Exploring Patient Perspectives Surrounding Telemedicine Versus In-Person Preoperative Visits

IMPORTANCE

Telemedicine was increasingly used to provide patients with an alternative to in-office visits during the COVID-19 pandemic. While previous studies have described the role of telemedicine for preoperative visits for other surgical specialties, the role of this modality in preoperative visits for gynecologic surgery has not been thoroughly explored.

OBJECTIVES

The aims of the study are to explore and compare patient experience, decision making, and satisfaction among women undergoing telemedicine or in-person preoperative visits.

STUDY DESIGN

This was a qualitative study of women who underwent a preoperative appointment with a urogynecologic surgeon or minimally invasive gynecologic surgeon at a single academic institution from April to May of 2021. Data were collected using semistructured phone interviews, which focused on visit content, visit type decision making, surgical preparedness/confidence, and past surgical experiences. Interviews were thematically analyzed until theoretical saturation was achieved in accordance with grounded theory.

RESULTS

Theoretical saturation occurred with 20 interviews. Participants were evenly divided between in-person and telemedicine visits. Major themes included visit content, experience/quality, surgeon perception, and surgical preparedness. Advantages of telemedicine visits were convenience and safety. Advantages of in-person visits were social factors, perceived medical or surgical severity, and preoperative physical examination. Disadvantages for telemedicine visits included technology concerns and difficulty accessing preoperative materials. The disadvantage of an in-person visit was the inability to have family present because of COVID hospital policy restrictions. Participants in both groups felt prepared for surgery and reported high satisfaction with their care.

CONCLUSIONS

Decision making for selecting an in-person or telemedicine visit is complex and involves balancing multiple advantages and disadvantages. Participant experience was similar for both visit types with high satisfaction.

Summary: 2021 International Consultation on Incontinence Evidence-Based Surgical Pathway for Pelvic Organ Prolapse

(1) Background: There is wide variation in the reported prevalence rates for pelvic organ prolapse (POP). There is also wide variation in the rate at which surgical interventions for pelvic organ prolapse are performed, as well as the type of interventions undertaken. As part of the International Consultation on Incontinence (ICI), our committee was tasked to produce evidence-based pathways for the surgical management of POP, any associated stress urinary incontinence (SUI), and bowel dysfunction. (2) Methods: To enable us to generate such evidence, we undertook a thorough search for the POP surgery-related, English-language scientific literature published up to April 2021. (3) Results: The committee evaluated the literature and made recommendations based on the Oxford grading system. (4) Conclusions: This review serves to provide a summary of the 2021 ICI surgical management of an evidence-based prolapse pathway and outline the evidence used to inform this guidance.

What drives success in models predicting heart failure outcome?

Introduction

The development of acute heart failure (AHF) is a critical decision-point in the natural history of heart failure and carries a dismal prognosis. The lack of appropriate risk-stratification tools for AHF patients limits physician ability to precisely tailor patient-specific therapy regimen at this important juncture. Machine learning (ML) based strategies may enhance risk stratification by incorporating analysis of high-dimensional patient data with multiple covariates and novel prediction methodologies.

In this study, we aimed at evaluating the drivers for success in prediction models and establishing an institute-tailored ML-based prediction model for real-time decision support.

Methods

We used a cohort of all AHF patients admitted during a 12 years period including 10,868 patients. A total of 372 covariates were collected from admission to the end of the hospitalization (demographics, lab-tests, medical therapies, echocardiographic and administrative data). Data preprocessing included features cleaning, train-test split, imputation and normalization. We assessed model performance across two axes (1) type of prediction method and (2) type and number of covariates. The primary outcome was one-year survival from hospital discharge. For the model-type axis we experimented with seven different methods: Logistic Regression (LR), Random Forest (RF), Cox model (Cox), XGBoost, a deep neural-network (NeuralNet) and an ensembled model.

Results

Data pre-processing methodology combined with multiple-covariates achieved an out-ofsample AUROC prediction accuracy of more than 80% with almost all prediction models: L1/L2-LR (80.4%/80.3%); Cox (80.1%); XGBoost (80.7%); NeuralNet (80.5%). The number of covariates was a significant modifier of prediction success (p<0.001), the use of multiple-covariates (372) performed better (AUROC 80.4% for L1-LR) compared with using only a set of known clinical covariates (AUROC 77.8%).

Conclusions

The choice of the predictive modeling method is secondary to the multiplicity and type of covariates for predicting AHF prognosis. The application of a structured data pre-processing combined with the use of multiple-covariates results in an accurate, institute-tailored, risk prediction in AHF.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Yad Hanadiv

Estimation of causal effects of binary treatments in unconfounded studies with one continuous covariate

The estimation of causal effects in nonrandomized studies should comprise two distinct phases: design, with no outcome data available; and analysis of the outcome data according to a specified protocol. Here, we review and compare point and interval estimates of common statistical procedures for estimating causal effects (i.e. matching, subclassification, weighting, and model-based adjustment) with a scalar continuous covariate and a scalar continuous outcome. We show, using an extensive simulation, that some highly advocated methods have poor operating characteristics. In many conditions, matching for the point estimate combined with within-group matching for sampling variance estimation, with or without covariance adjustment, appears to be the most efficient valid method of those evaluated. These results provide new conclusions and advice regarding the merits of currently used procedures.

Error adjustments for file linking methods using encrypted unique client identifier (eUCI) with application to recently released prisoners who are HIV+

Incarceration provides an opportunity to test for HIV, provide treatment such as highly active anti-retroviral therapy, as well as link infected persons to comprehensive HIV care upon their release. A key factor in assessing the success of a program that links released individuals to care is the time from release to receiving care in the community (linkage time). To estimate the linkage time, records from correction systems are linked to Ryan White Clinic data using encrypted Unique Client Identifier (eUCI). Most of the records that were linked using eUCI belong to the same individual; however, in some cases, it may link records incorrectly, or not identify records that should have been linked. We propose a Bayesian procedure that relies on the relationships between variables that appear in either of the data sources, as well as variables that exists in both to identify correctly linked records among all linked records. The procedure generates K datasets in which each pair of linked records is identified as a true link or a false link. The K datasets are analyzed independently, and the results are combined using Rubin's multiple imputation rules. A small validation dataset is used to examine different statistical models and to inform the prior distributions of the parameters. In comparison with previously proposed methods, the proposed method utilizes all of the available data and is both flexible and computationally efficient. In addition, this approach can be applied in other file linking applications.

