforcements were placed around the evaginations. These pulps remained vital and the roots completed normal development. Early diagnosis and treatment should be sought in cases of dens evaginatus to provide the greatest opportunity for complete root development.

Patterns of virus burden and T cell phenotype are established early and are correlated with the rate of disease progression in human immunodeficiency virus type 1-infected persons

Human immunodeficiency virus (HIV)-1 DNA and RNA levels and T lymphocyte cell surface markers were measured in blood serum and cell fractions from asymptomatic infected patients to find novel virologic and immunologic features in early disease predictive of subsequent clinical disease course. Thirty-two patients with rapid disease progression (rapid CD4+ cell loss and progression to clinical AIDS) were compared with 25 patients with stable infections (constant or rising CD4+ cell counts, no clinical disease manifestations). All HIV-1 burdens measured by polymerase chain reaction were consistently higher in specimens from rapid progressors than slow progressors. For each patient, virus burden remained relatively constant throughout the study period (mean, 42-44 months). Flow cytometry also disclosed stable lymphocyte immunophenotype patterns that correlated strongly with subsequent rapid progression to clinical disease. Thus, in early HIV-1 infection, a constellation of high virus burden and in vivo costimulatory antigen and lymphocyte activation abnormalities is predictive of rapid disease course.

Neuroretinitis, aseptic meningitis, and lymphadenitis associated with Bartonella (Rochalimaea) henselae infection in immunocompetent patients and patients infected with human immunodeficiency virus type 1

Bartonella (Rochalimaea) henselae causes a variety of diseases, including bacillary angiomatosis, peliosis hepatis, lymphadenitis, aseptic meningitis with bacteremia, and cat-scratch disease (CSD). Cases of B. henselae-related disease were collected from September 1991 through November 1993. Patients with suspected CSD, unexplained fever and lymphadenitis, or suspected B. henselae infection who were seen in the Infectious Diseases Clinic at Wilford Hall Medical Center (Lackland Air Force Base, TX) underwent physical and laboratory examinations. In addition to three previously described cases, 23 patients with R. henselae-related infection were identified. The patients included 19 immunocompetent individuals presenting with lymphadenitis (11), stellate neuroretinitis (5), Parinaud's oculoglandular syndrome with retinitis (1), chronic fatigue syndrome-like disease (1), and microbiologically proven adenitis without the presence of immunofluorescent antibodies to B. henselae (1) and four patients infected with human immunodeficiency virus type 1 presenting with isolated lymphadenitis (1), diffuse upper-extremity adenitis (1), neuroretinitis (1), and aseptic meningitis (1). A couple with neuroretinitis and their pet cat, a persistently fatigued patient, and a patient with Parinaud's oculoglandular syndrome were shown to have bacteremia. Tissue cultures were positive for B. henselae in three recent cases of adenitis. Twenty-two patients were exposed to cats. This series further demonstrates the similarities between B. henselae-related diseases and CSD and identifies several new syndromes due to B. henselae.

Presence of neutralizing antibodies to heterologous human immunodeficiency virus type 1 isolates in sera of infected individuals is not predictive of rate of disease progression

These studies were undertaken to examine whether the presence of human immunodeficiency virus type 1 (HIV-1)-neutralizing antibodies in sera of infected individuals would alter the rate of disease progression. HIV-1-infected individuals (n = 87) were initially examined for neutralizing activity in vitro against both laboratory and tissue culture-adapted clinical heterologous HIV-1 isolates. The neutralizing activities of sera were determined by a 90% or greater reduction in HIV-1 p24 levels in vitro. In a cross-sectional analysis of all infected individuals, we observed that sera from asymptomatic individuals neutralized a significantly greater number of heterologous HIV-1 isolates than sera from symptomatic patients. Patients who could be followed up longitudinally (n = 24) were then studied to determine the impact of neutralizing antibodies on the rate of disease progression. We observed no significant difference between the numbers of HIV-1 isolates neutralized in vitro by sera from patients who remained clinically stable and by those from patients who progressed rapidly. Our data indicated that the presence or absence of neutralizing antibodies to heterologous HIV-1 isolates was not associated with the rate of disease progression.

