Oxalate Determination: Analytical Problems Encountered with Certain Plant Species

Accurate quantitative determination of oxalate in chemical analyses of edible plants is important because oxalate is a poisonous compound. The traditional KMn04-oxalate reduction-oxidation (Dye) method of analyzing for plant oxalate content presents two problems: (a) Plant pectins are not entirely separated in the determination of watersoluble oxalate and interfere in the oxidation of oxalate; and (b) a brownish-black precipitate containing ferrous iron is precipitated at the same pH as calcium oxalate and the precipitate interferes in determination of both water- and acid-soluble oxalate. Our modification of the Dye method consists of (a) using double-distilled water as the diluting medium, (6) increasing the acidity of the water-soluble oxalate medium after plant digestion to obtain complete removal of pectins, and (c) eliminating the ferrous iron-containing precipitate by filtration. Oxalate in the ferrous iron-containing precipitate is determined as calcium and magnesium salts by atomic absorption spectrophotometry; the value thus obtained is added to the oxalate value from the oxidation- reduction method. An indirect analytic method for oxalate, in which all of the oxalate was precipitated as the calcium salt and then measured by atomic absorption spectrophotometry, proved to be inaccurate

The safety and efficacy of adefovir dipivoxil in patients with advanced HIV disease: a randomized, placebo-controlled trial

OBJECTIVE

Efficacy and safety of adefovir dipivoxil (adefovir) added to background antiretroviral therapy in advanced HIV disease.

DESIGN

Randomized, double-blind, placebo-controlled multicenter trial.

SETTING

Fifteen clinical trial units providing HIV primary care.

PARTICIPANTS

Adults with CD4 cell count < or = 100 x 10(6)/l, or 101-200 x 10(6)/l with prior nadir < or = 50 x 10(6)/l.

INTERVENTIONS

Oral adefovir or placebo 120 mg once daily.

MAIN OUTCOME MEASURES

Survival, cytomegalovirus (CMV) disease, plasma HIV-RNA, CD4 cell count, grade 4 drug toxicity, permanent drug discontinuation due to toxicity.

RESULTS

Among the 253 patients assigned adefovir and the 252 assigned placebo, respectively, 17 and 16 died (P = 0.88), and four and eight experienced CMV disease (P = 0.25). Mean change in log(10) plasma HIV-RNA in the adefovir and placebo groups, respectively, was 0.09 and -0.03 copies/ml at 6 months (P = 0.22) and 0.06 and -0.02 at 12 months (P = 0.87). Changes in CD4 cell counts were not different between groups. At 12 months the cumulative percent with proximal renal tubular dysfunction (PRTD) was 17% in the adefovir group and 0.4% in the placebo group (P < 0.0001, log rank test). Median time to resolution of PRTD was 15 weeks among patients assigned adefovir, and 16% of patients did not resolve completely 41 weeks after onset. More drug discontinuations occurred in the adefovir group than in the placebo group.

CONCLUSIONS

No virologic or immunologic benefit was observed when adefovir was added to background antiretroviral therapy in advanced HIV disease, and adefovir was associated with considerable nephrotoxicity. This study does not support the use of adefovir for treatment of advanced HIV disease in pretreated patients.

Screening CT of the brain determined by CD4 count in HIV-positive patients presenting with headache

BACKGROUND AND PURPOSE

Few studies have examined HIV-positive patients presenting with uncomplicated headache for clinical variables that might be predictive of those patients who would most benefit from CT. Because of the value of CD4 counts in predicting the relative risk of developing opportunistic infections and neoplasms, we assessed the diagnostic yield of screening CT in HIV-positive patients presenting with headache as sorted by CD4 count.

METHODS

We reviewed CT scan results and CD4 counts in patients presenting with headache uncomplicated by altered mental status, meningeal signs, neurologic findings, or symptoms of subarachnoid hemorrhage. For analysis, scans were considered positive or negative and were grouped according to CD4 counts of less than 200 cells/microL, 200 to 499 cells/microL, and equal to or greater than 500 cells/microL. The results were then analyzed using the chi2 test.

RESULTS

One hundred seventy-eight HIV-positive patients underwent a total of 204 unenhanced and contrast-enhanced CT examinations. One hundred twenty-eight (62.7%) of the scans were negative, and 76 (37.3%) were positive. Of the positive scans, 58 (76.3%) showed atrophy only and 18 (23.7%) showed mass lesions or white matter lesions. All cases that were positive for mass lesions or white matter lesions occurred in patients with CD4 counts less than 200 cells/microL (P = .04).

