Initial Assessment of Mucosal Capture and Leak Pressure After Gastrointestinal Stapling in a Porcine Model

BACKGROUND

Anastomotic leak is a leading cause of morbidity and mortality in gastrointestinal surgery. The serosal aspect of staple lines is commonly observed for integrity, but the mucosal surface and state of mucosa after firing is less often inspected. We sought to assess the degree of mucosal capture when using stapling devices and determine whether incomplete capture influences staple line integrity.

METHODS

Porcine ileum was transected in vivo and staple lines were collected and rated for degree of mucosal capture on a 5-point scale from 1 (mucosa mainly captured on both sides) to 5 (majority of mucosa not captured). Mucosal capture was also assessed in ex vivo staple lines, and fluid leakage pressure and location of first leak was assessed. Stapling devices studied were Echelon Flex GST with 60-mm blue (GST60B) and green (GST60G) cartridges, and Medtronic EndoGIA Universal with Tri-Staple Technology™ with 60 mm medium (EGIA60AMT) reloads (purple).

RESULTS

GST60B and GST60G staple lines produced significantly better mucosal capture scores than the EGIA60AMT staple lines (p < 0.001, in all tests). Compared to EGIA60AMT, leak pressures were 39% higher for GST60B (p < 0.001) and 23% higher for GST60G (p = 0.022). Initial staple line leak site was associated with incomplete mucosal capture 78% of the time.

CONCLUSIONS

There are differences in degree of mucosal capture between commercial staplers, and the devices that produce better mucosal capture had significantly higher leak pressures. Further research is needed to determine the significance of these findings on staple line healing throughout the postoperative period.

Sensitization to masked tones following notched-noise correlates with estimates of cochlear function using distortion product otoacoustic emissions

Neuronal gain adaptation has been proposed as the underlying mechanism leading to the perception of phantom sounds such as Zwicker tones and tinnitus. In this gain-adaptation theory, cochlear compression plays a significant role with weaker compression leading to stronger phantom percepts. The specific aim of this study was to find a link between the strength of neuronal gain adaptation and cochlear compression. Compression was assessed using distortion product otoacoustic emissions (DPOAEs). Gain adaptation is hypothesized to manifest itself in the sensitization observed for the detection of masked tones when preceded by notched noise. Perceptual thresholds for pure tones in notched noise were measured at multiple frequencies following various priming signals. The observed sensitization was larger than expected from the combined effect of the various maskers. However, there was no link between sensitization and compression. Instead, across subjects, stronger sensitization correlated with stronger DPOAEs evoked by low-level primaries. In addition, growth of DPOAEs correlated reliably with perceptual thresholds across frequencies within subjects. Together, the data suggest that short-term dynamic adaptation leading to perceptual sensitization is the result of an active process mediated by the outer hair cells, which are thought to modulate the gain of the cochlear amplifier via efferent feedback.

Role of the C-terminal actin binding domain in BCR/ABL-mediated survival and drug resistance

Philadelphia chromosome-positive, chronic myeloid leukaemia (CML) stem and progenitor cells have a survival and growth advantage compared with their normal counterparts. The mechanisms through which the BCR/ABL protein tyrosine kinase (PTK) induces these effects and the important domains within this protein are not fully defined. The F- and G-actin binding region of the BCR/ABL C-terminus may be important in BCR/ABL-mediated events, and we have investigated this by expressing a C-terminus deletion mutant of the temperature-sensitive BCR/ABL PTK, in a haemopoietic progenitor cell line, which models the chronic phase of CML. The truncated BCR/ABL PTK displayed similar levels of PTK activity when compared with wild type and activation of second messenger formation (in the form of sn-1,2-diacylglycerol) remains intact. On fibronectin substrata, localisation of the protein to the periphery of the cell was, however, dependent on the C-terminus of BCR/ABL PTK. Deletion of the C-terminus reversed both BCR/ABL-mediated apoptotic suppression and drug resistance although the progenitor cells did retain a proliferative advantage at low concentrations of growth factor. These results demonstrated that the C-terminal actin-binding domain of BCR/ABL is important for some of BCR/ABL PTK-mediated leukaemogenic effects.

Identification and characterization of a chitinase antigen from Pseudomonas aeruginosa strain 385

A chitinase antigen has been identified in Pseudomonas aeruginosa strain 385 using sera from animals immunized with a whole-cell vaccine. The majority of the activity was shown to be in the cytoplasm, with some activity in the membrane fraction. The chitinase was not secreted into the culture medium. Purification of the enzyme was achieved by exploiting its binding to crab shell chitin. The purified enzyme had a molecular mass of 58 kDa by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and a pI of 5.2. NH2-terminal amino acid sequencing revealed two sequences of M(I/L)RID and (Q/M/V)AREDAAAAM that gave an exact match to sequences in a translated putative open reading frame from the P. aeruginosa genome. The chitinase was active against chitin azure, ethylene glycol chitin, and colloidal chitin. It did not display any lysozyme activity. Using synthetic 4-methylumbelliferyl chitin substrates, it was shown to be an endochitinase. The Km and kcat for 4-nitrophenyl-beta-D-N,N'-diacetylchitobiose were 4.28 mM and 1.7 s(-1) respectively, and for 4-nitrophenyl-beta-D-N,N',N"-triacetylchitotriose, they were 0.48 mM and 0.16 s(-1) respectively. The pH optimum was determined to be pH 6.75, and 90% activity was maintained over the pH range 6.5 to 7.1. The enzyme was stable over the pH range 5 to 10 for 3 h and to temperatures up to 50 degrees C for 30 min. The chitinase bound strongly to chitin, chitin azure, colloidal chitin, lichenan, and cellulose but poorly to chitosan, xylan, and heparin. It is suggested that the chitinase functions primarily as a chitobiosidase, removing chitobiose from the nonreducing ends of chitin and chitin oligosaccharides.