A chemically defined liquid medium that supports primary isolation of Rochalimaea (Bartonella) henselae from blood and tissue specimens

Rochalimaea (Bartonella) henselae is a fastidious, slowly growing, gram-negative bacillus that is an etiologic agent of bacillary angiomatosis, cat scratch disease, and related syndromes. Accumulation of direct microbiologic evidence of the relationship between the organism and the syndromes compatible with cat scratch disease has been hindered by the difficulties in the primary isolation of the organism from infected tissue specimens. A chemically defined liquid medium was developed to support the growth of Rochalimaea species to facilitate study of the organism. This medium was also used successfully to isolate R. henselae from clinical specimens from infected patients and a domestic cat. Recovery of R. henselae in this was more successful than when recovery was attempted on solid agar. This cell-free, extract-free, defined medium additionally supported the growth of Rochalimaea quintana and Afipia felis.

DNA analysis of Huntington's disease in southern Chinese

Allelic frequencies of RFLPs at loci closely linked to the HD gene, D4S95, D4S91, D4S141, and D4S90, were determined in 13 Huntington's disease (HD) patients from nine Chinese families and 129 normal subjects. These were similar for non-HD and HD chromosomes and the HD gene in Chinese is associated with multiple haplotypes. Hence the HD gene probably arose independently in the background haplotypes of the Chinese population. The heterozygosity rates for the two most useful RFLP sites are 0.659 for D4S95-AccI VNTR and 0.494 for D4S141-HindIII. (CAG)n repeat numbers ranged from 12 to 27 in 174 normal chromosomes. In 52 meiotic recombinations, the (CAG)n repeats were stably inherited in normal families. In HD families, 12 of 13 HD patients had expanded (CAG)n repeats of 40 to 58. Additionally, 10 asymptomatic family members had expanded (CAG)n repeats and the inheritance of the expanded repeat was unstable in these families.

Serologic evaluation of human immunodeficiency virus type 1-infected individuals from Argentina and the United States indicates a similar distribution of subgroup B isolates

Utilizing peptides based on the V3 region of gp120, we undertook a serologic examination of human immunodeficiency virus type 1 (HIV-1)-infected individuals from Argentina to determine if prevalent HIV-1 isolates could be identified in this population. Our findings suggest that a similar pool of HIV-1 subgroup B isolates exists in both Argentina and the United States.

Electroencephalography, computed tomography and violence ratings of male patients in a maximum-security mental hospital

A retrospective study of brain investigations of 372 male patients in a maximum-security mental hospital patients is described. All computed tomography (CT) scan and electroencephalography (EEG) reports were collected and rated blind; patients were subsequently divided into 3 groups according to the violence rating of their pre-admission offending behaviour. The 3 groups were similar in their mean age, psychiatric diagnosis, Wechsler Adult Intelligence Scale score and proportions of patients investigated with EEG and CT. In the most violent group, 20% had focal temporal electrical abnormalities on EEG (slowing and/or sharp waves) and 41% had structural abnormalities localised to temporal lobe on CT (dilated temporal horn and/or reduced size of temporal lobe). The corresponding figures for the least violent group are 2.4% and 6.7% respectively. These results suggest that high violence rating scores are associated with temporal lobe abnormalities on CT and abnormal temporal electrical discharges on EEG.

Psychosocial impact of Huntington's disease on Hong Kong Chinese families

Twenty-eight asymptomatic relatives from 7 Chinese families with Huntington's disease (HD) received psychosocial assessment. One third of these subjects (n = 9) had symptoms of anxiety and depression that warranted a Present State Examination (PSE) diagnosis. One quarter of these subjects (n = 8) would contemplate suicide if their predictive testing indicated a high risk of having the disease. This suicidal risk was associated with a PSE diagnosis of depression and a stress-coping repertoire with a high proportion of coping strategies of the avoidance type at the time of interview. Early and close liaison with these subjects for the detection of mental symptoms and provision of counselling on a balanced and positive coping style is essential.

Rapid eye movement sleep behaviour disorder in a Chinese male

A case of rapid eye movement (REM) sleep behaviour disorder (RBD) is reported. The features and treatment of RBD are discussed and the importance of sleep laboratory evaluation on injury during sleep is highlighted.

Huntington's disease in Hong Kong Chinese: epidemiology and clinical picture

In a territory-wide survey of Huntington's disease (HD) in the Chinese population of Hong Kong, 20 patients from 11 families were identified from 1984 to 1991, giving a low period prevalence of 3.7 per 10(6) population. Six patients had died by 1991, hence the point prevalence was even lower, being 2.5 per 10(6) population. The male to female ratio was 3:1. No paternal transmission effect on the age of onset was observed. Apart from these differences, the clinical and pathological features were similar to those seen in the West.