CONCLUSION

A recent CD4 count provides an important predictor variable when considering performing CT in HIV-positive patients presenting with uncomplicated headache. Performing CT of the head for patients with CD4 counts equal to or greater than 200 cells/microL is of questionable value considering the low prevalence of positive CT findings. For this select group of patients, MR imaging may be more appropriate than CT. Patients with CD4 counts less than 200 cells/microL should undergo CT because of the high prevalence of positive scans.

A prospective randomized trial of four three-drug regimens in the treatment of disseminated Mycobacterium avium complex disease in AIDS patients: excess mortality associated with high-dose clarithromycin. Terry Beirn Community Programs for Clinical Research on AIDS

The optimal regimen for treatment of Mycobacterium avium complex (MAC) disease has not been established. Eighty-five AIDS patients with disseminated MAC disease were randomized to receive a three-drug regimen of clarithromycin, rifabutin or clofazimine, and ethambutol. Two dosages of clarithromycin, 500 or 1,000 mg twice daily (b.i.d.), were compared. The Data and Safety Monitoring Board recommended discontinuation of the clarithromycin dosage comparison and continuation of the rifabutin vs. clofazimine comparison. After a mean follow-up of 4.5 months, 10 (22%) of 45 patients receiving clarithromycin at 500 mg b.i.d. had died (70 deaths per 100 person-years) compared with 17 (43%) of 40 patients receiving clarithromycin at 1,000 mg b.i.d. (158 deaths per 100 person-years) (relative risk, 2.43; 95% confidence interval, 1.11-5.34; P = .02). After 10.4 months, 20 (49%) of 41 patients receiving rifabutin had died (81 deaths per 100 person-years) compared with 23 (52%) of 44 patients receiving clofazimine (94 deaths per 100 person-years) (relative risk, 1.20; 95% confidence interval, 0.65-2.19; P = .56). Bacteriologic outcomes were similar among treatment groups. In treating MAC disease in AIDS patients, the maximum dose of clarithromycin should be 500 mg b.i.d.

Cost-minimization analysis: A follow-up study of a telemedicine program

OBJECTIVE

To present the follow-up findings to a cost-benefit analysis of telemedicine subspecialty services provided between the Powhatan Correctional Center (PCC) of the Virginia Department of Corrections and the Medical College of Virginia Campus of Virginia Commonwealth University (MCV Campus).

METHODS

Costs included those of operating the telemedicine system, transportation, litigation avoidance, and the medical care itself.

RESULTS

Over a 12-month study period, the total number of consults completed through telemedicine was 290. The cost per visit of treating inmates at the MCV Campus clinics was $401. The cost per visit of treating inmates at PCC via telemedicine was $387, a net saving of $14 per visit with the use of telemedicine.

CONCLUSION

As a result of implementing telemedicine, the Department of Corrections for the State of Virginia was able to achieve a cost saving of $14 per visit. Nonmonetary cost savings, such as greater security and increased access to care, should be considered a net benefit as well.

The role of the mesangial cell and its matrix in the pathogenesis of diabetic nephropathy

Mesangial cells are pericyte-like cells which are found the glomeruli of the kidney. It is well known that they have important contractile and synthetic properties regulating the function of the glomerulus. During diabetes the synthesis of various extracellular matrix (ECM) components by mesangial cells are increased. In recent years it has been recognized that degradation of ECM may also be decreased in diabetes, contributing to the process of mesangium accumulation. The major enzymes responsible for ECM degradation are a large group of enzymes collectively known as matrix metalloproteinases (MMPs). The physiology of MMPs is complex and their activity is tightly regulated at many levels. The MMPs are synthesized as proenzymes and require activation via catalytic cleavage to become fully active. In this regard it is of importance that the mesangial cell and its pericellular matrix have a very active plasminogen cascade that can liberate plasmin locally to mediate matrix degradation both directly and indirectly, by activating the MMPs. In addition, the MMPs are regulated by transforming growth factor beta (TGF-beta). There is evidence that each of these pathways regulating the matrix degradation is affected by the diabetic environment and this will be the subject of this contribution.

Administration of ascorbic acid and an aldose reductase inhibitor (tolrestat) in diabetes: effect on urinary albumin excretion