Robust estimation of causal effects of binary treatments in unconfounded studies with dichotomous outcomes

The estimation of causal effects has been the subject of extensive research. In unconfounded studies with a dichotomous outcome, Y, Cangul, Chretien, Gutman and Rubin (2009) demonstrated that logistic regression for a scalar continuous covariate X is generally statistically invalid for testing null treatment effects when the distributions of X in the treated and control populations differ and the logistic model for Y given X is misspecified. In addition, they showed that an approximately valid statistical test can be generally obtained by discretizing X followed by regression adjustment within each interval defined by the discretized X. This paper extends the work of Cangul et al. 2009 in three major directions. First, we consider additional estimation procedures, including a new one that is based on two independent splines and multiple imputation; second, we consider additional distributional factors; and third, we examine the performance of the procedures when the treatment effect is non-null. Of all the methods considered and in most of the experimental conditions that were examined, our proposed new methodology appears to work best in terms of point and interval estimation.

Sacral mesh pullout strength based on suture location for sacrocolpopexy

BACKGROUND

We sought to compare the pullout strengths of the sacral end of the sacrocolpopexy mesh when attached using one suture at the first versus second sacral vertebral level (S1 vs. S2) in female cadaveric pelvises.

METHODS

The sacral vertebrae were isolated in 9 unembalmed female cadavers, and segments of polypropylene mesh were attached to the sacrum using stitches at either the S1 or S2 level. The free end of the mesh was pulled at a constant rate. Maximum tension prior to system failure was recorded for each specimen. Suture pullout strengths between the two groups were compared using the two-sample Wilcoxon rank-sum test.

RESULTS

In all but one specimen, failure of the system occurred at the point of suture attachment to the anterior longitudinal ligament. Among the nine specimens, median pullout strengths were 7.49 lb (interquartile range 7.95) at S1 and 3.15 lb (interquartile range 2.975) at S2 (p = 0.028).

CONCLUSION

The pullout strength of sutures used to attach the sacrocolpopexy mesh to the sacrum is significantly higher at the S1 level than at the S2 level.

Estimating energy expenditure in mice using an energy balance technique

OBJECTIVE

To compare, in mice, the accuracy of estimates of energy expenditure (EE) using an energy balance technique (TEEbal: food energy intake and body composition change) vs indirect calorimetry (TEEIC).

SUBJECTS

In 32 male C57BL/6J mice, EE was estimated using an energy balance (caloric intake minus change in body energy stores) method over a 37-day period. EE was also measured in the same animals by indirect calorimetry. These measures were compared.

RESULTS

The two methods were highly correlated (r(2)=0.87: TEEbal=1.07*TEEIC-0.22, P<0.0001). By Bland-Altman analysis, TEEbal estimates were slightly higher (4.6±1.5%; P<0.05) than TEEIC estimates (Bias=0.55 kcal per 24 h).

CONCLUSION

TEEbal can be performed in 'home cages' and provides an accurate integrated long-term measurement of EE while minimizing potentially confounding stress that may accompany the use of indirect calorimetry systems. The technique can also be used to assess long-term energy intake.

Peroxisome proliferator-activated receptor α (PPARα) activation advances locomotor activity and feeding daily rhythms in mice

Peroxisome proliferator-activated receptors (PPARs) are key mediators of energy homeostasis, and lipid and glucose metabolism that exhibit circadian expression. PPAR activating drugs are used clinically as lipid and glucose-lowering drugs. We evaluated the effect of long-term (11 weeks) PPARα and PPARγ activation using bezafibrate and rosiglitazone, respectively, on metabolism, locomotor activity and feeding rhythms of non-obese mice. We found that bezafibrate, but not rosiglitazone, led to no weight gain and a slight weight loss with reduced epididymal fat pads. Although rosiglitazone had a minor effect on 24-h food intake rhythm, bezafibrate treatment was accompanied by increased amplitude and an advanced acrophase of the 24-h feeding rhythm. Similarly, unlike rosiglitazone, bezafibrate treatment was accompanied by a significantly advanced acrophase of locomotor activity rhythm under constant darkness conditions. As disrupted circadian rhythms lead to obesity, PPARα activation can serve as a clinical target for the modulation of both circadian rhythms and metabolism.

WITHDRAWN: A comment on the application of statistical process control in the surgical arena

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Effects of chronic weight perturbation on energy homeostasis and brain structure in mice

Maintenance of reduced body weight in lean and obese human subjects results in the persistent decrease in energy expenditure below what can be accounted for by changes in body mass and composition. Genetic and developmental factors may determine a central nervous system (CNS)-mediated minimum threshold of somatic energy stores below which behavioral and metabolic compensations for weight loss are invoked. A critical question is whether this threshold can be altered by environmental influences and by what mechanisms such alterations might be achieved. We examined the bioenergetic, behavioral, and CNS structural responses to weight reduction of diet-induced obese (DIO) and never-obese (CON) C57BL/6J male mice. We found that weight-reduced (WR) DIO-WR and CON-WR animals showed reductions in energy expenditure, adjusted for body mass and composition, comparable (-10-15%) to those seen in human subjects. The proportion of excitatory synapses on arcuate nucleus proopiomelanocortin neurons was decreased by ∼50% in both DIO-WR and CON-WR mice. These data suggest that prolonged maintenance of an elevated body weight (fat) alters energy homeostatic systems to defend a higher level of body fat. The synaptic changes could provide a neural substrate for the disproportionate decline in energy expenditure in weight-reduced individuals. This response to chronic weight elevation may also occur in humans. The mouse model described here could help to identify the molecular/cellular mechanisms underlying both the defense mechanisms against sustained weight loss and the upward resetting of those mechanisms following sustained weight gain.

Testing treatment effects in unconfounded studies under model misspecification: logistic regression, discretization, and their combination

Logistic regression is commonly used to test for treatment effects in observational studies. If the distribution of a continuous covariate differs between treated and control populations, logistic regression yields an invalid hypothesis test even in an uncounfounded study if the link is not logistic. This flaw is not corrected by the commonly used technique of discretizing the covariate into intervals. A valid test can be obtained by discretization followed by regression adjustment within each interval.

Architectural differences in the bony pelvis of women with and without pelvic floor disorders

OBJECTIVE

To investigate the hypothesis that the architecture of the bony pelvis differs between women with and without pelvic floor disorders.

METHODS

We designed a case-control study of women who had undergone magnetic resonance imaging (MRI) of the pelvis at our institution. Records were reviewed to identify women with and without pelvic floor disorders (urinary or anal incontinence, other symptoms of urinary tract dysfunction, or pelvic organ prolapse). Pelvimetry techniques were standardized. Relevant measures included transverse diameter of the inlet, angle of the pubic arch, intertuberous diameter, interspinous diameter, sacrococcygeal length, depth of sacral curvature, anteroposterior conjugate, obstetrical conjugate, and anteroposterior outlet. Multiple logistic regression analysis was used to identify women with pelvic floor disorders as a function of their pelvic dimensions, controlling for potentially confounding variables.