Abdominal helical CT: milk as a low-attenuation oral contrast agent

One hundred ten consecutive patients were given either whole (4%) milk, 2% milk, water, barium suspension, or no oral contrast agent before abdominal computed tomography (CT). Results with whole milk were superior to those with all other agents for gastrointestinal distention, mural visualization, and pancreas-duodenum discrimination. In bowel loop discrimination, results with 4% milk were equal to those with barium but superior to those with all other agents. Whole (4%) milk is an effective low-attenuation oral contrast agent.

Declining CD4+ T-lymphocyte counts are associated with increased risk of enteric parasitosis and chronic diarrhea: results of a 3-year longitudinal study

From January 1991 through September 1994, we observed people who were infected with HIV to assess the impact of enteric parasite-associated diarrhea. Respondents answered comprehensive questionnaires covering clinical and epidemiologic information and provided stool specimens monthly, which were examined unstained as well as stained with trichrome, chromotrope 2R, and with Kinyoun carbol-fuchsin, and with indirect immunofluorescence for Cryptosporidium. In all, 602 participants, who were interviewed, provided stool specimens at 3254 monthly visits. Parasites were associated with 50 of 354 (14.1%) acute diarrheal episodes (lasting < or = 28 days) and with 97 of 279 (34.8%) chronic episodes (lasting > 28 days). A parasite was associated with 31 of 222 (14.0%) episodes that occurred when CD4+ counts were > or = 200 cells/microl and with 150 of 566 (26.5%) episodes that occurred when CD4+ counts were < 200 cells/microl. The most commonly identified parasite was C. parvum, which was associated with 18 of 354 (5.1%) acute episodes and 36 (12.9%) of the 279 chronic episodes of diarrhea. In this patient population, enteric protozoan parasites were commonly associated with illness, particularly as immunosuppression worsened, and were more likely to be associated with chronic rather than acute diarrhea.

Antimicrobial resistance in Neisseria gonorrhoeae in the United States, 1988-1994: the emergence of decreased susceptibility to the fluoroquinolones

Antimicrobial susceptibilities of Neisseria gonorrhoeae have been prospectively determined in the Gonococcal Isolate Surveillance Project of the Centers for Disease Control and Prevention. From 1988 through 1994, susceptibilities were determined for 35,263 isolates from 27 clinics. Patients were demographically similar to those in nationally reported gonorrhea cases. In 1994, 30.5% of isolates had chromosomally or plasmid-mediated resistance to penicillin or tetracycline. Penicillin resistance increased from 1988 (8.4%) to 1991 (19.5%) and then decreased in 1994 (15.6%). Tetracycline resistance decreased from 1988 (23.4%) to 1989 (17.3%) and then increased in 1994 (21.7%). Most isolates (99.9%) were highly susceptible to broad-spectrum cephalosporins. Isolates with decreased susceptibility to ciprofloxacin increased from 1991 (0.4%) to 1994 (1.3%); 4 isolates were ciprofloxacin-resistant. Ciprofloxacin-resistant strains may not respond to therapy with recommended doses of fluoroquinolones, and the clinical importance of strains with decreased susceptibility is unknown. The emergence of fluoroquinolone resistance in N. gonorrhoeae in the United States threatens the future utility of this class of antimicrobials for gonorrhea therapy.

Protection from Mycobacterium avium complex disease in human immunodeficiency virus-infected persons with a history of tuberculosis

Risk of Mycobacterium avium complex disease was examined in human immunodeficiency virus (HIV)-infected patients with and without a history of tuberculosis. Information was obtained by retrospective review of charts of patients in HIV clinics in 10 US cities. Among 1363 patients with <200 CD4 cells/mm3 seen at Grady Memorial Hospital (GMH), 11 (17%) of 66 with a history of a positive purified protein derivative (PPD) skin test acquired M. avium infection, while 29 (16%) of 185 who were PPD-negative (but not anergic) did not (P = .85). Only 4 (8%) of 49 GMH patients with a history of tuberculosis acquired M. avium infection compared with 252 (19%) of 1314 GMH patients without a history of tuberculosis (P = .05). Proportional hazards analysis of risk factors for M. avium infection among 441 persons with and 8702 persons without a history of tuberculosis in 9 other cities confirmed protection from M. avium infection in persons with a history of tuberculosis (relative risk, 0.52; 95% confidence interval, 0.36-0.76; P < .001). Prior tuberculosis provides protection against M. avium infection in HIV-infected persons, possibly by stimulation of antimycobacterial immunity.

Talc pleurodesis: talc slurry versus thoracoscopic talc insufflation in a porcine model

BACKGROUND

Pleurodesis using both talc slurry and thoracoscopic talc insufflation has been shown to be clinically effective. This study compares these two modalities of pleural talc instillation in an animal model.

METHODS

Eleven immature pigs underwent general endotracheal anesthesia. On one side, a slurry of 5 g sterile United States Pharmacopeia talc in 50 mL of saline solution was instilled through a thoracostomy tube. On the other side, the lung was deflated and 5 g of dry talc was insufflated under thoracoscopic visualization. The animals were sacrificed 30 days later, and the quality of pleural adhesions was graded from 0 to 2 (0 = absent; 1 = light; 2 = dense) in each of six regions of each hemithorax. The distribution of adhesions on each side was graded from 0 to 6, according to the number of areas that contained adhesions.

RESULTS

One animal died of anesthetic complications. Among the survivors, adhesions produced by both methods were dense and diffuse in 8 of 10 animals, and light and diffuse in 1 animal. One animal had light or absent adhesions on the talc slurry side, and dense and diffuse adhesions on the thoracoscopic talc insufflation side. There was no difference between the techniques for density of adhesion scores (talc slurry, 9.9 +/- 2.2; thoracoscopic talc insufflation, 10.0 +/- 2.5) or distribution of adhesion scores (talc slurry, 5.5 +/- 1.0; thoracoscopic talc insufflation, 5.8 +/- 0.4) (p > 0.1).

CONCLUSIONS

Effective pleurodesis in a porcine model can be obtained with either talc slurry or thoracoscopic talc insufflation.