The important role of ascorbic acid (AA) as an anti-oxidant is particularly relevant in diabetes mellitus where plasma concentrations of AA are reduced. This study was conducted to evaluate the effects of treatment with AA or an aldose reductase inhibitor, tolrestat, on AA metabolism and urinary albumin excretion in diabetes. Blood and urine samples were collected at 0, 3, 6, 9, and 12 months from 20 diabetic subjects who were randomized into two groups to receive either oral AA 500 mg twice daily or placebo. Systolic and diastolic blood pressures, HbA1c, plasma lipids, urinary albumin, and total glycosaminoglycan excretion were measured at all time points, and heparan sulphate (glycosaminoglycan) was measured at 0 and 12 months. The same parameters, as well as urinary AA excretion, were determined at 0 and 3 months for 16 diabetes subjects receiving 200 mg tolrestat/day. AA treatment increased plasma AA (ANOVA, F ratio = 12.1, p = 0.004) and reduced albumin excretion rate (AER) after 9 months (ANOVA, F ratio = 3.2, p = 0.03), but did not change the other parameters measured. Tolrestat lowered plasma AA (Wilcoxon's signed-rank test, p < 0.05), but did not change AER or the other parameters measured. The ability of AA treatment to decrease AER may be related to changes in extracellular matrix or improvement in oxidative defence mechanism. Unlike the rat model of diabetes, inhibition of aldose reductase did not normalize plasma AA or AER in humans. In fact, tolrestat reduced the plasma AA concentration, a phenomenon which may be due to increased utilization of AA. Dietary supplementation of AA in diabetic subjects may have long-term benefits in attenuating the progression of diabetic complications.

Experience with a cross-study endpoint review committee for AIDS clinical trials. Terry Beirn Community Programs for Clinical Research on AIDS

OBJECTIVES

To describe the methods and results of a standardized system for clinical endpoint determination for defining and reviewing endpoints in clinical trials for HIV-infected individuals.

DESIGN

A system was developed utilizing standard definitions for the 24 diagnoses or clinical events that serve as trial endpoints and together define the combined endpoint 'progression of HIV disease. A common set of case report forms were used for all trials. Thus, an event of Pneumocystis carinii pneumonia (PCP), for example, for a subject co-enrolled in an antiretroviral trial and a PCP prophylaxis trial was only reported once.

METHODS

A central committee was established to define clinical events and review endpoints across all studies. Events were classified according to established criteria for confirmed, probable and possible levels of certainty.

RESULTS

This report describes the methods used to ascertain and review endpoints, and summarized 2299 clinical events for 8097 subjects enrolled in one or more of nine clinical trials. Data on the diagnostic certainty of events and agreement between site clinicians and the endpoint committee are presented.

CONCLUSIONS

Uniform classification of endpoints across AIDS clinical trials can be accomplished by multicenter, multitrial organizations with standardized definitions and review of endpoint documentation. Our experience suggests that nurse coordinators reviewing all submitted endpoints for every trial are warranted and the need for external review by a clinical events committee may depend on the type of trial conducted.

Revision of HIV center medical staging scale

HIV-related symptomatology represents both an indirect measure of immune functioning and a clinically significant indicator of disease progression. The most widely used classification system for HIV-related symptomatology is the Center for Disease Control (CDC) system. Although the CDC scale has widely recognized clinical utility, it provides only nominal-level measurement, which may be problematic for both clinicians and researchers. This article describes the revision and validation of the HIV Center Medical Staging Scale (rHCMSS), and ordinal-level physical illness scale that provides a means of independently measuring the progression of HIV-disease symptomatology and immunological decline. Concurrent use of the rHCMSS, the CDC classification system, and T-lymphocyte and viral load data will provide a more comprehensive indication of HIV-disease progression for clinical and research purposes.

High glucose inhibits effect of ascorbic acid on [35S] sulphate incorporation in mesangial cell and matrix proteoglycan

Expansion of the glomerular mesangium is a consistent finding of diabetic nephropathy. Negatively charged proteoglycans are an integral part of the mesangium and their synthesis and degradation is disturbed in many forms of glomerulosclerosis. The metabolism of ascorbic acid (AA), which plays an important role in extracellular matrix regulation, is known to be abnormal in diabetes. The action of AA has also been shown to be inhibited by high glucose (HG) concentration. In this study we investigated the effect of AA and HG on proteoglycan (PG) synthesis by examining the incorporation of [35S] sulphate into PG in the cellular, matrix and media components of rat mesangial cell (MC) cultures. MC were grown in 9 or 25 mM glucose for 8 days, with and without the addition of AA. Sulphation of PG was measured by adding 50 microCi of [35S] sulphuric acid to the culture medium and precipitating 35S-labelled PG with cetylpyridinium chloride. In this study AA was shown to have a stimulatory effect on the overall incorporation of [35S] sulphate into cell and matrix PG and this was inhibited by 25 mM glucose. Correcting for protein synthesis and specific activity of [35S] sulphate showed that HG inhibits AA stimulation by decreasing sulphation of the individual PG molecules. These findings may be of particular importance in the pathophysiology of nephropathy in diabetes, a condition where AA concentration is already compromised.