RESULTS

Subjects included 59 women with pelvic floor disorders and 39 women without pelvic floor disorders. Women with pelvic floor disorders had a wider transverse inlet, wider intertuberous diameter, wider interspinous diameter, greater sacrococcygeal length, deeper sacral curvature, and narrower anteroposterior outlet. When controlling for the confounding effects of age, race, and parity, we found that a wider transverse inlet (odds ratio 3.425) and a shorter obstetrical conjugate (odds ratio 0.233) were significantly associated with pelvic floor disorders.

CONCLUSION

A wide transverse inlet and narrow obstetrical conjugate are associated with pelvic floor disorders. We speculate that these features of bony pelvic architecture may predispose the patient to neuromuscular and connective tissue injuries, leading to the development of pelvic floor disorders.

Development of an evolutionarily novel structure: fibroblast growth factor expression in the carapacial ridge of turtle embryos

The turtle shell, an evolutionarily novel structure, contains a bony exoskeleton that includes a dorsal carapace and a ventral plastron. The development of the carapace is dependent on the carapacial ridge (CR), a bulge in the dorsal flank that contains an ectodermal structure analogous to the apical ectodermal ridge (AER) of the developing limb (Burke. 1989a. J Morphol 199:363-378; Burke. 1989b. Fortschr Zool 35:206-209). Although the CR is thought to mediate the initiation and outgrowth of the carapace, the mechanisms of shell development have not been studied on the molecular level. Here, we present data suggesting that carapace formation is initiated by co-opting genes that had other functions in the ancestral embryo, specifically those of limb outgrowth. However, there is divergence in the signaling repertoire from that involved in limb initiation and outgrowth. In situ hybridizations with antisense riboprobes derived from Trionyx spiniferous fibroblast growth factor-10 (tfgf10) and Trachemys scripta (T. scripta) fibroblast-growth factor 8 (tfgf8) cDNAs were performed on sections of early T. scripta embryos (< 30 days). Expression of tfgf10 was localized to the mesenchyme subjacent to the ectoderm of the CR. In the chick limb bud, FGF10 is known to be expressed in the early limb-forming mesenchyme and is capable of inducing FGF8 in the AER to initiate the outgrowth of the limb bud. Although the expression of tfgf8 was found in the AER of the developing turtle limb, it was not seen in the CR. Thus, the initiation of the carapace is in agreement with FGF10 expression in the CR, but FGF8 does not appear to have a role in mediating early carapace outgrowth.

[Hypervitaminosis D in institutionalized elderly in Buenos Aires]

Several studies have shown that vitamin D (Vit. D) deficiency in elderly people enhances bone mass loss. Most of these studies have been carried out in areas of low solar irradiation. In order to establish Vit. D circulating levels in elderly people in our community (34 degrees S) and their relationship with bone metabolism, 34 men and 33 women were studied at the end of the summer. These subjects, all residents of nursing homes, had a mean age of 81.9 + 8.1 years (range 69-99). Calcemia, parathyroid hormone (PTH and 25-hydroxyvitamin D (25(HO)D) were measured in serum and bone markers in serum and urine. Bone densitometry (BMD) of cortical and trabecular bone in the forearm (distal third of the radius (R33%) and ultradistal (RUD), respectively) were performed using X-ray absorptiometry. We found: 1) Low serum 25(HO)D (14.4 + 1.7 ng/ml) at summer's end. 40.5% showed levels < 10 ng/ml. 2) Secondary hyperparathyroidism (PTH: 169.4 + 30.9 pg/ml), 3) Hypocalcemia was observed in 34.5% of elderly people, 4) increased bone turnover in the subpopulation with hypovitaminosis D. 5) The serum levels of 25(HO)D correlated with BMD R33% (r = 0.55, n = 54, P < 0.001), with BMD RUD (r = 0.50, n = 54, P < 0.001) and with PTH (r = -0.44, n = 42, P < 0.01). A deficiency of Vit.D was found in our population of elderly people, probably due to diminished epidermic production of its precursors and/or to scant exposure to sunlight in the elderly. The decrease is associated to age. The positive correlation of 25(HO)D with bone mass (cortical and trabecular bone) underscores its importance for the preservation of bone mass. Hyperparathyroidism, triggered by Vit. D deficit, enhances bone loss.

Boys with Asperger's disorder, exceptional verbal intelligence, tics, and clumsiness

Five boys with both Asperger's disorder and Tourette syndrome, exceptional verbal intelligence, and clumsiness are reported. Each presented at early elementary school age with a prominent complaint of social difficulties with peers. History was notable for a flapping stereotypy and the neurological examination revealed motor and/or vocal tics and numerous motor soft signs. Highly specialized interests were characteristics. Language prosody and/or pragmatics was impaired. Despite exceptional verbal intelligence, the children were not, according to their teachers and parents, faring well either socially or academically. Motor difficulties, manifested psychometrically as a significant performance IQ disadvantage, interfered with school performance and social adjustment. Tics, although not noted by parents in the clinical history, compounded their social difficulties. Asperger's disorder in these highly verbal children overlaps with pervasive developmental disorder (PDD) on account of the socioemotional difficulties and stereotypies seen in both. Asperger's disorder and Tourette syndrome overlap in these children on account of the tics. Finally, Asperger's disorder and the right-hemisphere-based learning disorders overlap on account of the visuoperceptual and attentional deficits that can occur in both.

Growth hormone--insulin-like growth factor-I (IGF-I) axis in prepubertal children with chronic renal failure

The hypothalamic-pituitary insulin-like growth factor I (IGF-I) axis was evaluated in 12 children with chronic renal failure (CRF) aged 3.2 to 16.5 yr (mean 9.5) on chronic dialysis, and in 13 renal transplantation patients aged 7.5 to 15.0 yr (mean 11.1). Height standard deviation score (SDS) was -2.8 +/- 0.5 (mean +/- SE) and -3.0 +/- 0.3 SDS (p = NS), and growth velocity was 3.7 +/- 0.4 and 1.5 +/- 0.3 cm/year (p < 0.01), respectively. Mean nocturnal growth hormone (mean GH) and number of pulses > 5 ng/ml in CRF and transplantation children were 4.2 +/- 0.8 vs 2.4 +/- 0.3 ng/ml, p = 0.08 and 1.7 +/- 0.2 vs 1.0 +/- 0.2, p < 0.05, respectively. In transplant children there was a positive correlation between mean GH and growth velocity (p < 0.02). GH peak response and the area under the curve post GH releasing hormone test were significantly higher in CRF and transplant children treated with deflazacort (new steroid derived from prednisolone) vs transplant children treated with methylprednisone. Mean serum IGF-I levels were -0.5 +/- 0.2 SDS for chronological age (CA) in CRF patients and +0.8 +/- 0.2 SDS(CA) in transplant patients, p = NS. In the latter, serum IGF-I values were positively correlated with growth velocity (p < 0.02) and negatively correlated with methylprednisone dose (p < 0.05).

