Reducing antibiotic treatment duration for ventilator-associated pneumonia (REGARD-VAP): a trial protocol for a randomised clinical trial

INTRODUCTION

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in intensive care units (ICUs). Using short-course antibiotics to treat VAP caused by Gram-negative non-fermenting bacteria has been reported to be associated with excess pneumonia recurrences. The "REducinG Antibiotic tReatment Duration for Ventilator-Associated Pneumonia" (REGARD-VAP) trial aims to provide evidence for using a set of reproducible clinical criteria to shorten antibiotic duration for individualised treatment duration of VAP.

METHODS AND ANALYSIS

This is a randomised controlled hierarchical non-inferiority-superiority trial being conducted in ICUs across Nepal, Thailand and Singapore. The primary outcome is a composite endpoint of death and pneumonia recurrence at day 60. Secondary outcomes include ventilator-associated events, multidrug-resistant organism infection or colonisation, total duration of antibiotic exposure, mechanical ventilation and hospitalisation. Adult patients who satisfy the US Centers for Disease Control and Prevention National Healthcare Safety Network VAP diagnostic criteria are enrolled. Participants are assessed daily until fever subsides for >48 hours and have stable blood pressure, then randomised to a short duration treatment strategy or a standard-of-care duration arm. Antibiotics may be stopped as early as day 3 if respiratory cultures are negative, and day 5 if respiratory cultures are positive in the short-course arm. Participants receiving standard-of-care will receive antibiotics for at least 8 days. Study participants are followed for 60 days after enrolment. An estimated 460 patients will be required to achieve 80% power to determine non-inferiority with a margin of 12%. All outcomes are compared by absolute risk differences. The conclusion of non-inferiority, and subsequently superiority, will be based on unadjusted and adjusted analyses in both the intention-to-treat and per-protocol populations.

ETHICS AND DISSEMINATION

The study has received approvals from the Oxford Tropical Research Ethics Committee and the respective study sites. Results will be disseminated to patients, their caregivers, physicians, the funders, the critical care societies and other researchers.

TRIAL REGISTRATION NUMBER

NCT03382548.

Effectiveness of a sepsis programme in a resource-limited setting: a retrospective analysis of data of a prospective observational study (Ubon-sepsis)

OBJECTIVE

To evaluate the effectiveness of a Sepsis Fast Track (SFT) programme initiated at a regional referral hospital in Thailand in January 2015.

DESIGN

A retrospective analysis using the data of a prospective observational study (Ubon-sepsis) from March 2013 to January 2017.

SETTING

General medical wards and medical intensive care units (ICUs) of a study hospital.

PARTICIPANTS

Patients with community-acquired sepsis observed under the Ubon-sepsis cohort. Sepsis was defined as modified Sequential Organ Failure Assessment (SOFA) Score ≥2.

MAIN EXPOSURE

The SFT programme was a protocol to identify and initiate sepsis care on hospital admission, implemented at the study hospital in 2015. Patients in the SFT programme were admitted directly to the ICUs when available. The non-exposed group comprised of patients who received standard of care.

MAIN OUTCOME

The primary outcome was 28-day mortality. The secondary outcomes were measured sepsis management interventions.

RESULTS

Of 3806 sepsis patients, 903 (24%) were detected and enrolled in the SFT programme of the study hospital (SFT group) and 2903 received standard of care (non-exposed group). Patients in the SFT group had more organ dysfunction, were more likely to receive measured sepsis management and to be admitted directly to the ICU (19% vs 4%). Patients in the SFT group were more likely to survive (adjusted HR 0.72, 95% CI 0.58 to 0.88, p=0.001) adjusted for admission year, gender, age, comorbidities, modified SOFA Score and direct admission to the ICUs.

CONCLUSIONS

The SFT programme is associated with improved sepsis care and lower risk of death in sepsis patients in rural Thailand, where some critical care resources are limited. The survival benefit is observed even when all patients enrolled in the programme could not be admitted directly into the ICUs.

TRIAL REGISTRATION NUMBER

NCT02217592.

Predictive Validity of the qSOFA Score for Sepsis in Adults with Community-Onset Staphylococcal Infection in Thailand

The quick sequential organ failure assessment (qSOFA) score has had limited validation in lower resource settings and was developed using data from high-income countries. We sought to evaluate the predictive validity of the qSOFA score for sepsis within a low- and middle-income country (LMIC) population with culture-proven staphylococcal infection. This was a secondary analysis of a prospective multicenter cohort in Thailand with culture-positive infection due to Staphylococcus aureus or S. argenteus within 24 h of admission and positive (≥2/4) systemic inflammatory response syndrome (SIRS) criteria. Primary exposure was maximum qSOFA score within 48 h of culture collection and primary outcome was mortality at 28 days. Baseline risk of mortality was determined using a multivariable logistic regression model with age, gender, and co-morbidities significantly associated with the outcome. Predictive validity was assessed by discrimination of mortality using area under the receiver operating characteristic (AUROC) curve compared to a model using baseline risk factors alone. Of 253 patients (mean age 54 years (SD 16)) included in the analysis, 23 (9.1%) died by 28 days after enrollment. Of those who died, 0 (0%) had a qSOFA score of 0, 8 (35%) had a score of 1, and 15 (65%) had a score ≥2. The AUROC of qSOFA plus baseline risk was significantly greater than for the baseline risk model alone (AUROC_qSOFA = 0.80 (95% CI, 0.70–0.89), AUROC_baseline = 0.62 (95% CI, 0.49–0.75); p < 0.001). Among adults admitted to four Thai hospitals with community-onset coagulase-positive staphylococcal infection and SIRS, the qSOFA score had good predictive validity for sepsis.

Longitudinal profiling of plasma cytokines in melioidosis and their association with mortality: a prospective cohort study

OBJECTIVES

To characterize plasma cytokine responses in melioidosis and analyse their association with mortality.