Patterns of psychogeriatric referral and attendance at three different settings in Hong Kong

In order to analyze whether the referral system and nature of care exert any effect on the characteristics of patients, subjects aged 60 or above attending three medical centers on the Hong Kong Island between August and December 1990 were studied with respect to their age, sex, and psychiatric diagnosis. Psychiatric diagnoses were made in 98% of subjects at the psychogeriatric assessment service (PAC) (predominantly chronic organic brain syndrome), in 79.6% at the university psychiatric unit (mainly acute psychiatric problems, substance abuse, and deliberate self-harm), and in 20% at the general outpatient clinic (largely sleep and anxiety-related disorders). There was overrepresentation of the very old (above 80) and underutilization of counseling service at PAC. In Hong Kong, the psychogeriatric needs of the very old and of those with minor emotional disturbances associated with aging, retirement, and bereavement deserve reassessment.

Longitudinal analysis of the humoral immune response to human immunodeficiency virus type 1 (HIV-1) gp160 epitopes in rapidly progressing and nonprogressing HIV-1-infected subjects

Antibody response to conserved human immunodeficiency virus type 1 (HIV-1)IIIB gp160 epitopes was longitudinally examined in HIV-1-infected persons. Twelve hundred individuals were evaluated, and sequential sera from 25 rapidly progressing (RP) and 30 nonprogressing (NP) subjects collected over an average of 4 years were examined. Initial sera from the RP group contained greater reactivity to a gp120 epitope defined by peptide 503-528 than did sera from the NP group (P < .001). Reactivity declined with sequential sera for the RP group, paralleling disease progression. Conversely, antibody recognition to this site developed in 23% of the NP group with time. However, 60% of the NP group never developed a response to this epitope. This suggests sequential examination of antibody response to an epitope within the gp120 carboxyl-terminus may have prognostic significance. No association between antibodies directed against the gp160 epitopes and in vitro neutralizing activity against HIV-1IIIB was observed.

Litigation, sleep, symptoms and disabilities in postaccident pain (fibromyalgia)

Twenty-four patients with chronic postaccident pain were studied with self-rating symptom checklists, polysomnography and disability questionnaires. All except one had fibromyalgia. Eight had litigation resolved (R) while 16 had medicolegal claims still unresolved (UR). Patients from the R group were older, with a longer duration of symptoms and more occupation handicap compared to those from the UR group. There were no significant differences between the 2 groups in other demographic data, nature of accident, symptoms, polysomnographic findings and disability. Medicolegal claim status in these patients did not differentiate the outcome of their symptoms. Implications for litigation, treatment and further studies are discussed.

Removable partial denture framework try-in

Removable partial denture frameworks must fit accurately to function properly and not cause injury to remaining teeth or soft tissue. This article presents a logical method and rationale for seating a removable partial denture framework and a review of several disclosing media used in the try-in procedure.

Syndrome of Rochalimaea henselae adenitis suggesting cat scratch disease

OBJECTIVE

To describe a clinical syndrome of cat scratch disease caused by Rochalimaea henselae, including methods for isolation of the organism from tissue and for identification.

DESIGN

Case series.

SETTING

U.S. Air Force referral hospital infectious diseases clinic.

PATIENTS

Two previously healthy patients.

MAIN MEASUREMENTS AND RESULTS

Two immunocompetent patients who had handled cats developed unilateral upper-extremity adenitis associated with a distal papular lesion and fever. The adenitis and distal lesions persisted and progressively worsened. Cultures of the involved lymph nodes from both patients grew R. henselae, a recently described organism associated with bacillary angiomatosis and peliosis hepatis in human immunodeficiency virus-infected patients and with bacteremia in immunocompromised and immunocompetent hosts. The organism was characterized as oxidase negative and X-factor dependent and had a characteristic pattern in analysis of whole-cell fatty acids differing from Afipia felis, a bacterium that has been associated with cat scratch disease. The identity of the isolate was confirmed by analysis of whole-cell fatty acids using gas chromatography and by amplification of the citrate synthetase gene sequence and analysis of the polymerase chain reaction-amplified product. The organisms were broadly susceptible to a variety of antimicrobials by broth microdilution; however in-vitro resistance to first-generation cephalosporins correlated with clinical failure of therapy.