Radiological features of a symptomatic splenic hamartoma

Symptomatic splenic hamartomas are rare in the pediatric age group, with only four previous reports in the literature. Splenic hamartoma has been reported as a solid homogeneous mass without calcification on CT and ultrasound (US), and only one previous report of the findings on MRI has been published. We report a case of a large symptomatic splenic hamartoma in a 14-year-old girl who presented with splenomegaly, pancytopenia and growth retardation. A solid mass with multiple punctate foci resembling calcifications was seen on US. The mass was heterogeneous and better demarcated on enhanced CT. Radiocolloid scintigraphy demonstrated uptake within the lesion, but less than that of normal spleen. The mass was isointense relative to normal splenic tissue on T1-weighted MRI (0.5 T) and of increased intensity with T2 weighting. At splenectomy, a red pulp hamartoma was identified, which contained nodules of hyalinization and necrosis thought to account for the punctate foci seen on US.

Fluconazole compared with endoscopy for human immunodeficiency virus-infected patients with esophageal symptoms

BACKGROUND & AIMS

The best initial treatment of human immunodeficiency virus (HIV)-infected patients with esophageal symptoms is unknown. The outcome, including safety and cost-effectiveness, of fluconazole compared with endoscopy as a treatment strategy for HIV-infected patients with new-onset esophageal symptoms was evaluated.

METHODS

During a 53-month period, 134 HIV-infected patients with esophageal symptoms were randomized prospectively to groups receiving either standard doses of fluconazole or endoscopy.

RESULTS

Among the 68 patients in the fluconazole group, a complete symptomatic response was observed in 56 patients (82%), usually within 1 week. The most common endoscopic findings in the 66 patients in the endoscopy group included Candida esophagitis alone in 42 patients (64%) and ulcerative esophagitis in 10 patients (15%). Patients responding to empirical antifungal therapy or who had Candida esophagitis alone at endoscopy were less like to have severe symptoms (P = 0.027) or odynophagia as the only symptom (P < 0.001) but more frequently had odynophagia and dysphagia (P = 0.007) and thrush (P = 0.002). Empirical fluconazole was cost-effective, saving $738.16 per patient.

CONCLUSIONS

Empirical oral antifungal therapy with fluconazole is highly efficacious, safe, and cost-effective for HIV-infected patients with new-onset esophageal symptoms.

Chronic unexplained diarrhea in human immunodeficiency virus infection: determination of the best diagnostic approach

BACKGROUND & AIMS

Chronic unexplained diarrhea is a common complication of human immunodeficiency virus infection, although the best diagnostic approach is unknown. The purpose of our study was to evaluate the clinical use of endoscopy for the evaluation of this problem.

METHODS

Patients infected with human immunodeficiency virus with chronic unexplained diarrhea underwent upper endoscopy to the jejunum followed by colonoscopy.

RESULTS

Forty-eight patients were evaluated. A potential cause of diarrhea was found in 21 patients (44%; 95% confidence interval, 30%-58%). Colonoscopy with biopsy identified an etiology in 13 patients, including cytomegalovirus colitis alone in 9. In all but 1 patient with colonic disease, the diagnosis was made by biopsy of the rectosigmoid colon. Upper endoscopy with biopsy identified microsporidiosis in 7 patients and cryptosporidiosis in 2 patients. Logistic regression analysis identified weight loss and duration of diarrhea (P < 0.001) as the only independent predictors for diagnosis. No patient without weight loss and a CD4 lymphocyte count of > 100/mm3 had a diagnosis established. Of the 25 patients without a diagnosis in whom long-term follow-up was available, improvement or spontaneous resolution of diarrhea occurred in 9 (38%).

CONCLUSIONS

Clinical parameters are helpful in predicting which patients may benefit from endoscopic examination.

The presence of Enterocytozoon bieneusi spores in the lamina propria of small bowel biopsies with no evidence of disseminated microsporidiosis. Enteric Opportunistic Infections Working Group

Enterocytozoon bieneusi is the most frequently reported microsporidial infection of humans. In patients with the acquired immunodeficiency syndrome, Enterocytozoon infects the lining epithelial cells of the small intestine, hepatobiliary tract, and gallbladder. Because Enterocytozoon has been thought to be limited to infecting lining epithelial cells, the mechanism of spread of E bieneusi within the intestine, to the biliary tract, and, in two case reports, to distant organs remains unknown. This report describes a patient with acquired immunodeficiency syndrome and intestinal microsporidiosis due to E bieneusi. Histopathologic examination of well-oriented biopsies from the duodenum and jejunum revealed both intra- and extracellular spores of Enterocytozoon extending deeply into the lamina propria, where they were located adjacent to capillaries. The patient has not developed disseminated disease 20 months after the initial diagnosis. In this patient, the demonstration of E bieneusi spores in extraepithelial tissues does not appear to be associated with development of subsequent systemic infection.

Leucine enkephalin effects on paracellular and transcellular permeation pathways across brain microvessel endothelial cell monolayers

Leucine enkephalin (YGGFL) effects on markers for transcellular and paracellular permeation across the blood-brain barrier (BBB) were investigated in vitro with bovine brain microvessel endothelial cell (BMEC) monolayers in primary culture. Intact YGGFL, but not metabolites of YGGFL, stimulated BMEC uptake of lucifer yellow (LY), a marker for fluid-phase endocytosis, in a concentration-dependent manner. However, D-[Ala2]-leucine enkephalin (YAGFL), a YGGFL analogue that altered BMEC monolayer permeability, had no effect on LY uptake. In part, these results suggested that YGGFL's effects on fluid-phase uptake might not relate directly to enhanced BMEC transcellular permeability in the presence of the peptide. The measurement of the fluorescence anisotropy of membrane-bound diphenyl-hexatriene probes did not show substantial peptide-induced changes in membrane lipid packing order (i.e., membrane fluidity) and indicated a limited role for membrane perturbations in YGGFL-induced changes in BMEC monolayer permeability. Conversely, the apparent permeability coefficients showed size-dependent YGGL-induced alterations for passage of membrane-impermeant substances across BMEC monolayers. The apparent permeability coefficients of low-molecular-weight (low-mol-wt) molecules (mannitol, sucrose, and fluorescein) were increased on exposure to YGGFL. The apparent permeability coefficients for high-mol-wt molecules, FITC dextran conjugates (4, 20, and 71.6 Kd), were not affected by exposure to YGGFL. Transmission electron micrographs of lanthanum (Stoke's radius, 10 A) exclusion from BMEC intercellular junctions supported these observations. Collectively, results from this study suggest that YGGFL enhanced BMEC permeability either by altering paracellular openings or through formation of a small pore in the monolayers to allow preferential penetration of low-mol-wt or small molecular size (< 10 A) substances.