METHODS

A prospective longitudinal study was conducted in two hospitals in Northeast Thailand to enrol 161 individuals with melioidosis, plus 13 uninfected healthy individuals and 11 uninfected individuals with diabetes to act as controls. Blood was obtained from all individuals at enrolment (day 0), and at days 5, 12 and 28 from surviving melioidosis patients. Interferon-γ (IFN-γ), interleukin-1β (IL-1β), IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, IL-17A, IL-23, and tumour necrosis factor-α (TNF-α) were assayed in plasma. The association of each cytokine and its dynamics with 28-day mortality was determined.

RESULTS

Of the individuals with melioidosis, 131/161 (81%) were bacteraemic, and 68/161 (42%) died. On enrolment, median levels of IFN-γ, IL-6, IL-8, IL-10, IL-23 and TNF-α were higher in individuals with melioidosis compared with uninfected healthy individuals and all but IFN-γ were positively associated with 28-day mortality. Interleukin-8 provided the best discrimination of mortality (area under the receiver operating characteristic curve 0.78, 95% CI 0.71-0.85). Over time, non-survivors had increasing IL-6, IL-8 and IL-17A levels, in contrast to survivors. In joint modelling, temporal trajectories of IFN-γ, IL-6, IL-8, IL-10 and TNF-α predicted survival.

CONCLUSIONS

In a severely ill cohort of individuals with melioidosis, specific pro- and anti-inflammatory and T helper type 17 cytokines were associated with survival from melioidosis, at enrolment and over time. Persistent inflammation preceded death. These findings support further evaluation of these mediators as prognostic biomarkers and to guide targeted immunotherapeutic development for severe melioidosis.

Melioidosis in patients with suspected tuberculosis in Cambodia: a single-center cross-sectional study

SETTING

Melioidosis-Burkholderia pseudomallei infection-is increasingly recognized in Cambodia, a country with a high incidence of tuberculosis (TB). Melioidosis and TB can be clinically indistinguishable.

OBJECTIVE

To quantify the proportion of patients with clinically suspected TB who had melioidosis by testing sputum for B. pseudomallei.

DESIGN

This was a prospective, 6-month cross-sectional single-center study at a Cambodian provincial referral hospital among patients with suspicion of TB who provided sputum specimens for testing. TB was diagnosed using sputum Xpert^® MTB/RIF molecular assay or culture; melioidosis was diagnosed using sputum culture for B. pseudomallei.

RESULTS

Of 404 patients evaluated for possible TB, 52 (12.9%, 95%CI 9.8-16.5) had TB. Four patients (1.0%, 95%CI 0.3-2.5) had melioidosis; none had concurrent TB or an existing medical risk factor for melioidosis, although two were farmers, an occupational risk factor.

CONCLUSION

One per cent of patients being evaluated for TB at a Cambodian provincial referral hospital had culture-proven respiratory melioidosis, a highly lethal infection. None had previously recognized medical conditions that would increase their risk of melioidosis. Testing for melioidosis should be considered in patients presenting with suspected TB in Cambodia.

Macrophage-targeted drugamers with enzyme-cleavable linkers deliver high intracellular drug dosing and sustained drug pharmacokinetics against alveolar pulmonary infections

Intracellular bacterial infections localized to the lung alveolar macrophage (AM) remain one of the most challenging settings for antimicrobial therapy. Current systemic antibiotic treatment fails to deliver sustained doses to intracellular bacterial reservoirs, which necessitates prolonged treatment regimens. Herein, we demonstrate a new intracellular enzyme-cleavable polymeric prodrug with tailored ciprofloxacin release profiles in the lungs and AM. The targeted polymeric prodrug, termed "drugamers", incorporates (1) hydrophilic mannose residues to solubilize the antibiotic cargo and to target and enhance AM uptake and intracellular delivery, and (2) enzyme-cleavable linkage chemistry to provide high and sustained intracellular AM drug dosing. Prodrug monomers, derived from the antibiotic ciprofloxacin, were synthesized with either an intracellular protease cleavable dipeptide linker or a hydrolytic phenyl ester linker. RAFT polymerization was used to copolymerize the prodrug monomers and mannose monomer to synthesize well-defined drugamers without requiring a post-polymerization conjugation step. In addition to favorable in vivo safety profiles following intratracheal administration, a single dose of the drugamers sustained ciprofloxacin dosing in lungs and AMs above the minimum inhibitory concentration (MIC) over at least a 48 h period. The enzyme-cleavable therapeutic achieved a >10-fold increase in sustained ciprofloxacin in AM, and maintained a significantly higher whole lung PK as well. Ciprofloxacin dosed in identical fashion displayed rapid clearance with a half-life of approximately 30 min. Notably, inhalation of the mannose-targeted ciprofloxacin drugamers achieved full survival (100%) in a highly lethal mouse model of pneumonic tularemia, contrasted with 0% survival using free ciprofloxacin. These findings demonstrate the versatility of the drugamer platform for engineering the intracellular pharmacokinetic profiles and its strong therapeutic activity in treating pulmonary intracellular infections.

TLR4 genetic variation is associated with inflammatory responses in Gram-positive sepsis

OBJECTIVES

To identify important pathogen recognition receptor (PRR) pathways regulating innate immune responses and outcome in Staphylococcus aureus sepsis.

METHODS

We analysed whether candidate PRR pathway genetic variants were associated with killed S. aureus-induced cytokine responses ex vivo and performed follow-up in vitro studies. We tested the association of our top-ranked variant with cytokine responses and clinical outcomes in a prospective multicentre cohort of patients with staphylococcal sepsis.