CONCLUSION

Rochalimaea henselae can be a cause of cat scratch disease in immunocompetent patients.

Significant infections due to Bacillus species following abrasions associated with motor vehicle-related trauma

Non-anthracis Bacillus species are ubiquitous gram-positive spore-forming organisms that were once believed to be nonpathogenic but are now recognized as causing a variety of infections. We report a new aspect of trauma associated with bacillus infection: clinically significant infection by Bacillus species in patients who are involved in motor vehicle accidents and sustain injury related to road contact. Cases were evaluated retrospectively from May 1990 through December 1991. Four patients who had documented infections with Bacillus species and who were involved in motor vehicle accidents associated with road trauma were identified during this period. The antibiotic susceptibility profile of the Bacillus species consistently demonstrated resistance to beta-lactam antibiotics. This series of cases illustrates an additional aspect of disease associated with bacteria of the Bacillus species that should be considered for patients who have sustained injuries from motor vehicle accidents associated with road trauma.

Fabrication of an obstructive sleep apnea prosthesis

Obstructive sleep apnea, a sleep disorder, is becoming more prevalent and requires prompt and effective treatment by the dental and medical specialties. Conservative treatment modalities (ie, intraoral devices that prevent or minimize airway obstruction by the tongue) are recommended for treating mild to moderate forms of OSA. This article describes a simplified technique for fabricating an intraoral OSA prosthesis.

Short- and long-term retention of a nursing home education program on metered-dose inhaler technique

OBJECTIVE

To evaluate an education program on metered-dose inhaler (MDI) technique designed for nurses and trained medication aides (TMAs).

DESIGN

The education program included a handout, a lecture incorporating a videotape on correct inhaler and device technique, and hands-on experience with placebo inhalers. The participants' ability to verbalize and demonstrate correct MDI technique was assessed by the same two-person teams before, immediately after, and two months after the program.

SETTING

Five nursing homes.

PARTICIPANTS

Fifty-six nurses and TMAs practicing in nursing homes.

MAIN OUTCOME MEASURES

Learning and retention.

RESULTS

The participants' mean (+/- SD) verbal and demonstration scores increased immediately after the program by 68 +/- 18 points for verbalization and 47 +/- 16 points for demonstration. The participants were always better at demonstrating than verbalizing MDI technique. The participants' baseline verbal and demonstration scores correlated with the amount learned. Learning was influenced by the individual nursing home (verbal and demonstration) and personal use (demonstration only), but not by academic degree, previous training, past instruction of a patient, or current care of a patient who was receiving inhaler therapy. After two months, the scores were lower than immediately after the program test by 0-92 points for verbalization and 10-80 points for demonstration; however, the mean scores were still significantly greater (p less than 0.05) than the baseline scores. Retention of knowledge on the correct technique was greater for the demonstration component. Retention was influenced only by the nursing home in which the participant worked, and not any of the other variables.

CONCLUSIONS

Our structured education program significantly improved inhaler technique; however, to maintain retention of the material, the program should be frequently repeated.

Unusual case of Klüver-Bucy syndrome in a Chinese boy

Following an encephalopathic illness, a 13-year-old Chinese boy had a partial form of Klüver-Bucy syndrome with emotional disturbance, recent memory loss, hypersexuality, and polyphagia. Other unusual features included narcolepsy, polydipsia, and polyuria. Virologic studies failed to incriminate the etiologic agent, including herpes simplex virus. Brain biopsy of the frontal lobe demonstrated Alzheimer type II astrocytosis.

Diffusion-controlled reactions of enzymes. An approximate analytic solution of Chou's model

Based on Chou's model, a criterion was derived, by which one can judge whether or not the physical picture of the critical spherical shell described by Chou for an enzyme-substrate fast reaction system can emerge. Furthermore, for those reaction systems with such a physical picture, an approximate analytical solution was presented, which can be easily handled to calculate the upper limit of the diffusion-controlled reaction and the corresponding concentration distribution of substrate molecules on the surface of the major protein outside the active site. The results thus obtained are in good agreement with those computed by Chou et al. through the approach of numerical solution. Furthermore, the physical significance of the criterion and its relation to the critical spherical shell are substantiated during the process of derivation, which is very helpful for gaining an insight into this kind of biomolecular system with surprisingly high reaction rates.