CONCLUSIONS

Patients with CRF and growth retardation have a higher number of GH peaks and slightly elevated mean GH levels compared to transplant patients. After renal transplantation GH secretion may be influenced by glucocorticoids as shown by the lower GH response to GHRH which improved with deflazacort and the inverse correlation between methylprednisone dose and IGF-I levels.

Long-term administration of a sucrose-rich diet to normal rats: relationship between metabolic and hormonal profiles and morphological changes in the endocrine pancreas

The aim of the present investigation was to study normal rats fed a sucrose-rich diet (SRD) for a prolonged period (up to 30 weeks) (1) to obtain additional data on the hormonal and metabolic patterns induced by this treatment and (2) to provide information on changes taking place in the pancreatic islet cell populations. We found that long-term feeding with a SRD resulted in a steady state of hypertriglyceridemia and hyperglycemia in which insulin levels remained unchanged and unable to compensate for the increased demands of the developing metabolic changes. The endocrine pancreas showed a significant increase of both islet number and B-cell area, as well as changes in the profile of islet cell distribution. However, these changes were not accompanied by an increase in the pancreatic content of immunoreactive insulin (IRI). It may therefore be postulated that the newly emerged B-cell mass has some sort of derangement with the increased insulin demand resulting from insulin resistance induced by the long-term SRD feeding. Thus, feeding a SRD to normal rats may prove to be an attractive animal model for studying the role of environmental nutritional factors in the unsettled issue of the relationship between insulin resistance and relative insulin deficiency. The model might provide key information for understanding the pathophysiology of human diseases such as type II diabetes, dyslipidemia, and a number of entities included in so-called syndrome X.

Cellular localization of antiviral polyoxometalates in J774 macrophages

The cellular localization of the polyoxometalates, K12H2[P2W12O48].24H20 (JM 1591), K10[P2W18-Zn4(H2O)2O68].20H2O (JM 1596), and [Me3NH]8[Si2W18Nb6O77] (JM 2820) were examined in cultured J774 cells by inhibition of cellular uptake of acetylated low-density lipoprotein (LDL) and by electron microscopy. All three polyoxometalates inhibited the cellular uptake of acetylated LDL, suggesting that the polyoxometalates block the association of acetylated LDL with cellular scavenger receptors. Fluorescence microscopy showed increased numbers of vacuoles in the presence of polyoxometalates, suggesting their uptake by cells. Using scanning electron microscopy (SEM), no significant cell surface morphological differences were observed between treated and non-treated J774 cells, suggesting that the compounds are not toxic to J774 cells up to a concentration of 200 micrograms/ml. Transmission electron microscopy (TEM) revealed large amounts of high electron dense granules were observed in the ramifying system of tubular cavities and vacuoles. TEM-energy dispersive spectroscopy (EDS) X-ray microanalysis was unable to differentiate the dense particles, most likely because the amount of tungsten in the cells was below the limit of detection. X-ray microanalysis conducted using the SEM-wavelength dispersive spectroscopy (WDS) detected tungsten, averaging 0.45 +/- 0.16% (mean +/- S.D.), in the J774 cells treated with JM 2820, suggesting that this polyoxometalate was taken up by the macrophages or was bound to their surface. Polyoxometalates interact at the cell surface and appear to be taken up by J774 macrophages. The cellular localization of polyoxometalates may be associated with anti-HIV activity.

Hypothalamic-pituitary thyroid abnormalities in children after renal transplantation

Patients with a successful renal transplant may have abnormalities in thyroid function. We evaluated serum thyroid hormone levels, serum thyrotropin (TSH) response to thyrotropin-releasing hormone (TRH), and the circadian pattern of serum TSH in 18 children aged 6.6-19.4 years (median 12.6 years), 4.0 +/- 2.9 years after renal transplantation. In 14 children, immunosuppressive therapy included methylprednisone [mean (+/-SD) 0.17 +/- 0.05 mg/ kg per day], while in 11 it included deflazacort (0.32 +/- 0.1 mg/kg per day). Seven children were studied twice, under methylprednisone and again while on deflazacort therapy. Mean total and free thyroxine (T4) values were significantly below the mean control levels (total T4 108.5 +/- 21.5 vs. 118.7 +/- 22.1 nmol/l, P < 0.05 and free T4 14.4 +/- 4.0 vs. 18 +/- 4.9 pmol/l, P < 0.001). Morning basal TSH levels were within the normal range. The mean TSH increment after TRH was 4.4 +/- 3.5 mU/l, significantly lower than that of controls (10.8 +/- 4.26, P < 0.001). Of 7 patients on methylprednisone, 4 had nocturnal TSH surges below the normal range (95% confidence limits 47%-300%); this occurred in 3 of 8 patients on deflazacort therapy. The TSH response to TRH was correlated with deflazacort dose. Patients on methylprednisone and deflazacort therapy had similar thyroid alterations. Our findings support the hypothesis that after renal transplantation some children have hypothalamic-pituitary thyroid abnormalities in which glucocorticoids may play a significant role.

Dietary fish oil normalize dyslipidemia and glucose intolerance with unchanged insulin levels in rats fed a high sucrose diet

The aim of this study was to investigate the relationship between the lipid-lowering effects of fish oils and concomitant consequences on glucose tolerance and insulin sensitivity in an experimental animal model of hypertriglyceridemia induced by high sucrose intake. To achieve this goal, male Wistar rats were fed a semi-synthetic sucrose rich diet (SRD) (w/w: 62.3% sucrose, 8% corn oil, 17% protein) for 90 days. At the time, a well established and permanent hypertriglyceridemia accompanied by glucose intolerance was present. After that, one half of the animals continued on the SRD up to 120 days. The other half received an SRD in which the source of fat was substituted by cod liver oil (w/w 7% CLO plus 1% corn oil) from day 90 to 120 (SRD+CLO). Control rats were fed a semi-synthetic diet (CD) (w/w: 62.5% corn starch, 8% corn oil, 17% protein) throughout the 120 days experimental period. Results obtained after the experimental period show that the hypertriglyceridemia and glucose intolerance ensuing long term feeding normal rats with a sucrose-rich diet could be completely reversed mediating no change in circulating insulin levels by shifting the source of fat in the diet from corn oil to cod liver oil. These findings suggest that manipulation of dietary fats may play a role in the management of the lipid disorders associated with glucose intolerance and insulin resistance.