Predictors of survival in patients with AIDS and disseminated Mycobacterium avium complex disease

Patients with AIDS and disseminated Mycobacterium avium complex disease (DMAC), as defined by the presence of a positive blood culture for MAC, were studied retrospectively to define the natural history of DMAC. All patients had fevers, severe anemia (hematocrit < 26%), or both. Eighty-seven (76%) had signs, symptoms, or laboratory findings related to the gastrointestinal tract, but no distinct syndrome was identified. Sixty-nine patients received antimycobacterial therapy; assignment to therapy was not randomized. In a proportional hazards analysis, shorter survival was associated with higher initial level of mycobacteremia (relative risk [RR], 1.86; 95% confidence interval [CI], 1.49-2.31; P < .001), while administration of antimycobacterial chemotherapy (RR, 0.42; 95% CI, 0.26-0.70; P < .001) and antiretroviral therapy (RR, 0.40; 95% CI, 0.22-0.73; P < .01) had protective effects. Thus, the initial level of mycobacteremia of patients with DMAC may have prognostic value, and administration of antimycobacterial and antiretroviral agents may be associated with prolonged survival.

Leucine-enkephalin metabolism in brain microvessel endothelial cells

The metabolism of leucine-enkephalin was investigated in primary cultures of bovine brain microvessel endothelial cell (BMEC) monolayers. Leucine-enkephalin was hydrolyzed slowly with less than 40% of the peptide metabolized following a 5-h incubation with intact BMEC monolayers at 37 degrees C. Following separation and extraction of BMEC enzymes into cytosolic and membrane-bound fractions, leucine-enkephalin was observed to be labile in the presence of both cytosolic and membrane-associated enzymes. A much greater concentration of enkephalin-hydrolyzing enzyme was associated with the cytosolic fraction. Resulting metabolite profiles for leucine-enkephalin appeared to be the result of interactions of the peptide with primarily aminopeptidases and angiotensin-converting enzyme. Our results suggested that extensive metabolism of leucine-enkephalin solely by BMECs in the cerebro-vasculature would require internalization by the cells and presentation to cytosolic enzymes.

Low serum levels of oral antimycobacterial agents in patients with disseminated Mycobacterium avium complex disease

Twenty-seven human immunodeficiency virus-infected patients with disseminated Mycobacterium avium complex disease who were treated with oral antimycobacterial agents (clofazimine, ciprofloxacin, ethambutol, and rifampin) were studied to evaluate the usefulness of monitoring serum drug concentrations and testing in vitro susceptibility of M. avium complex (MAC) isolates. Twenty patients tolerated treatment with three or four antimycobacterial agents for at least 8 weeks; mycobacteremia was eradicated in 7 (35%). The in vitro susceptibilities of MAC isolates to antimycobacterial agents were similar for these 7 and for the 13 who did not respond to antimycobacterial treatment. Serum drug levels were below the expected range in 6 of the 7 whose mycobacteremia was cleared and in 9 of the 13 nonresponders (P = .41). These low serum concentrations of antimycobacterial drugs may be due to impaired drug absorption in patients with AIDS and disseminated MAC disease.

A prospective evaluation of Mycobacterium avium complex colonization of the respiratory and gastrointestinal tracts of persons with human immunodeficiency virus infection

To describe the natural history of Mycobacterium avium complex (MAC) in the respiratory or gastrointestinal tract of persons with human immunodeficiency virus (HIV) infection, 67 HIV-infected patients with CD4+ cell counts < 200/mm3 and initial negative MAC blood cultures were followed prospectively. Patients were screened every 3 months with cultures and smears of sputum, rectal swab, and blood for mycobacteria. Fourteen patients (20.9%) developed positive blood cultures for MAC (23.4%/year). Sputum cultures revealed MAC in 3 (21%) of the 14 patients at 1, 2, and 8 months before dissemination; no smears were positive. No rectal swab cultures or smears were positive before dissemination. Colonization of the respiratory and gastrointestinal tracts in persons with HIV infection and < 200/mm3 CD4+ cells is infrequently detected with currently available techniques. Screening cultures and smears of sputum and stool do not appear to be sensitive methods for detection of early MAC infection.

Survival prognosis of HIV-infected patients

Previous studies of survival after a diagnosis of acquired immunodeficiency syndrome (AIDS) have reported variation in temporal trends in association with age, gender, race, mode of transmission, lymphadenopathy, antiretroviral therapy, and presence of specific opportunistic infections at diagnosis. We used a logistic regression model to assess the effect of these factors while controlling for other potential predictors of time from initial CD4 cell count to death in 839 HIV-infected patients at a public hospital in Atlanta, Georgia. Our study found that a CD4 level of < 200 cells/microliters [odds ratio (OR) = 1.71; 95% confidence interval (CI) of 1.58, 1.85] and the presence of an AIDS-indicating condition (initial diagnosis OR = 2.50 and CI of 1.93, 3.24; diagnosis of a second AIDS condition OR = 3.02 and CI of 2.08, 4.40) are independently predictive of survival in HIV-infected persons. Furthermore, specific clinical manifestations of AIDS vary in their contribution to progression from diagnosis of AIDS to death. Therefore, changes in survival of AIDS patients must take into account changes over time in the relative frequency of specific AIDS-indicating diagnoses.

Maintenance of CD4+ cells by thymopentin in asymptomatic HIV-infected subjects: results of a double-blind, placebo-controlled study

OBJECTIVE

To assess the efficacy and safety of thymopentin in HIV-infected patients who had not yet developed AIDS.