RESULTS

An intronic TLR4 polymorphism and expression quantitative trait locus, rs1927907, was highly associated with cytokine release induced by stimulation of blood from healthy Thai subjects with S. aureus ex vivo. S. aureus did not induce TLR4-dependent NF-κB activation in transfected HEK293 cells. In monocytes, tumor necrosis factor (TNF)-α release induced by S. aureus was not blunted by a TLR4/MD-2 neutralizing antibody, but in a monocyte cell line, TNF-α was reduced by knockdown of TLR4. In Thai patients with staphylococcal sepsis, rs1927907 was associated with higher interleukin (IL)-6 and IL-8 levels as well as with respiratory failure. S. aureus-induced responses in blood were most highly correlated with responses to Gram-negative stimulants whole blood.

CONCLUSIONS

A genetic variant in TLR4 is associated with cytokine responses to S. aureus ex vivo and plasma cytokine levels and respiratory failure in staphylococcal sepsis. While S. aureus does not express lipopolysaccharide or activate TLR4 directly, the innate immune response to S. aureus does appear to be modulated by TLR4 and shares significant commonality with that induced by Gram-negative pathogens and lipopolysaccharide.

Challenges and solutions of remote sensing at offshore wind energy developments

Radar is becoming an important tool used to gather data on bird and bat activity at proposed and existing land-based wind energy sites. Radar will likely play an even more important role at the increasing development of wind energy offshore, given both the lack of knowledge about bird and bat activity offshore and the increased difficulty in obtaining offshore information. Most radar studies to date have used off-the-shelf or modified marine radars. However, there are several issues that continue to hinder the potential usefulness of radar at wind energy sites, with offshore sites providing a particular suite of challenges. We identify these challenges along with current or developing solutions.

[Frequency of occurrence of Hepatitis C virus markers and risk factors among hospital personnel in the Novosibirsk region]

The occurrence of markers, the genotypic variety of isolates and the profile of risk factors with respect to viral hepatitis C among 629 employees of the Regional Clinical Hospital (RCH) in Novosibirsk and 1,020 employees of the Central District Hospital (CDH) in Iskitim were studied in a cross-sectional investigation. The occurrence of hepatitis C virus (HCV) markers was 5.1% in RCH and 2.2% in CDH. Among the risk factors in the population under study were: the medical history of blood transfusions (TF) with 0 TF, anti-HCV = 2.3%; 1 TF, = 5.7% > 1 TF, = 13.5% (p < 0.001); general anesthesia (GA) with < or = 2 GA, anti-HCV = 2.8%; > 2 GA, = 7.8% (p = 0.002); surgical interventions (SU) with 0 SU, = 1.9%; > 0 SU, = 4.3% (p = 0.012); the intravenous use of drugs (OR = 31.8); age (< or = 25 years, anti-HCV IgG = 8.6% > 25 years, = 4.5%); the number of partners of the opposite sex < or = 4 partners, = 2.4%; > 4 partners, = 6.9%; p < 0.001). The probable risk factors at a working place (pricks and cuts, contamination of mucous membranes with blood and other biological fluids, etc.) proved to be faintly related with the status of HBV infection. HBV isolates detected in the examined persons (35 examinees) were distributed by genotypes as follows: 60% of subtype 1b, 28.6% of subtype 2a/2c, 11.4% of subtype 3a. HBV of genotype 1a was not detected in the examined specimens, while the detection rate of genotype 2a/2c was considerably greater than in specimens obtained in the European and Asian parts of Russia (according to the data reported earlier).

Outcome of meningitis caused by Streptococcus pneumoniae and Haemophilus influenzae type b in children in The Gambia

In developing countries, endemic childhood meningitis is a severe disease caused most commonly by Streptococcus pneumoniae or Haemophilus influenzae type b (Hib). Although many studies have shown that fatality rates associated with meningitis caused by these organisms are high in developing countries, little is known about the long-term outcome of survivors. The purpose of this study was to assess the importance of disabilities following pneumococcal and Hib meningitis in The Gambia. 257 children aged 0-12 years hospitalized between 1990 and 1995 with culture-proven S. pneumoniae (n = 134) or Hib (n = 123) meningitis were included retrospectively in the study. 48% of children with pneumococcal meningitis and 27% of children with Hib meningitis died whilst in hospital. Of the 160 survivors, 89 (55%) were followed up between September 1996 and October 1997. Of the children with pneumococcal meningitis that were traced, 58% had clinical sequelae; half of them had major disabilities preventing normal adaptation to social life. 38% of survivors of Hib meningitis had clinical sequelae, a quarter of whom had major disabilities. Major handicaps found were hearing loss, mental retardation, motor abnormalities and seizures. These data show that despite treatment with effective antibiotics, pneumococcal and Hib meningitis kill many Gambian children and leave many survivors with severe sequelae. Hib vaccination is now given routinely in The Gambia; an effective pneumococcal vaccine is needed.

Long-term morbidity and mortality following hypoxaemic lower respiratory tract infection in Gambian children

Acute lower respiratory infections (ALRI) are the main cause of death in young children worldwide. We report here the results of a study to determine the long-term survival of children admitted to hospital with severe pneumonia. The study was conducted on 190 Gambian children admitted to hospital in 1992-94 for ALRI who survived to discharge. Of these, 83 children were hypoxaemic and were treated with oxygen, and 107 were not. On follow-up in 1996-97, 62% were traced. Of the children with hypoxaemia, 8 had died, compared with 4 of those without. The mortality rates were 4.8 and, 2.2 deaths per 100 child-years of follow-up for hypoxaemic and non-hypoxaemic children, respectively (P = 0.2). Mortality was higher for children who had been malnourished (Z-score < -2) when seen in hospital (rate ratio = 3.2; 95% confidence interval (CI) = 1.03-10.29; P = 0.045). Children with younger siblings experienced less frequent subsequent respiratory infections (rate ratio for further hospitalization with respiratory illness = 0.15; 95% CI = 0.04-0.50; P = 0.002). Children in Gambia who survive hospital admission with hypoxaemic pneumonia have a good prognosis. Survival depends more on nutritional status than on having been hypoxaemic. Investment in oxygen therapy appears justified, and efforts should be made to improve nutrition in malnourished children with pneumonia.