Growth acceleration in children with chronic renal failure treated with growth-hormone-releasing hormone (GHRH)

Growth retardation is a prominent clinical manifestation in children with chronic renal failure (CRF). Nine children with CRF (3 on conservative treatment; 3 on dialysis and 3 after renal transplantation) aged 1.6 to 14.0 (x +/- SE: 8.1 +/- 1.4) years, were treated with twice daily subcutaneous injections of 26 +/- 2.4 micrograms/kg/day growth-hormone-releasing-hormone [GHRH (1-29) NH2 Serono (Geref)] during 3 to 6 months. Mean serum urea and creatinine remained stable, although 2 patients on conservative treatment showed a moderate increase in serum creatinine. At the start of the study, height SDS was -2.2 +/- 0.2 (x +/- SE), growth velocity was 4.5 +/- 1.0 cm/year (-2.3 +/- 0.6 DS for chronological age) and growth hormone (GH) response to acute GHRH test (1 microgram/kg IV) was 62 +/- 17.5 ng/ml. Five patients increased height velocity from 3.8 +/- 0.7 to 8.0 +/- 1.2 cm/year (paired t test, p < 0.05). The peak GH response to GHRH was significantly higher in the group of growth non-responders than in the responders (p < 0.05). In conclusion, 5 out of 9 short children with CRF, 3 on conservative treatment, 1 on dialysis and 1 post renal transplantation, showed improved growth in response to GHRH therapy. No consistent effect on renal function was detected. GHRH may be an alternative therapy to increase growth velocity in patients with CRF.

Effect of moderate levels of dietary fish oil on insulin secretion and sensitivity, and pancreas insulin content in normal rats

The effect of omega-3 fatty acids derived from fish and marine mammals on subjects with normal glucose tolerance is still unclear. The aim of the present study was to test whether the hypolipidemia that follows the chronic administration of cod liver oil, rich in polyunsaturated fatty acids (omega-3), to normal rats is accompanied by changes in glucose metabolism, insulin secretion and sensitivity, and pancreatic insulin content. To achieve this goal, male Wistar rats were fed with a semisynthetic diet (w/w): 62.5% cornstarch, 7% cod liver oil plus 1% corn oil, and 17% protein (CD + CLO). Control rats were fed with the same semisynthetic diet with the only exception that the source of fat was 8% (w/w) corn oil (CD). Both diets were administered ad libitum for 1 month. At the end of the experimental period, the results obtained were as follows (mean +/- SEM): serum triacylglycerol (mM): CD + CLO 0.21 +/- 0.04 vs. CD 0.58 +/- 0.05 (p < 0.05); free fatty acids (microM): CD + CLO 257 +/- 20 vs. CD 288 +/- 22 (p = NS); total cholesterol (mM): CD + CLO 1.13 +/- 0.09 vs. CD 1.82 +/- 0.06 (p < 0.05); high-density lipoprotein cholesterol (mM): CD + CLO 0.58 +/- 0.08 vs. CD 1.07 +/- 0.04 (p < 0.05); plasma glucose (mM): CD + CLO 6.30 +/- 0.29 vs. CD 6.28 +/- 0.10 (p = NS); liver triacylglycerol (mumol/liver): CD + CLO 104.1 +/- 11.4 vs. CD 136.8 +/- 4.3 (p < 0.05); glycogen (mumol/g wet weight): CD + CLO 298.3 +/- 21.0 vs. CD 297.0 +/- 19.0 (p = NS); glucose-6-phosphate dehydrogenase (U/liver): CD + CLO 37.9 +/- 2.2 vs. CD 58.8 +/- 5.0 (p < 0.05); triacylglycerol secretion (nmol/min/100 g body weight): CD + CLO 101.0 +/- 2.0 vs. CD 166.0 +/- 9.7 (p < 0.01); removal of fat emulsion (K2% min-1): CD + CLO 15.0 x 10(-2) +/- 0.8 x 10(-2) vs. CD 8.2 x 10(-2) +/- 0.2 x 10(-2) (p < 0.01); intravenous glucose tolerance (kg 10(-2): CD + CLO 2.68 +/- 0.37 vs. CD 2.70 +/- 0.14 (p = NS); immunoreactive insulin (microU/ml/ min): with the area under the curve between 0 and 30 min CD + CLO 544 +/- 60 vs. CD 1,050 +/- 38 (p < 0.05), with the area under the curve between 0 and 60 min CD + CLO 1,188 +/- 150 vs. CD 2,160 +/- 137 (p < 0.05), and pancreas insulin content (microU/mg pancreas): CD + CLO 1.85 +/- 0.29 vs. CD 2.04 +/- 0.12 (p = NS). In conclusion, the present study shows that the strong hypolipidemic effect produced by the administration of low doses of fish oil to normal rats is accompanied by a significant reduction of plasma insulin levels without changes in glucose tolerance. Since no changes in pancreatic insulin content were observed, lower plasma insulin levels, both basal and after an intravenous glucose challenge, may be the result of an increased peripheral insulin sensitivity in normoglycemic animals.

Vasodilatory effects of propylthiouracil in patients with alcoholic cirrhosis

BACKGROUND/AIMS

An experimental study has shown that propylthiouracil increases portal blood flow in normal rats. Whether propylthiouracil has a similar effect in patients with alcoholic cirrhosis remains to be demonstrated. The aim of this study was to evaluate the effects of oral propylthiouracil (300 mg) on systemic and portal hemodynamics in patients with alcoholic cirrhosis.

METHODS

Plasma propylthiouracil levels were also measured by high performance liquid chromatography in five patients with alcoholic cirrhosis. In eight patients with cirrhosis, mean arterial pressure, cardiac output and portal blood flow were evaluated before and after placebo and propylthiouracil administration. Hemodynamic measurements were performed by the Doppler technique. The plasma peak level of propylthiouracil was achieved at 1.4 +/- 0.1 h in patients with alcoholic cirrhosis. This time was chosen to express hemodynamic changes.

RESULTS

Propylthiouracil administration caused a significant increase in portal blood flow (+16.5%, p < 0.05) in patients with alcoholic cirrhosis. This effect was associated with a mild and significant rise in cardiac output (from 5.8 +/- 0.2 to 6.1 +/- 0.3 l/min, p < 0.05) and a decrease in peripheral vascular resistance (from 1171 +/- 69 to 1070 +/- 67 dyn . s-1 . cm-5, p < 0.01). A significant correlation was observed between changes in portal blood flow and peripheral vascular resistance (r = 0.79, p < 0.05). No significant changes were observed after placebo.

CONCLUSIONS

Our findings show that propylthiouracil has a vasodilatory effect in patients with alcoholic cirrhosis. We postulate that this effect could be the mechanism by which propylthiouracil decreases hypermetabolic state, and increases oxygen delivery to the liver, in patients with alcoholic liver diseases.