DESIGN

Patients were stratified into asymptomatic or symptomatic groups and randomized to receive either thymopentin (50 mg) or placebo, subcutaneously, double-blind for 24 or 52 weeks, three times a week.

SETTING

Patients were enrolled at three sites (two hospital clinics and one private practice).

PATIENTS

Of 91 HIV-seropositive patients (52 asymptomatic and 39 symptomatic) from whom HIV could be isolated from peripheral blood, 45 were enrolled for 24 weeks and 46 for 52 weeks of double-blind evaluation.

MAIN OUTCOME MEASURES

Virological, immunological and clinical evaluations were performed before and during treatment.

RESULTS

Thymopentin-treated asymptomatic patients had more CD4+ cells, as demonstrated by a greater area under the percentage CD4+ cells curve (P = 0.03) and a shorter median time to a 20% increase in percentage of CD4+ cells (P = 0.04) in the first 24 weeks, with similar trends in the 52-week study. By 24 weeks no asymptomatic thymopentin-treated and two placebo-treated patients (9.1%, Kaplan-Meier estimate) had progressed to constitutional symptoms (P = 0.12; two-tailed Wilcoxon-Gehan test), with only one further progression in a placebo-treated patient in the subset followed for 52 weeks. Symptomatic patients receiving thymopentin or placebo were similar in both CD4+ cell levels and disease progression (two progressions to AIDS in each group). No serious adverse effects attributable to thymopentin were observed.

CONCLUSIONS

These results, if confirmed, indicate that thymopentin, by maintaining CD4+ cells, could slow or arrest immune decline and consequent disease progression at the asymptomatic stage of HIV infection.

Pelvic inflammatory disease and fertility. A cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results

From 1960 10 1984, 2,501 women underwent diagnostic laparoscopy (index laparoscopy) because of a clinical suspicion of acute pelvic inflammatory disease (PID). Of these women, 1,844 had abnormal laparoscopic findings (patients) and 657 had normal findings (control subjects). The reproductive events after index laparoscopy of 1,732 patients and 601 control subjects were followed. The patients and control subjects were followed for a total of 13,400 and 3,958 woman-years, respectively. During the follow-up period, 1,309 (75.6%) of the patients and 451 (75.0%) of the control subjects attempted to conceive. Of these women, 209 (16.0%) of the patients and 12 (2.7%) of the control subjects failed to conceive. A total of 141 (10.8%) of the patients and 0 (0%) of the control subjects had confirmed tubal factor infertility, 21 (1.6%) of the patients and 3 (0.7%) control subjects had other causes of infertility, and 47 (3.6%) patients and 9 (2.0%) control subjects did not have a complete infertility evaluation. Additional information on tubal morphology (hysterosalpingography, laparoscopy, or laparotomy) in women from couples for whom evaluation was incomplete indicated that 165 (12.2%) patients and 4 (0.9%) of the control subjects had abnormal tubal function or morphology after index laparoscopy. Tubal factor infertility after PID was associated with number and severity of PID episodes. The ectopic pregnancy rate for first pregnancy after index laparoscopy was 9.1% among the patients and 1.4% among control subjects.

Disseminated Mycobacterium avium Complex Infection: Clinical Identification and Epidemiologic Trends

To evaluate the incidence of disseminated Mycobacterium avium complex infection (DMAC) and to define the association between signs and symptoms and development of DMAC in patients with human immunodeficiency virus (HIV) infection, all cases of DMAC at Grady Memorial Hospital Infectious Disease Clinic (Atlanta) between 1985 and 1990 were reviewed, and a prospective study of the association of symptoms with DMAC was done. Between 1985 and 1990, DMAC occurred in 16% of patients with AIDS. Incidence increased from 5.7% in 1985-1988 to 23.3% in 1989-1990 (P less than .001). Median time from AIDS diagnosis to diagnosis of DMAC increased from 4.5 months in 1985-1988 to 8 months in 1989-1990 (P less than .02). In the prospective study, DMAC was seen only in persons with a CD4+ count less than 100 cells/mm3 and was associated with fever (P less than .03), anemia (P less than .001), weight loss (P less than .01), diarrhea (P less than .01), and elevated alkaline phosphatase (P less than .01). It is recommended that all such HIV-infected persons have mycobacterial blood cultures done.

Comparison of amphotericin B with fluconazole in the treatment of acute AIDS-associated cryptococcal meningitis. The NIAID Mycoses Study Group and the AIDS Clinical Trials Group

BACKGROUND

Intravenous amphotericin B, with or without flucytosine, is usually standard therapy for cryptococcal meningitis in patients with the acquired immunodeficiency syndrome (AIDS). Fluconazole, an oral triazole agent, represents a promising new approach to the treatment of cryptococcal disease.

METHODS

In a randomized multicenter trial, we compared intravenous amphotericin B with oral fluconazole as primary therapy for AIDS-associated acute cryptococcal meningitis. Eligible patients, in all of whom the diagnosis had been confirmed by culture, were randomly assigned in a 2:1 ratio to receive either fluconazole (200 mg per day) or amphotericin B. Treatment was considered successful if the patient had had two consecutive negative cerebrospinal fluid cultures by the end of the 10-week treatment period.

RESULTS

Of the 194 eligible patients, 131 received fluconazole and 63 received amphotericin B (mean daily dose, 0.4 mg per kilogram of body weight in patients with successful treatment and 0.5 mg per kilogram in patients with treatment failure; P = 0.34). Treatment was successful in 25 of the 63 amphotericin B recipients (40 percent; 95 percent confidence interval, 26 percent to 53 percent) and in 44 of the 131 fluconazole recipients (34 percent; 95 percent confidence interval, 25 percent to 42 percent) (P = 0.40). There was no significant difference between the groups in overall mortality due to cryptococcosis (amphotericin vs. fluconazole, 9 of 63 [14 percent] vs. 24 of 131 [18 percent]; P = 0.48); however, mortality during the first two weeks of therapy was higher in the fluconazole group (15 percent vs. 8 percent; P = 0.25). The median length of time to the first negative cerebrospinal fluid culture was 42 days (95 percent confidence interval, 28 to 71) in the amphotericin B group and 64 days (95 percent confidence interval, 53 to 67) in the fluconazole group (P = 0.25). Multivariate analyses identified abnormal mental status (lethargy, somnolence, or obtundation) as the most important predictive factor of a high risk of death during therapy (P less than 0.0001).