The dexamethasone suppression test and treatment outcome in elderly depressed patients participating in a placebo-controlled multicenter trial involving moclobemide and nortriptyline

The dexamethasone suppression test (DST) was conducted in 95 elderly DSM-III-R depressed patients randomized for treatment with moclobemide (MOC; 400 mg daily), nortriptyline (NT; 75 mg daily), or placebo (PBO) in a 7-week double-blind multicenter study. Patients were assessed weekly using various clinical scales, including the 17-item Hamilton Depression Rating Scale. The DST was administered at baseline and at the end of treatment. At baseline, no relationship was found between DST status and the various clinical scales used. At the end of treatment, suppressors (DST-) had significantly improved clinical ratings compared to nonsuppressors (DST+), and were mostly found among those treated with NT (71%) as compared to MOC (41%) or PBO (33%) (p < .03). On the other hand, baseline DST measures influenced treatment outcome; DST+ patients had a greater number of treatment responders to NT (48%) than MOC (19%) or PBO (20%) (p < .07). For DST- patients, the situation was reversed: NT, 7%; MOC, 31%. Postdexamethasone cortisol levels were lower in MOC responders (p < .07). An interaction was found between DST and drug-specific response. The DST may be a useful adjunct for predicting and evaluating the outcome of antidepressant therapy.

Comparison of fluvoxamine, imipramine, and placebo in the treatment of outpatients with panic disorder

Fluvoxamine and imipramine were compared to placebo in an 8-week doubleblind randomized multicentre trial comprising of 148 outpatients between 19 and 57 years of age (mean: 35) with a DSM-III-R diagnosis of Panic Disorder. mean daily dose at endpoint was: fluvoxamine, 171.4 mg; imipramine 164.7 mg. The mean number of panic attacks per week at baseline were 10.9, 14.4 and 6.5 for fluvoxamine, imipramine and placebo, respectively. The intent-to-treat analysis of the change from baseline (difference score) of the number of panic attacks at endpoint revealed: a difference of 3.3 attacks (95% CI: -0.3, 6.8) between fluvoxamine and placebo and a difference of 6.0 attacks (95% CI: 1.5, 10.5) between imipramine and placebo. Treatment was stopped prematurely in 31 (62%) on fluvoxamine, 16 (33%) on imipramine and 29 (58%) on placebo. The number of patients withdrawing due to intolerance was 13 (26%) for fluvoxamine, 10 (21%) for imipramine and 4 (8%) for placebo. The number of patients withdrawing due to lack of efficacy was 10 (20%) for fluvoxamine, 4 (8%) for imipramine and 12 (24%) for placebo. Overall, this study demonstrated that fluvoxamine was not effective in the treatment of panic disorder but did show a strong effect for imipramine. A chance occurrence of significantly fewer number of panic attacks in the placebo group at baseline may limit the conclusions of this study.

Peripartum hypopituitarism and lymphocytic hypophysitis

The classical cause of postpartum hypopituitarism is Sheehan's syndrome, in which an obstetric catastrophe is associated with hypotension. However, with improvements in obstetric care, the most common cause now may be lymphocytic hypophysitis. Five women with postpartum hypopituitarism, whose symptoms occurred during or immediately after pregnancy, had detailed endocrine and pituitary imaging for the duration of follow-up. Two presented with visual symptoms, and three with non-specific illnesses related to varying deficiencies of anterior pituitary hormones. Four were unable to lactate, and four were initially amenorrhoeic. Initially, four of the five women had enlarged pituitary glands on magnetic resonance imaging. Four have to some extent recovered pituitary function. One patient had associated thyroiditis: in two cases antinuclear antibodies became positive during follow-up, and in one of these dsDNA antibody was also detected. In no case were pituitary antibodies detected. None had complicated pregnancies or deliveries, and the two who had caesarean sections had no episodes of hypotension. The presentation of secondary hypothyroidism combined with ACTH deficiency in four of the five women strongly suggests lymphocytic hypophysitis. This diagnosis should be considered in postpartum women with general malaise and persistent amenorrhoea, as well as in women who develop visual impairment in the last trimester of pregnancy without antecedent pituitary disease. A conservative policy of management of the pituitary enlargement should be pursued as this resolves.

Reversible and selective inhibitors of monoamine oxidase A in the treatment of depressed elderly patients

The treatment of depression in the elderly population needs a thorough and careful work-up and an aggressive therapeutic approach. Any treatment initiative in this population often becomes difficult because of accompanying physical illness, concomitant medication, possible degenerative changes in central nervous system and age-related altered metabolic status. Despite unevenness in research findings, pharmacological treatment remains the mainstay of management of depression among elderly people. Currently available antidepressants, although effective, are problematic because of the increased vulnerability of the elderly to side effects. Recent research efforts to improve the efficacy and safety of drug treatment of depression resulted in development of reversible and selective monoamine oxidase inhibitors of the isoenzyme A (RIMA), with antidepressant efficacy comparable to tricyclic antidepressants and newer generation antidepressants. RIMAs include moclobemide, brofaromine, toloxatone and cimoxatone. Moclobemide is the most investigated available RIMA for therapeutic use at present. Its absorption and disposition in elderly individuals do not differ significantly from those in young healthy volunteers and depressed patients. The results of present clinical studies show that, in elderly depressed patients, moclobemide is at least as effective as other antidepressants. Its particular advantage is, however, that it is as well tolerated in elderly people as in younger people. There are only few significant adverse events, and they are generally less frequent and less severe than those with TCAs. An additional attribute of moclobemide seems also to be its beneficial effect on cognitive functions.