Thyroid function and serum IGF-1 in children before and after liver transplantation

We report results of serum thyroid hormone and IGF-1 concentrations in 20 children, 1.2 to 13.6 years old, with various degrees of chronic liver dysfunction (CLD), before and after successful orthotopic liver transplantation (OLT). Ten children presented with moderate chronic liver disease (CLD-M) with prothrombin time (PT) > 50% and serum albumin concentration > 3 g/dl; 7 children had severe chronic liver disease (CLD-S) with PT < 50% and serum albumin concentration < 3 g/dl; and 7 children who had received an OLT, who had normal liver function at the time of the study. Four of the latter group were also studied before OLT. Patients with CLD-M had normal mean +/- SD serum levels of total T3 (2.0 +/- 0.7 nmol/l), total T4 (125 +/- 25.9 nmol/l) and fT4 concentrations (16 +/- 2.8 pmol/l). In contrast, children with CLD-S showed a significant decrease in thyroid hormones together with normal basal TSH values (T3 0.8 +/- 0.0 nmol/l; T4 45.6 +/- 19.5 nmol/l; fT4 7.4 +/- 1.1 pmol/l; TSH 3.8 +/- 0.9 mU/l). Patients who received a successful OLT showed mean peripheral thyroid hormone concentrations significantly higher than CLD-S patients (T3 1.7 +/- 0.7 nmol/l, p < 0.005; T4 92.8 +/- 18.2 nmol/l, p < 0.001; fT4 14.5 +/- 3.1 pmol/l, p < 0.001). A significant correlation was found between thyroid hormone levels and PT or serum albumin. In the nine patients with CLD-M and CLD-S in whom serum IGF-1 concentration was measured, values found (mean +/- SD 0.08 +/- 0.05 U/ml) were below the 95% confidence limit of matched controls.

Multiphasic metabolic changes in the heart of rats fed a sucrose-rich diet

Long term feeding a sucrose-rich diet (SRD) to normal Wistar rats led to multiphasic changes in the activity of the pyruvate dehydrogenase complex (PDH), characterized by a significant decrease in PDHa (active form) in the short term on SRD (3 weeks) when compared to control rats fed the standard chow (STD). Although PDHa returned spontaneously to control values in the medium term (6-8 weeks) on SRD, an even more pronounced decrease was recorded when rats were kept long term on the SRD (15 weeks). Low PDHa levels recorded in the short and long term were accompanied by a two fold increase in heart acetyl-CoA concentration and the acetyl-CoA/CoASH ratio. Tissue long-chain acyl-CoA and triacylglycerol levels were also significantly higher in SRD fed rats. Spontaneous normalization of all the above metabolic parameters was observed during the medium term on SRD. Glucose-6-phosphate levels remained within control values during the short and medium term, in contrast to a two fold increase recorded in the long term on SRD. Glycogen concentrations were found moderately elevated only in the long term. Citrate concentrations were slightly increased in the short and greatly in the long term, and the fructose-2,6-bisphosphate/citrate ratio was found significantly decreased only during the long term on SRD. After 3 weeks on SRD, the protal vein Insulin/Glucagon (I/G) molar ratio was three times higher in SRD than STD rats, as opposed to an unchanged I/G ratio found in the long term.(ABSTRACT TRUNCATED AT 250 WORDS)

Autologous cord blood transfusion

Newborn piglets were exsanguinated (60% of blood volume) and retransfused 1 h later. One test group received adult pig red blood cells, the other piglet cord blood cells; controls were infused with plasma. While all controls died, satisfactory results were achieved in piglets transfused with either adult or foetal blood. The feasibility of collecting human cord blood for transfusion was assessed in 100 samples of human cord blood. Blood was collected aseptically and aerobic and anaerobic cultures set up. All samples of cord blood were sterile, and all were Mycoplasma negative. Coagulation parameters were analysed in eight cord plasma samples stored at -20 degrees C for 45 days. No significant abnormalities were found immediately after birth or after storage.

Hyperinsulinemia in normotensive offspring of hypertensive parents

Hyperinsulinemia and insulin resistance have been extensively reported in adult patients with essential hypertension. The aim of this study was to examine serum glucose and insulin levels both in the fasting state and after 0.25 g/kg IV glucose and to relate those findings to the status of intracellular Na+ and red blood cell Na(+)-Li+ countertransport in a population of 21 normolipemic normotensive offspring of hypertensive parents (N-EH) and 13 control children without a history of parental essential hypertension or diabetes mellitus matched for age, body mass index, and pubertal stage. Offspring of hypertensive parents presented significantly higher serum insulin levels both after an overnight fast (17.4 +/- 1.6 versus 11.6 +/- 1.6 microU/mL in control [mean +/- SEM], P < .01) and after intravenous glucose than control subjects (insulin area under the curve, 3015 +/- 310 and 2057 +/- 234 microU/mL per hour, respectively, P < .01). No relation could be established between the high red blood cell Na(+)-Li+ countertransport (343 +/- 22 versus 215 +/- 15 mumol/L per hour, N-EH versus control; P < .002) or high intracellular Na+ (9.8 +/- 0.28 versus 8.7 +/- 0.36 mEq/L, N-EH versus control) and hyperinsulinemia found in children of hypertensive parents. We conclude that the time precedence of hyperinsulinemia (and possibly insulin resistance) over the appearance of clinical hypertension in a high-risk population further supports the contention that an abnormal insulin action may play a pathogenetic role in essential hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

Etiology of acute pelvic inflammatory disease proven by laparoscopy

BACKGROUND

Only a few studies have investigated the etiology of acute pelvic inflammatory disease (PID) in laparoscopy-proven cases using pelvic samples for culture. Most of these studies were conducted in North America and Scandinavia.

GOAL OF THE STUDY

To study the microbial etiology of laparoscopy-proven acute pelvic inflammatory disease in Israeli women.

STUDY DESIGN

A prospective survey of women admitted to a hospital for treatment of acute pelvic inflammatory disease. All diagnoses were laparoscopy confirmed. Specimens for culture were obtained from the pelvic cavity via the laparoscope, and two serum samples were sent for serologic studies.

RESULTS

Forty patients were studied. Their mean age was 34.4 years of age, and 27.5% had a history of PID. Chlamydia trachomatis infection was diagnosed in 14 (35%) patients (group A). Facultative and/or anaerobic bacteria were isolated from pelvic specimens of 7 (17.5%) patients (group B), one of these patients also had positive chlamydial serology. Mycoplasma hominis was cultured from a pelvic specimen of one woman, and herpes simplex virus grew from a pelvic sample of another patient in whom C. trachomatis was also found. In 19 (47.5%) women, the microbial etiology could not be determined (group C). In no case was Neisseria gonorrhoeae isolated. Stage I (mild) PID was diagnosed most often in group A (75% vs. 14% in group B [P < 0.02]), whereas the opposite was true for stage III (severe) PID (71.4% in group B vs 25% in group A [P = 0.07]). Tubal abscess was mainly diagnosed in group B patients (57% vs 16.6% in group A [P = 0.09]).