CONCLUSIONS

Fluconazole is an effective alternative to amphotericin B as primary treatment of cryptococcal meningitis in patients with AIDS. Single-drug therapy with either drug is most effective in patients who are at low risk for treatment failure. The optimal therapy for patients at high risk remains to be determined.

The impact of a clinic for adults with HIV infection on the microbiology laboratory

The Infectious Diseases Clinic (IDC) discussed serves adults who are seropositive for human immunodeficiency virus. The authors reviewed the outpatient and inpatient microbiology tests of a three-month period during 1989 for a systematic sample of IDC patients. The 249 patients in the sample had 682 microbiology tests performed during the period (mean 2.7 tests per patient). Tests most frequently requested were mycobacterial culture, routine blood culture, and cryptococcal antigen determination. Patients with acquired immunodeficiency syndrome (43% of IDC patients) accounted for 63% of the requested IDC tests. IDC patients comprised about 2.4% of patients served but accounted for 3.9% of the requested microbiology tests and 6.6% of the microbiology work load for reported tests. Using Centers for Disease Control case projections, the authors estimated that services to IDC patients in 1993 would comprise 6.6% of all microbiology tests and 10.6% of the microbiology work load. The implications of these data for microbiology probably also apply to other laboratory testing and emphasize the need for more efficient ways to use and perform diagnostic studies required by patients with HIV infection.

Survival of patients with acquired immune deficiency syndrome and disseminated Mycobacterium avium complex infection with and without antimycobacterial chemotherapy

The contribution of disseminated Mycobacterium avium complex (DMAC) infection to the morbidity and mortality of patients with acquired immune deficiency syndrome (AIDS) is unclear. Previous studies that suggested the decreased survival of patients with AIDS and DMAC had incomplete information on patient immunologic status and follow-up. We studied patients with AIDS and DMAC and compared their survival with that of AIDS patients without DMAC but with other comparable risk factors for survival. Case and control subjects were similar in terms of CD4 cell count, prior AIDS status, history of antiretroviral therapy, history of Pneumocystis carinii prophylaxis, and year of diagnosis. A group of 39 patients with untreated DMAC had significantly shorter survival, mean of 5.6 +/- 1.1 months (median 4 months), than 39 matched patients with AIDS but without DMAC, mean 10.8 +/- 1.3 months (median 11 months, p less than 0.0001). The survival of 16 additional patients with DMAC who received antimycobacterial therapy, mean of 9.5 +/- 1.4 months (median 8 months), was not significantly shorter than that of an additional 16 matched control subjects, mean 11.7 +/- 1.9 months (median 11 months, p = 0.58). Patients with treated DMAC survived significantly longer than those with untreated DMAC (p less than 0.01). We conclude that untreated DMAC significantly shortens survival. Moreover, these results indicate that patients with DMAC who receive antimycobacterial therapy do not experience the shortened survival seen in untreated DMAC.

Analgesia in dogs after intercostal thoracotomy. A comparison of morphine, selective intercostal nerve block, and interpleural regional analgesia with bupivacaine

Three postoperative analgesic protocols were assigned randomly to 24 healthy dogs after thoracotomy at the left fourth intercostal space. Morphine was administered parenterally to eight dogs after tracheal extubation; selective intercostal nerve blocks with bupivacaine hydrochloride and epinephrine were administered to eight dogs before closure of the thorax; and bupivacaine hydrochloride and epinephrine were administered through an interpleural catheter to eight dogs after tracheal extubation. Heart rate, respiratory rate, rectal temperature, hematocrit, plasma protein, blood gas, and pain score evaluations were recorded before surgery and 30 minutes, 1 hour, 2 hours, and 3 hours after extubation. Morphine caused significant decreases in blood pH and blood oxygen tensions, and significant increases in carbon dioxide tensions. Dogs treated with intercostal nerve blocks had no significant changes in these parameters, and dogs treated with interpleural bupivacaine had significant decreases in blood oxygen tension. All dogs had significant decreases in rectal temperature, and hypothermia was prolonged after morphine. Analgesia was initially adequate in most dogs, but some dogs in each treatment group had recurrence of pain and were treated with interpleural bupivacaine. One dog developed pneumothorax. Interpleural administration of bupivacaine produced analgesia equal to that produced by systemic administration of morphine or selective intercostal nerve block with bupivacaine. Bupivacaine was easily readministered through an interpleural catheter. Respiratory compromise was less in dogs treated with bupivacaine than in dogs treated with morphine. After intercostal thoracotomy, interpleural bupivacaine provided prolonged analgesia with fewer blood gas alterations than morphine.

Intraoperative monitoring of ischiatic nerve function with sensory evoked potentials

Serial recordings of sensory evoked potentials (SEP) generated in response to stimulation of each tibial nerve were obtained from 23 anesthetized dogs. Five dogs were anesthetized for 3 hours to evaluate changes in serial SEP during general anesthesia. Nonsurgical and surgical manipulations were performed on one hind limb of five dogs to determine the effects of limb positioning and nerve retraction on SEP. In 13 dogs, the ischiatic nerve was exposed surgically and retracted until the SEP deteriorated and disappeared, to determine the relationship between amount of tension on the nerve and the time to complete deterioration of the SEP. Sensory evoked potential waveforms, which consisted of two to five peaks, were stable throughout the anesthetic period. The first two peaks were the most stable. Latency of the first two peaks was the easiest and most reliable parameter to evaluate. Although the peak latency in recordings from the superior hind limb was always slightly longer, SEP recordings from the inferior limb were good controls to monitor nerve function. There was considerable variation in sensitivity to nerve retraction. The technique proved to be a reliable way to monitor nerve function in normal anesthetized dogs.