Ventral pallidal microinjections of receptor-selective opioid agonists produce differential effects on circling and locomotor activity in rats

Locomotor activity was investigated following microinjections of receptor-selective opioid agonists into the ventral pallidum (VP) of rats. In Expt. 1, male Long-Evans rats were treated with unilateral microinjections of the mu agonist [D-Ala2-MePhe4, Gly-ol5]-enkephalin (DAGO), the delta agonist [D-Pen2, D-Pen5]-enkephalin (DPDPE) or the kappa agonist U50,488H, and the rate and duration of circling behaviour were measured. DAGO (0.01, 0.1, 1.0 nmol) produced a dose-dependent increase in contralateral circling; pretreatment with 1.0 mg/kg naltrexone blocked the circling induced by the highest dose. The behavioral effect was largest when injections were targeted at the VP rather than structures dorsal to the VP. In contast to DAGO, intrapallidal DPDPE (0.01, 0.1, 1.0, 10.0 nmol) produced a slight increase in contralateral circling only at the highest dose and U50, 488H (0.01, 0.1, 1.0, 10.0 nmol) produced no effect. In Expt. 2, the effects of bilateral injections of DAGO, DPDPE and U50,488H were tested in photocell activity boxes. DAGO produced a dose-dependent increase in locomotor activity and this increase was decreased by 1.0 mg/kg naltrexone. A slight increase in activity was observed with the highest dose of DPDPE, and a slight decrease was observed with the highest dose of U50,488H. These findings confirm that opiate actions in the VP contribute to opiate-induced locomotion and suggest that mu and to some extent delta receptors are involved in this behavior.

Multidimensional work sampling to study the activities of decentralized clinical pharmacists

Self-reported multidimensional work sampling (MDWS) was used to study the activities of decentralized clinical pharmacists at six hospitals in Portland, Oregon, and Seattle-Tacoma, Washington, in March through June 1989. A community hospital, a university hospital, and a hospital associated with a health maintenance association were selected in each city, and pharmacists at each site who provided clinical services were recruited. Each pharmacist wore a random reminder device and recorded the activity during which the device sounded by writing on a card numbers assigned to describe work activity, contact, location, and function. Of 6609 classifiable observations, 34.5% (2280) were of clinical activities and 35.8% distributive activities. Pharmacists spent 28.6% of their clinical time reviewing and assessing patients' charts, 17.1% on clinical rounds, 15.9% on activities related to therapeutic drug monitoring, 10.2% providing drug information, 11.6% attending or giving formal education, 6.1% doing research, and 2.6% attending meetings. The average pharmacist spent less than 10 minutes each day with patients but spent a substantial portion of time providing clinical services to other health professionals. Self-reported, multidimensional work sampling appears to be a valuable method for describing and monitoring decentralized pharmacists' work activities at multiple sites and work settings.

Thalidomide: treatment of severe recurrent aphthous stomatitis in patients with AIDS

An increasing number of AIDS patients have been noted to suffer severe recurrent aphthous stomatitis (RAS), a condition often associated with high morbidity that remains unresponsive to conventional therapeutic interventions. In two cases thalidomide was administered to successfully treat AIDS patients with RAS. Both patients experienced complete abatement of pain shortly after therapy was initiated. Ulcerations that were present for months resolved after three or four weeks of thalidomide therapy without any adverse effects. Thalidomide appears to be an effective agent for the treatment of severe RAS unresponsive to traditional therapies.

Effects of naltrexone on nucleus accumbens, lateral hypothalamic and ventral tegmental self-stimulation rate-frequency functions

Rats trained to lever-press for electrical stimulation of the nucleus accumbens, lateral hypothalamus, or ventral tegmental area, were tested with a range of stimulation frequencies to assess the effects of naltrexone (2.5, 5.0, 10.0, 20.0 mg/kg, i.p.) during sessions beginning 15 or 45 min after injection. Naltrexone, when effective, shifted the rate-frequency functions to the right; the magnitude of the effect depended on site of stimulation and on the delay after injection. The greatest effect was observed with stimulation of the nucleus accumbens and the least with stimulation of the ventral tegmental area. There was a greater attenuation of responding during the late test sessions than during the early ones. The time course of naltrexone's effect on brain stimulation reward was determined for the highest dose by measuring a rat's rate of responding over a 3 h period in sessions with immediate access (5-min delay) or delayed access (45-min delay) to stimulation. The greatest decreases in responding were observed 45, 65, and 85 min after injection and the delay in access made little difference. The fact that the drug was more effective 45 min after injection explains some of the inconsistencies in the literature; the fact that its effectiveness was independent of early exposure to stimulation would suggest pharmacological rather than experiential factors as the explanation of the delayed effectiveness.

Primary cardiac lymphoma in a patient with acquired immune deficiency syndrome

A 34-year-old male prisoner with a history of intravenous drug abuse presented with fever, lymphadenopathy, weight loss, and recent onset of congestive heart failure. Serologic testing was positive for antibodies to human immune deficiency virus. There was intense myocardial uptake of gallium. Autopsy showed a primary immunoblastic lymphoma involving only the myocardium. While primary cardiac lymphoma is an extremely rare condition, the incidence may be higher in patients with acquired immune deficiency syndrome (AIDS) and should be suspected in cases with atypical cardiomyopathy.

Immunological characterization of an exopolysaccharide from the Staphylococcus aureus strain Smith diffuse

Exopolysaccharides (EXPs) of Staphylococcus aureus are associated with virulence in animal models. An EXP from the S. aureus strain Smith diffuse was previously detected in 64.3% of S. aureus clinical isolates. EXP was isolated from culture supernatants of this strain after DNAase, RNAase, phosphodiesterase I and lysostaphin treatment, and was further purified by cation-exchange and molecular-sieve chromatography. Isoelectric focusing revealed a pI of 3.6 for the EXP while the pI of teichoic acid was less than 2.7. Crossed immunoelectrophoresis with homologous Smith diffuse antisera indicated that the EXP contained two immunological components. A major precipitin line persisted after the antisera had been absorbed with the non-EXP-producing variant strain, Smith compact, while the second component was removed. Tandem immunoelectrophoresis also demonstrated that the EXP was distinct from teichoic acid. The EXP contained 2-amino-2-deoxyglucuronic acid, glucose, mannose and galactose. No fatty acids or nucleic acids were present and total protein content was less than 2%. Teichoic acid could not be demonstrated in the EXP, thus further substantiating the immunological studies. S. aureus EXP isolated by the present method can be used for further serological and virulence studies.