CONCLUSION

In Israel, C. trachomatis is the most common cause of PID, while gonococci are rarely involved in this infection.

Carriage of methicillin-resistant Staphylococcus aureus by non-hospitalized subjects in Israel

The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in the anterior nares and axilla was studied in 920 non-hospitalized subjects: 350 drug addicts, 350 individuals presenting at a hospital emergency room for various reasons, and 220 hospital health care workers. S. aureus was isolated from 105 (11.4%) subjects, in six (6.3%) of whom the isolates were methicillin-resistant. The isolation rate of the organism and the prevalence of resistant strains in the different subgroups were, respectively: drug-addicts, n = 32 (9.1%), n = 2 (6.9%); emergency room patients, n = 36 (10.2%), n = 1 (3.2%); and hospital health care workers, n = 37 (16.8%), n = 3 (8.5%). Our findings suggest that MRSA remains uncommon in the community, while the prevalence of S. aureus carriage (including methicillin-resistant strains) in hospital personnel is quite similar in divergent geographical areas.

Effect of therapy with a new glucocorticoid, deflazacort, on linear growth and growth hormone secretion after renal transplantation

Deflazacort is an oxazoline compound derived from prednisolone with similar antiinflammatory effects but fewer side effects. We studied changes in kidney function, growth velocity, weight/height ratio, and growth hormone secretion before and a year after substitution of deflazacort for methylprednisone in nine patients aged 9 to 15 years, 4 years after renal transplantation; all were in Tanner pubertal stage 1. Methylprednisone (mean +/- SEM: 0.2 +/- 0.02 mg/kg per day) was replaced by deflazacort (0.3 +/- 0.03 mg/kg per day) for a mean period of 15 months. Serum creatinine and calculated creatinine clearance did not change significantly during deflazacort treatment. Growth velocity increased from 1.5 +/- 0.3 to 3.2 +/- 0.5 cm/yr (p < 0.005) in the nine patients. Weight/height ratio decreased from 28.4% +/- 8.5% to 16% +/- 6.7% (p < 0.005). Cushingoid appearance decreased in all patients. Mean spontaneous growth hormone secretion increased from 2.5 +/- 0.4 to 4.4 +/- 1.2 ng/ml (p < 0.05). Our findings indicate that immunosuppressive treatment with deflazacort is as effective as methylprednisone and is associated with fewer side effects.

"In vitro" effects of insulin on the PDH complex of the isolated perfused heart of rats fed a sucrose-rich diet

We have recently reported that the "in situ" myocardial concentrations of the active form of the Pyruvate Dehydrogenase Complex (PDHa) were significantly decreased in hearts obtained from normal rats fed for 3 weeks on an isocaloric sucrose rich (63%) diet (SRD) when compared to age matched controls fed on the standard laboratory chow (STD). Since, on the one hand SRD rats present glucose intolerance and impaired "in vivo" insulin action and, on the other hand the effects of insulin on the interconversion of heart PDH remains a controversial matter, we found it relevant to study the effects of insulin on the PDH complex in the "in vitro" perfused (Langendorff technique) heart preparations obtained from SRD rats. After a 35 minute perfusion period with 5.5 mM glucose as the only nutrient in the perfusate, PDHa as a percentage of total PDH was found to remain significantly lower in SRD hearts (M +/- SEM 32.6 +/- 2.3) when compared to STD hearts (68.3 +/- 4.6, P less than 0.05) in spite of comparable total PDH activities in both groups of animals. Although the addition of insulin to the perfusate (20 mu/ml) resulted in a significant increase in the percentage of PDHa (45.8 +/- 3.4) of SRD heart, values attained still remained significantly lower than those obtained in STD controls (67.5 +/- 3.6; P less than 0.05). Simultaneously, the addition of insulin to the perfusate, significantly reduced the Acetyl-CoA/CoASH ratio in SRD hearts although this ratio remained still much higher than those observed in STD controls under the same experimental conditions.

Peritonitis caused by Pseudomonas putrefaciens in patients undergoing continuous ambulatory peritoneal dialysis

Three cases of peritonitis caused by Pseudomonas putrefaciens in patients undergoing continuous ambulatory peritoneal dialysis are described. In two cases asymptomatic colonization of the dialysate preceded overt infection. All patients responded successfully to standard antibiotic therapy with gentamicin or ofloxacin. This is the first report of peritonitis caused by P. putrefaciens.

Evidence of hypothalamic-pituitary thyroid abnormalities in children with end-stage renal disease

Patients with end-stage renal disease may have abnormalities of growth and of gonadal and thyroid hormones, so we attempted to determine the mechanisms that may be involved in the altered thyroid function. We evaluated serum thyroid hormone levels, their changes immediately after hemodialysis, the serum thyrotropin (thyroid-stimulating hormone (TSH) response to thyrotropin releasing hormone, and the circadian pattern of serum TSH in nine children with end-stage renal disease who were between 7 1/2 years and 17 years 1 month of age. Seven patients had been receiving hemodialysis for a median of 3.3 years; the other two were receiving continuous ambulatory peritoneal dialysis. Four patients had low serum total thyroxine (T4) values, and all nine had low free T4 values. Mean concentrations of total T4, free T4, and total triiodothyronine (T3), which were significantly less than normal before hemodialysis, returned to normal levels immediately after dialysis. Postdialysis thyroid hormone increases did not correlate with the decrease in weight or the increase in hematocrit observed immediately after dialysis. All but one patient had basal TSH levels within the normal range. Three patients had a deficient TSH response to thyrotropin releasing hormone, and the TSH response was prolonged in all of them. The mean (+/- SD) nocturnal TSH surge was 50 +/- 68%. Five of the eight patients studied had a nocturnal TSH surge below the normal range (95% confidence limits 47% to 300%). Serum free T4 values correlated with the TSH nocturnal surge (r, 0.73; p less than 0.05). Our findings support the hypothesis that some patients with end-stage renal disease have central hypothyroidism.

Prevalence of sexually transmitted pathogens among women attending a methadone clinic in Israel

OBJECTIVE

To assess the prevalence of sexually transmitted pathogens in drug-addicted women in Tel Aviv, Israel.

DESIGN

A prospective study conducted between March and July 1987.

SETTING

A methadone clinic in Tel Aviv, Israel.

SUBJECTS

Sixty four asymptomatic female drug addicts were studied; 38 of them were declared practising prostitutes.