Urinary tract infections in female patients

Urinary tract infections are a common problem in female patients. Twenty-five per cent of patients with an initial infection will develop recurrent infections, with reinfection of the urine some time after the urine has been sterilized being the most common situation. Most adult patients have no urinary tract abnormality, with the infecting organism coming from the rectum and colonizing the vagina before colonizing the bladder. In children with urinary tract infections, there is a higher incidence of urinary tract abnormalities. The author presents a plan of management for various clinical problems.

Predicting acute pelvic inflammatory disease: a multivariate analysis

A multivariate logistic regression analysis of patient symptoms and signs and laboratory findings associated with the diagnosis of acute pelvic inflammatory disease was performed with use of data from 628 women who were clinically diagnosed as having the disease for the first time at the University of Lund, Sweden. In 414 women (65.9%) acute pelvic inflammatory disease was laparoscopically confirmed. We developed a mathematical model that correctly predicted 87.0% of the cases of acute pelvic inflammatory disease and had an overall correct classification rate of 75.6%. Variables that were good predictors of acute pelvic inflammatory disease were purulent vaginal discharge, erythrocyte sedimentation rate greater than or equal to 15 mm/hr, positive gonorrhea result, adnexal swelling on bimanual examination, and rectal temperature greater than or equal to 38 degrees C. Furthermore, we developed "mixed model I" and "mixed model II," which combine simple clinical parameters and laparoscopy in varying degrees. In mixed model I the sensitivity, specificity, and overall classification values were 93%, 67.2%, and 84.5%; in mixed model II these values were 100%, 67.2%, and 89.2%. Use of relatively simple and reproducible clinical parameters can identify those women who would most benefit from laparoscopy to diagnose acute pelvic inflammatory disease.

Long-term immunogenicity and efficacy of hepatitis B vaccine in homosexual men

To study the duration of antibody persistence and protection provided by the hepatitis B vaccine, we followed 773 homosexual men for five years after completion of vaccination. Among the 635 participants in whom antibody levels above 9.9 sample ratio units (SRU) developed after vaccination, 15 percent lost antibody altogether, and in another 27 percent, antibody levels declined below 10 SRU within five years. The extent of the maximal antibody response strongly predicted the persistence of protective antibody. Hepatitis B infection occurred in 55 men; 8 of these infections were clinically important (characterized by the presence of the hepatitis B surface antigen and elevation of liver-enzyme levels), and two of the patients became hepatitis B virus carriers. The long-term risk of hepatitis B infection was inversely related to the maximal antibody response to vaccine. Most severe infections occurred among those who responded poorly or had no response to the vaccination. The risk of late infection with hepatitis B in those with an initially adequate vaccine response increased markedly when antibody levels decreased below 10 SRU, but only 1 of 34 late infections resulted in viremia and liver inflammation. A second series of vaccinations induced a moderate antibody response in 50 percent of the subjects who initially had no response or a poor response; however, the persistence of antibody was poor. Both antibody loss and the risk of severe disease should be considered when booster-dose strategies for the hepatitis B vaccine are being designed.

High failure rates in outpatient treatment of salpingitis with either tetracycline alone or penicillin/ampicillin combination

Eight hundred twenty-five ambulatory women with a clinical diagnosis of salpingitis were randomized to a 10-day course of either penicillin/ampicillin or tetracycline. Forty-four percent of women had gonococcal salpingitis and 56% nongonococcal salpingitis. Overall, both regimens cured equal proportions of women: At 30 days, 81% were cured by penicillin/ampicillin and 82% by tetracycline. However, the proportion of women with gonococcal salpingitis cured by 30 days was significantly greater than that of women with nongonococcal salpingitis. By 30 days, 14% of women with gonococcal salpingitis and 21% of women with nongonococcal salpingitis were not cured by either regimen. These data suggest that both regimens were only marginally acceptable for women with gonococcal salpingitis and that neither regimen was acceptable for nongonococcal salpingitis.

Evaluation of a C-reactive protein latex agglutination detection test with sera from patients with sexually transmitted diseases

A total of 149 sera, including 79 pre- and posttreatment sera from 33 patients with disseminated gonococcal infections, 18 from patients with uncomplicated gonococcal infections, 6 from patients with pelvic inflammatory disease, 4 from patients with genital Chlamydia trachomatis infections, and 42 from normal volunteers, were examined for C-reactive protein with a latex agglutination C-reactive protein detection kit (Difco Laboratories, Detroit, Mich.). Results were quantitated with LC-Partigen C-reactive protein radial immuno-diffusion plates (Calbiochem-Behring, La Jolla, Calif.). Positive latex agglutination results were observed in all of the pretreatment sera and some of the posttreatment sera of patients with disseminated gonococcal infections and in two sera from patients with pelvic inflammatory disease, which corresponded to quantitative C-reactive protein levels in the radial immunodiffusion plates. C-reactive protein levels were not detectable in the serum samples from normal volunteers or patients with uncomplicated gonococcal infections or genital chlamydial infections. Positive latex agglutination occurred as early as 20 s in sera with high C-reactive protein levels, and all positive results were observed within 90 s of the 3-min test limit. Positive latex test results were obtained with C-reactive protein levels as low as 1 mg/dl (10 micrograms/ml).

Serogrouping of Neisseria gonorrhoeae: correlation of serogroup with disseminated gonococcal infection

Gonococci can be divided into serogroups WI, WII, and WIII by coagglutination. To assess the clinical correlation of serogroups of gonococci, we studied isolates of gonococci from patients with disseminated and uncomplicated gonococcal infections in three cities in the United States. Strains of Neisseria gonorrhoeae belonging to serogroup WI represented 85 (84%) of 101 isolates from patients with disseminated gonococcal infection (DGI) and 68 (40%) of 168 isolates from patients with uncomplicated gonorrhea (P less than .001). The auxotype Arg-, Hyx-, Ura- (AHU) represented 62 (61%) of 101 isolates from DGI and 54 (32%) of 168 isolates from uncomplicated infection (p less than .001); all AHU isolates were serogroup WI. Among other auxotypes, WI strains represented 25 (64%) of 39 isolates from patients with DGI and 14 (12%) of 114 from uncomplicated infections (P less than .001). In Atlanta only, 13 (34%) of 38 isolates from DGI were AHU, but 31 (82%) were serogroup WI (P less than .001). Thus gonococci of serogroup WI are associated with DGI in these cities of the United States, and this correlation appears to be independent of auxotype. Serogroup WI is correlated with serum resistance.