Mycobacterium haemophilum infection in a patient with acquired immune deficiency syndrome

Mycobacterium haemophilum was isolated from wrist and ankle aspirates as the organism responsible for tenosynovitis in a patient with acquired immune deficiency syndrome. Mycobacterium isolates recovered from synovial fluid were identified as hemin requiring by their failure to grow on subculture unless the medium was supplemented with hemin. M. haemophilum is of low virulence and rarely associated with infections in humans. This is the first documented case of M. haemophilum infection in a patient with acquired immune deficiency syndrome.

Staphylococcal peritonitis in patients on continuous peritoneal dialysis

During 1984, 35 patients undergoing continuous peritoneal dialysis experienced 77 cases of peritonitis with 55 cases (71.4%) related to staphylococci. Coagulase-negative staphylococci were isolated in 41 cases, while Staphylococcus aureus was found in 14. A coexisting tunnel infection was more often associated with S. aureus (7/14) than with coagulase-negative staphylococci (2/41) (P less than 0.01). Likewise, eradication of the infection necessitated catheter removal more frequently with S. aureus (5/14) than with coagulase-negative staphylococci (2/41) (P less than 0.01). Of the 41 coagulase-negative staphylococci, 35 were characterized as to species, adherence, and production of two exopolysaccharides. Staphylococcus epidermidis was the most frequent coagulase-negative species (29/35). Peritonitis cases caused by coagulase-negative staphylococci that lacked adherence and exopolysaccharides were more frequently associated with complications (4/6) than were those organisms with either or both properties of adherence or exopolysaccharide production (5/29). There were no appreciable differences in antibiotic susceptibilities. Staphylococcal peritonitis remains a significant cause of morbidity in continuous peritoneal dialysis patients. The incidence of complications was not directly linked to staphylococcal properties of adherence or exopolysaccharide production.

Adenovirus type 2 encephalitis and concurrent Epstein-Barr virus infection in an adult man

A 30-year-old bisexual male prisoner with a history of intravenous drug abuse manifested encephalitis. Adenovirus type 2 was isolated from brain tissue obtained by a biopsy and there was a concurrent fourfold rise in the antibody titer. In addition, an initial negative result from a slide test for infectious mononucleosis heterophil antibodies (Monospot) test converted to positive and there was an increase in the IgG antibody titer to Epstein-Barr virus (EBV) viral capsid antigen. Although he was anergic to skin test antigens, T-cell subsets and lymphocyte transformation study results were normal. This case demonstrated a rare adenovirus encephalitis with a simultaneous EBV infection in a patient at risk for acquired immunodeficiency syndrome, who had minimal evidence of T-cell deficiency.

Evaluation of a Cordia-IC enzyme-linked immunosorbent assay kit for the detection of circulating immune complexes

A commercial kit (Cordia-IC) from Cordis Laboratory, Miami, Fla., was compared with the Raji cell radioimmunoassay for its ability to detect circulating immune complexes (CIC) in sera from 30 control subjects and 118 patients with infectious diseases. The 118 patients were categorized into the following groups: (i) 23 patients with bacterial endocarditis, (ii) 41 patients with bacteremia from an infected intravascular catheter or access device, and (iii) 54 patients with Staphylococcus aureus bacteremia related to a deep tissue infection. The Cordia-IC was comparable to the Raji cell radioimmunoassay in intraassay variability (4.0 versus 8.0%) and interassay reproducibility (8.7 versus 20.0%). Neither assay found CIC amounts above 12.5 micrograms equivalents (eq) of aggregated human gamma globulin (AHG) per ml in any of the 30 control individuals. In group 1, Cordia-IC detected 19 of 23 positives (mean, 73.6 micrograms eq of AHG per ml), whereas the Raji cell detected 16 of 23 positives (mean, 54.8 micrograms eq of AHG per ml). In group 2, Cordia-IC detected 19 of 41 positives (mean, 20.6 micrograms eq of AHG per ml), whereas the Raji cell detected 16 of 41 positives (mean, 15.1 micrograms eq of AHG per ml). In group 3, Cordia-IC found 38 of 54 positives (mean, 28.0 micrograms eq of AHG per ml), whereas the Raji cell found 32 of 54 positives (mean, 23.9 micrograms eq of AHG per ml). Statistically, these findings were not significantly different in any of the three patient groups (P> 0.15), and there was an overall good correlation between the results obtained by the two assays (r+0.64, P<0.001). The Cordia-IC provided a suitable assay for the detection of CIC and might find application in routine clinical laboratories.

Enzyme-linked immunosorbent assay for detection of immunoglobulin G and M antibodies to teichoic acid in intravascular staphylococcal disease

An enzyme-linked immunosorbent assay (ELISA) for detection of IgG and IgM antibodies to cell-wall teichoic acids of Staphylococcus aureus and three defined coagulase-negative staphylococci was tested using serum samples from 11 cases of intravascular coagulase-negative staphylococcal infections, 13 cases of Staphylococcus aureus endocarditis, and 24 patients with no evidence of infection. IgG antibody titers to all four teichoic acids in the 13 patients with Staphylococcus aureus endocarditis were significantly different from those in noninfected control patients (p less than 0.0001). In contrast, IgG antibody titers in serum from 11 cases of intravascular coagulase-negative staphylococcal infection were not significantly different from those in control sera. There were no differences in IgM antibody titers of the three groups. Although the ELISA was sensitive in detecting Staphylococcus aureus endocarditis, it was not reliable in the detection of intravascular coagulase-negative staphylococcal infections, even when tested with specific teichoic acid.