METHODS

Cervical specimens were obtained for cultures, and blood samples were drawn for serological tests. Demographic data and sexual histories were obtained using a standard questionnaire.

RESULTS

Chlamydia trachomatis was detected in the cervix of 25% of women; 98% had antibody titres (greater than 1:64). Mycoplasma hominis and Ureaplasma urealyticum were isolated in 57% and 65% respectively. Gardnerella vaginalis was detected in 17% of women, and herpes simplex virus was cultured from two prostitutes. Five per cent of women were carriers of HBsAg, while 57% had HBSs and/or HBc antibodies. Only one prostitute had specific treponemal antibodies. In no case were gonococci or group B streptococci isolated, and HIV serology was invariably negative.

CONCLUSION

Chlamydia and genital mycoplasmas appear to be the prevailing pathogens in Israeli drug-addicted women, while gonococci and Treponema pallidum occur only rarely.

Biochemical abnormalities in the heart of rats fed a sucrose-rich diet: is the low activity of the pyruvate dehydrogenase complex a result of increased fatty acid oxidation?

We have previously shown that normal Wistar rats fed for 3 weeks with an isocaloric sucrose-rich (63%) diet (SRD) develop high levels of plasma free fatty acids and increased triacylglycerol content in the myocardium. We are now reporting that these changes are accompanied by remarkably low levels of the active form of the pyruvate dehydrogenase complex (PDHa; mean +/- SEM, 37.2% +/- 3.7% of the total activity) when compared with levels found in hearts donated by control rats fed the standard chow diet (STD; 71.0% +/- 2.8%; P less than .01). Increased concentrations of both long-chain acyl-CoA (0.21 +/- 0.03 v 0.06 +/- 0.01 mumol.g dry weight-1 found in STD; P less than .01) and acetyl-CoA (0.17 +/- 0.05 v 0.09 +/- 0.01 found in STD; P less than .01), as well as a relative decrease in coenzyme A (CoASH) (0.21 +/- 0.02 v 0.32 +/- 0.05 from STD; P = NS), resulting in an increased acetyl-CoA/CoASH ratio (0.80 +/- 0.13 v 0.29 +/- 0.03 in STD; P less than .01) may have stimulated the PDH kinase, leading in turn to an inactivation of the PDH complex. The above enzymatic and metabolic changes in the in situ heart of SRD-fed rats were still present after perfusing them for 35 minutes with a Krebs-Henseleit buffer containing 11 mmol/L glucose as the only exogenous substrate.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence of cryptosporidiosis in Israeli children with diarrhoea

In a prospective study, Cryptosporidium oocysts were detected in seven (3.25%) immunocompetent children with diarrhoea. The predominant clinical features were watery diarrhoea and vomiting. The patients' mean age was 19 years and infection was more common in late summer-autumn than in the rest of the year. This first survey on cryptosporidiosis in Israeli children has shown a prevalence similar to that observed in other developed countries.

Varied presentations of sporadic group A streptococcal bacteremia: clinical experience and attempt at classification

The epidemiologic, clinical, and laboratory aspects of group A streptococcal bacteremia were studied in 33 patients seen at two urban hospitals in the Tel Aviv (Israel) area, over an 8-year period. Most patients (two-thirds) were female. Clinically significant bacteremia was observed in 26 patients, two of whom acquired their infection (puerperal sepsis) during hospitalization. A portal of entry, mainly cutaneous, was recognized in 61% of the patients, and a chronic underlying condition was observed in 69%. The case-fatality rate was 27%, with death occurring predominantly in patients admitted with shock or cryptogenic bacteremia. Our clinical experience and literature review show that the presentation of group A streptococcal bacteremia is diverse, with transient bacteremia of uncertain clinical significance on one end of the spectrum and overwhelming sepsis on the other. A practical classification of the various clinical forms of group A streptococcal bacteremia is proposed.

Cultured skin fibroblasts in schizophrenia: quantitative two-dimensional electrophoresis

Recent developments in the standardization and commercial availability of quantitative high resolution two-dimensional electrophoresis make feasible the systematic search for protein alterations characteristic of psychiatric disorders. To avoid the effects of such variables as drug intake or diet on quantitative protein makeup that might obscure its relationship to diagnosis, the investigators studied cultured fibroblasts derived from the skin biopsies of psychiatric patients. Although the method was able to resolve human fibroblast protein mixtures into 1,125 spots, no significant deviation in the quantitation of any individual spot was found to characterize the fibroblasts of patients with schizophrenia.

Cross resistance to ciprofloxacin and other antimicrobial agents among clinical isolates of Acinetobacter calcoaceticus biovar anitratus

Using an agar dilution assay, for 66 of 104 (63.5%) clinical isolates of Acinetobacter calcoaceticus biovar anitratus, the MIC of ciprofloxacin was greater than or equal to 1.0 micrograms/ml. Cross resistance was demonstrable to ciprofloxacin and gentamicin (P less than 0.001), amikacin (P less than 0.01), cefotaxime (P less than 0.001), azlocillin (P less than 0.001), ceftazidime (P less than 0.001), trimethoprim-sulfamethoxazole (P less than 0.001), and minocycline (P less than 0.05). The mean MIC of ciprofloxacin for drug-susceptible isolates was consistently lower than that for resistant isolates; however, these differences were significant only for amikacin (P = 0.036).

Cellular pharmacology of doxorubicinol alone and combined with verapamil in pancreatic cancer cell lines

The cellular accumulation/retention and cytotoxicity of doxorubicinol (DOXOL) were determined in three pancreatic cancer cell lines, which display primary or intrinsic resistance to doxorubicin (DOX). The studies reported here were performed in the presence and in the absence of verapamil, a calcium antagonist which we have previously shown to potentiate the cytotoxicity of DOX in our panel of pancreatic cancer cell lines. The accumulation/retention of DOXOL, as assayed by HPLC, was not enhanced by 6.6 microM verapamil in these cell lines. No aglycone metabolites were detected in any of the cell lines. The DOXOL cytotoxicity was enhanced 2.0 to 2.9-fold in two of the cell lines. The dose-related accumulation of DOX, as compared to that of DOXOL, was 7.5 to 10-fold greater at 0.1 microM, 3.6 to 6.5-fold greater at 1.0 microM, and 1.9 to 2.4-fold greater at 10 microM. In contrast, for two of our more sensitive cell lines, DOX was 25 to 27 times more cytotoxic than DOXOL. The present study suggests that (a) verapamil's effect on the cytotoxicity of DOX is not mediated by changes in the accumulation/retention nor the cytotoxicity of DOXOL; (b) metabolism of DOXOL does not influence its cytotoxicity nor that of DOX; and (c) DOXOL'S lower antitumor potency as compared to DOX cannot be fully explained by differences in intracellular accumulation.