Comparison of cefuroxime and penicillin in the treatment of uncomplicated gonorrhea

In a randomized double-blind trial, 216 men and 142 women infected with uncomplicated gonorrhea were treated with either 1.5 g of cefuroxime or 4.8 x 10(6) U of aqueous procaine penicillin G intramuscularly and 1.0 g of probenecid. The cure rates in the treatment groups were 96 and 95%, respectively. Intramuscularly administered cefuroxime was better tolerated than was procaine penicillin. Comparative antibiotic susceptibility studies revealed that cefuroxime and penicillin were about equally active and that both were more active than cefamandole or cefoxitin. Because cefuroxime is not degraded by the action of beta-lactamase enzymes, it has promise as an alternative to spectinomycin in the treatment of penicillinase-producing Neisseria gonorrhoeae infections.

The prevention of hepatitis B with vaccine. Report of the centers for disease control multi-center efficacy trial among homosexual men

A randomized, double-blind, vaccine/placebo trial of the Merck 20-micrograms hepatitis B virus (HBV) vaccine was done among 1402 homosexual men attending venereal disease clinics in five American cities. Vaccination was followed by only minimal side effects. Two doses of vaccine induced antibody in 80% of vaccine recipients. A booster dose 6 months after the first dose induced antibody in 85% of recipients and markedly increased the proportion of recipients who produced high antibody titers. The incidence of HBV events was markedly less in the vaccine recipients compared to that in the placebo recipients (p = 0.0004). Between month 3 and 15 after the first dose, 56 more significant HBV events (hepatitis, or hepatitis B surface antigen positive, or both) occurred in the placebo group while only 11 occurred in the vaccine group. Ten of the 11 HBV events in the vaccine recipients occurred in hypo- or nonresponders to the vaccine. This vaccine appears to be safe, immunogenic, and efficacious in preventing infection with hepatitis B virus.

Hepatitis B in homosexual men: prevalence of infection and factors related to transmission

Of 3,816 homosexual men examined in five sexually transmitted disease clinics in the United States, 6.1% had hepatitis B surface antigen, 52.4% had antibody to hepatitis B surface antigen, and 3.0% of the men who had no other indicator of infection with hepatitis B virus (HBV) had antibody to hepatitis B core antigen. The rate of seropositivity for HBV indicated by the presence of one or more of these serologic markers was 61.5%; seropositivity was significantly related to the duration of regular homosexual activity and to the number of nonsteady male sexual contacts in the four months before the patients were interviewed. Anal-genital intercourse, oral-anal intercourse, and rectal douching were significantly related to evidence of HBV infection, but oral-oral contact and oral-genital contact were not. Trauma to the rectal mucosa is a feature common to the practices that were significantly related to seropositivity for HBV.

Treatment of uncomplicated gonococcal infection with trimethoprim-sulfamethoxazole

The efficacy of trimethoprim-sulfamethoxazole (TMP-SMZ; 80 mg of TMP and 400 mg of SMZ per tablet; nine tablets taken once daily for three days; total, 27 tablets) was compared with the U.S. Public Health Service recommended regimen of 2 g of tetracycline daily for five days for the treatment of uncomplicated genital gonorrhea. Fourteen (3%) of the 461 patients treated with tetracycline and 24 (5%) of the 477 patients treated with TMP-SMZ failed to be cured; the difference between the two groups was not significant. Treatment of patients with TMP-SMZ was more likely to fail if the isolates of Neisseria gonorrhoeae had MICs of > or = 0.5 microgram of TMP/ml and > or = 9.5 micrograms of SMZ/ml. Adverse effects were more often reported by patients receiving TMP-SMZ. The results show that TMP-SMZ is an effective therapy for uncomplicated gonococcal infections in men and women and may also eliminate agents causing postgonococcal urethritis. The utility of this drug combination may be limited by the adverse effects that are associated with the large dose used.

Urethritis in women attending an STD clinic

Of an unselected group of 159 women attending a sexually transmitted diseases (STD) clinic 20% (32) had symptoms of urethritis. A positive correlation existed between the finding of more than 10 polymorphonuclear leucocytes (PMNL) per high-power field in the Gram-stained urethral smear and the presence of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis. Conversely, these organisms were rarely isolated if no PMNL were present. Fewer cultures gave positive results for these organisms if micturition had occurred less than four hours before examination. C trachomatis was recovered from the urethra or endocervix in 29/150 (19 . 3%) and from the urethra alone in six women. In contrast, N gonorrhoea was never recovered from the urethra in the absence of endocervical infection. Of the 159 women 10% had bacteriuria due to non-sexually transmissible agents; 50% had asymptomatic bacteriuria. All, however, had other urethral pathogens isolated as well. Thus, sexually transmitted disease agents are highly prevalent in women attending an STD clinic who have signs and symptoms of urethritis. As in non-gonococcal urethritis in men, C trachomatis may be an important cause of urethritis in women.

Gonococcal tenosynovitis-dermatitis and septic arthritis. Intravenous penicillin vs oral erythromycin

Twenty-three patients with disseminated gonococcal infections--15 with acute tenosynovitis, six with septic monoarticular arthritis, and two with both--were randomly given five days of erythromycin stearate or estolate, 500 mg orally every six hours (13 patients), or crystalline aqueous penicillin G potassium, 1 million units intravenously every three hours for three days (ten patients). There were no treatment failures. Cultures taken one and seven days and two and four weeks after completion of therapy were uniformly negative. Clinical resolution was rapid in both groups, as judged by response of fever, joint tenderness, and disappearance of joint effusion. Orally administered erythromycin is a useful alternative to penicillin in the treatment of disseminated gonococcal infections, particularly in penicillin-allergic pregnant women.