Antiserum agar method for identification of Smith type exopolysaccharides in clinical isolates of Staphylococcus aureus

We used an antiserum agar method to identify clinical Staphylococcus aureus strains producing an exopolysaccharide antigenically identical to the S. aureus Smith diffuse strain. S. aureus blood isolates were obtained from 137 patients, and three additional isolates were obtained from bone debridement. The 140 patients were clinically divided into the following groups: endocarditis (7 patients); pneumonia, empyema, or both (33 patients); intravascular device (34 patients); superficial or wound infection or both (35 patients); deep tissue infections (18 patients); and 6, unknown bacteremias (13 patients). Ninety (64.3%) of the total 140 S. aureus isolates were found to produce precipitin halos on the antiserum agar. The percentage was greatest in the isolates from the endocarditis group (100%) and least in deep tissue infections (55.5%). The presence of clinical S. aureus strains producing exopolysaccharides antigenically identical to the Smith diffuse strain exopolysaccharide appears to be a common phenomenon.

Detection of encapsulation in Staphylococcus aureus by use of antiserum agar

We examined an antiserum agar method to study its reliability in screening Staphylococcus aureus strains for capsule production. The encapsulated S. aureus Smith diffuse strain was compared with its nonencapsulated variant, Smith compact, in CCY medium containing 0.5% NaCl and 5.0% Smith diffuse rabbit antiserum. A halo was visible surrounding colonies of the Smith diffuse strain but not the Smith compact strain. On this same medium, the protein A-producing Cowan I strain possessed a halo that was visible on photographs. Single high-salt medium is known to inhibit protein A production, halo formation by the strains was also compared in 7.5% NaCl medium. The halo surrounding the Cowan I strain was not present when the salt content of the medium was increased. In contrast, the halo surrounding the Smith diffuse strain persisted in the 7.5% NaCl medium. By use of this medium, the antiserum agar technique may be valuable for the identification of encapsulated staphylococci without appreciable interference from protein A.

Detection of anti-teichoic acid immunoglobulin G antibodies in experimental Staphylococcus epidermidis endocarditis

An enzyme-linked immunosorbent assay (ELISA) was developed for the detection of rabbit immunoglobulin G (IgG) antibodies to purified cell wall teichoic acids from the Staphylococcus aureus Lafferty strain and three strains of coagulase-negative staphylococci. Significant immunological cross-reactivity occurred only between the teichoic acid of S. aureus and one coagulase-negative preparation. The ELISA was used to determine the serum IgG response to Staphylococcus epidermidis in a rabbit model of aortic valve endocarditis. Blood samples were drawn before inoculation and then every 5 days until death or sacrifice at 32 to 35 days postinoculation. Valve vegetations were culture positive at autopsy in 16 (59%) of the 27 catheterized rabbits. Antibody titers in this culture-positive group and the culture-negative group began to rise as early as day 6. Although both groups demonstrated an antibody response, the culture-positive group attained a significantly higher titer on days 26 and 31. Antibodies also rose in a control group of rabbits without a heart catheter but which were inoculated with bacteria. Again, the antibody titer was significantly less than that for the culture-positive group. This ELISA may be useful for the diagnosis of coagulase-negative staphylococcal infections in humans.

Evaluation of a commercial counterimmunoelectrophoresis kit for detection of Staphylococcus aureus teichoic acid antibodies

A commercial kit from Diagnostica, Inc., Miami Fla., was studied for its ability to detect antibodies to the teichoic acids of Staphylococcus aureus. A comparative study of the Diagnostica counterimmunoelectrophoresis (CIE) system and our gel double-diffusion method was undertaken with 156 serum samples from 142 patients. Included were 25 cases of staphylococcal and non-staphylococcal endocarditis, 30 cases of S. aureus bacteremia, 19 cases of nonbacteremic S. aureus infection, 39 cases of hospitalized patients without a staphylococcal infection, and 29 normal controls. Agreement between methodologies was attained in 138 (88.5%) of the 156 samples tested and in 127 (89.4%) of the 142 patients. Of 13 patients with culture-proven S. aureus endocarditis, significant antibody titers were found in all patients (100%) by CIE and in 12 patients (92.3%) by double diffusion. No significant titers were found in normal sera by CIE, but four sera were positive by double diffusion. Of 80 sera from patients with no evidence of S. aureus infection, 4 (5.0%) were positive by CIE and 7 (8.8%) were positive by double diffusion. The Diagnostica CIE kit appears to provide a suitable means for the detection of deep-seated S. aureus infections.

Gallium-67 scintigraphy in abdominal anaerobic abscesses

Three cases of anaerobic abdominal abscesses showing poor uptake on Ga-67 scintiscans are presented. The significance of this and possible mechanisms for it are discussed.

The effects of energy and carbohydrate restriction in patients with chronic diabetes mellitus

Thirty-five freshly presenting, diabetic patients received 5 hour, 100 g oral glucose tolerance tests when first seen and after a period of carbohydrate and energy restriction. After treatment, the significant improvement in glucose tolerance was accompanied by increased insulin secretion and lower concentrations of blood ketone bodies, lactate, glycerol, FFA, triglycerides, cholesterol and pre-beta lipoprotein. There were no significant changes in serum growth hormone or blood pyruvate concentrations. Improvement in glucose tolerance was greater in patients who were obese (greater than 115% of desirable body weight for height) on presentation and was related to the improvement in insulin secretion and the diminished lipolysis. An hypothesis to explain the changes in insulin secretion is prosposed. Eleven out of the 35 patients showed sufficient improvement in glucose tolerance to require no treatment other than diet.

Is the growth-hormone response to insulin due to hypoglycaemia, hyperinsulinaemia or a fall in plasma free fatty acids?

Seven normal male volunteers were given a 2 h intravenous infusion of insulin (2 mu kg-1 min-1). During the first hour, in which nomoglycaemia was maintained by glucose infusion, no detectable increase in growth hormone (GH) secretion occurred. When controlled symptomatic hypoglycaemia was produced during the second hour of the insulin infusion a brisk rise in plasma GH concentration was observed in all the subjects studied. Since it was possible that the falls in the concentration of plasma free fatty acids (FFA) occurring during infusion of insulin also acted as a stimulus to GH release the study was repeated in four subjects but normoglycaemia was maintained throughout the entire 2 h period of insulin infusion. In these experiments there was no rise in plasma GH concentration although a similar fall in plasma FFA was produced. These results clearly indicate that hypoglycaemia per se was the important stimulus to GH secretion and not hyperinsulinaemia or a lowering of plasma FFA. Furthermore there appeared to be a threshold hypoglycaemic stimulus to GH secretion. In no subject was a rise in plasma GH seen without a fall in plasma glucose greater than 1.4 mmol/l. Prolonged mild hypoglycaemia did not stimulate GH secretion.

Evaluation in clinical practice of Dextrostix and the Eyetone Reflectance Meter

Venous blood glucose concentration measured by Dextrostix-Eyetone Reflectance Meter method were compared with conventional enzymatic measurements of plasma glucose in the same 373 blood samples over the range of 0.55-22.2 mmol/l (10-400 mg/100 ml). Agreement between the two methods was good up to 5.5 mmol/l (100 mg/100 ml) but above 11.1 mmol/l (200 mg/100 ml) the Dextrostix-Eyetone method gave higher results for glucose concentration. The Dextrostix-Eyetone method is a reliable means of confirming or refuting the clinical diagnosis of hypoglycaemia and is useful in the day-to-day management of diabetes mellitus in situations where insulin dosage requirements are varying and where access to clinical laboratory facilities are not readily available.

Control of blood glucose during labour in diabetic women with combined glucose and low-dose insulin infusion

During 15 labours in diabetic women blood glucose concentrations were controlled with simultaneous infusion of insulin and glucose. The mean insulin infusion rate was between 1 and 2 U/h. No infant showed evidence of neonatal hypoglycaemia. The procedure is simple to use and may be carried out in any labour ward.

Acromegaly caused by pulmonary carcinoid tumours

Two patients are described whose acromegaly was cured by removal of a bronchial carcinoid tumour. One had an enlarged pituitary fossa and evidence is presented that in this patient the tumour was not secreting growth hormone. The evidence available suggests that the tumour was producing a growth hormone releasing substance. It is suggested that some cases of the pluriglandular syndrome may be secondary to small bronchial carcinoid tumours that produce substances as yet unidentified, that stimulate the growth and hyperactivity of other endocrine tissue.

Horner's syndrome and headache due to carotid artery disease

Horner's syndrome was accompanied by ipsilateral pain in the head, face, or neck in eight patients. In all cases angiography showed narrowing of the internal carotid artery in a pattern compatible with dissection within the arterial wall. In one patient in whom this diagnosis was substantiated by surgical exploration biopsy of the arterial wall showed changes typical of cystic medial necrosis. It is suggested that this clinical presentation constitutes a distinct syndrome.

Metabolic responses to monocomponent human insulin infusions in normal subjects and patients with liver and endocrine disease

Hypoglycaemic and growth hormone responses were studied at different steady-state plasma insulin concentrations during a graded infusion of monocomponent human insulin. The control group consisted of ten volunteer subjects. The other groups studied included women taking oral contraceptives and patients with obesity, thyrotoxicosis, myxoedema, acromegaly, diabetes mellitus (moderate and severe) and liver disease. The hypoglycaemic response was measured in two ways: (i) the percentage reduction in plasma glucose below basal, and (ii) the rate of fall of plasma glucose (Kg-%/min). Insulin sensitivity was greatest in the normal subjects and in the other groups decreased in the order thyrotoxicosis greater than oral contraceptive greater than obesity greater than myxoedema greater than acromegaly greater than liver disease. Insulin sensitivity was difficult to assess in the diabetic patients because basal plasma glucose concentrations were elevated. At any given insulin concentration, the diabetics metabolized approximately the same amount of glucose as the normal subjects but the fact that this rate of glucose turnover occurred at higher plasma glucose concentrations probably indicated insulin resistance. Within each group Kg at each dose level of insulin correlated with the steady state plasma insulin concentration during the same infusion period. Diminishing sensitivity to insulin was reflected in an increasing fasting plasma insulin and insulin/glucose ratio except in patients with diabetes. GH responses to insulin infusion in normal subjects reflected the pattern of fall of plasma glucose. In the diabetic patients GH secretion appeared to be related to the infusion of insulin and occurred before plasma glucose had fallen to hypoglycaemic levels. GH secretory patterns were within normal limits in women taking oral contraceptives and in seven of eleven patients with liver disease but were impaired in three of seven patients with thyrotoxicosis and four of five patients with myxoedema. Four obese patients had a markedly delayed but eventually normal GH response.

Treatment of diabetic coma with continuous low-dose infusion of insulin

Thirty-eight patients in diabetic coma from four different centres were treated with a continuous low-dose intravenous infusion of insulin at an average dose of 7.2 IU/hr. All patients recovered rapidly except for one profoundly shocked patient who died. The mean fall in plasma glucose was 58% four hours after the start of insulin. Blood ketone bodies and plasma free fatty acids showed a similar response. There was no significant difference in plasma glucose response according to severity of acidosis or previous treatment with insulin. Hypokalaemia was uncommon. In the treatment of diabetic coma this technique has proved simple, safe, and effective.