Drug interaction potential with inhibitors of HIV protease

We conducted a retrospective chart review to estimate the potential for drug interactions in subjects infected with the human immunodeficiency virus-1 when a protease inhibitor was added to existing therapy. Medical records of 50 patients in each of three immunologic strata (CD4 cell counts/microl < 100, 100-199, 200-500) were randomly selected from records of all patients receiving care at the clinic; 114 records were evaluable. The probabilities of one interaction or more were 31%, 42%, and 77% of patients if treated with indinavir, saquinavir, and ritonavir, respectively, across all CD4 groups; when the CD4 count was below 100 cells/microl, the probabilities were 55%, 63%, and 93%. Many of these interactions, however, resulted from administration of rifabutin, a drug likely to decrease in importance as less toxic alternatives become more widely administered. The potential for drug interactions is high when starting protease inhibitor therapy, especially in patients with low CD4 cell counts who receive ritonavir. Concurrent therapy must be evaluated before treatment, as many agents are either contraindicated or require dosage modification.

High glucose reduces generation of plasmin activity by mesangial cells

Mesangium enlargement is a central feature of diabetic nephropathy and almost certainly plays a pathogenic role in this condition. Previous studies have shown that mesangium degradation is reduced in a high glucose mileau. Plasmin has been shown to play an important role in extracellular matrix degradation, both directly and through its ability to activate the matrix metalloproteinases. We therefore investigated how high glucose concentration may affect the various components of the plasminogen cascade on mesangial cells and whether it impairs the ability of the mesangial cell to generate plasmin activity. Result showed decreased binding of plasminogen and the urokinase type plasminogen activator to the mesangial cell surface while the tissue type plasminogen activator and the plasminogen activator-1 associated with mesangial cells were increased. The net effect of these changes was a reduced capacity of mesangial cell layers to generate plasmin activity in a high glucose environment. We postulate that this may be of importance in the reduced mesangium degradation which occurs in diabetes.

Urinary glycosaminoglycan excretion in NIDDM subjects: its relationship to albuminura

Nephropathy is a serious microvascular complication of diabetes mellitus which is preceded by a period of microalbuminura. Increased loss of proteoglycan (PG) from glomerular basement (GBM) has been postulated to alter glomerular charge selectivity which contributes to urinary loss of albumin. In this study we measured the excretion of urinary glycosaminoglycans (GAG), the degradation products of PG, in 82 non-insulin-dependent (NIDDM) (Type 2) diabetic and 34 non-diabetic subjects. We found that diabetic subjects had a significantly higher GAG urinary excretion rate compared to non-diabetic subjects (12.54 +/- 5.67 vs 8.80 +/- 3.99 micrograms glucuronic acid min-1, p = 0.0001). Categorizing for albuminuric status shows that the diabetic normo-, micro- and macroalbuminuric groups have a higher GAG excretion rate than non-diabetic subjects. Heparan sulphate (HS) GAG urinary excretion was measured in 25 samples from diabetic subjects and 18 non-diabetic subjects. Diabetic subjects excreted more HS GAG than controls both as a rate or as a percentage of total GAG (3.70 +/- 1.94 vs 2.38 +/- 1.48 micrograms glucosamine min-1, p = 0.02; 31.6% +/- 12.5 vs 23.1% +/- 10.4, p = 0.02). Categorizing for albuminuric status shows that micro- and macro-albuminuric groups have a significantly higher HS GAG excretion rate than non-diabetic subjects. We conclude that, as in IDDM, excretion of GAG and HS GAG is higher in NIDDM and may precede the development of microalbuminuria.

Cell-associated proteoglycans of retinal pericytes and endothelial cells: modulation by glucose and ascorbic acid

Abnormalities of retinal pericytes and endothelial cells are prominent features of diabetic retinopathy. In this study, we used cultures of bovine retinal cells to examine the regulation of cell-associated proteoglycans, a class of highly sulfated macromolecules important in the regulation of cell growth. Bovine retinal pericytes and endothelial cells were radiolabeled with 35SO4 and cell-associated proteoglycans were removed from the cell surface, quantified, and characterized. The effects of high glucose concentration (25 mM), phorbol 12,13-dibutyrate (PDBu, 0.1 microM), and ascorbic acid (0.1 mM) on cell-associated proteoglycans and growth of these cells were studied. Our results showed that both the ionically bound and the membrane-intercalated forms of cell-associated proteoglycans are present on retinal cells. The predominant cell-associated proteoglycan of pericytes is chondroitin sulfate and for endothelial cells it is heparan sulfate. High glucose concentration and ascorbic acid increased the cell-associated proteoglycans on pericytes but reduced them on endothelial cells. In contrast to this divergent trend, high glucose concentration and ascorbic acid inhibited the growth of both pericytes and endothelial cells. The effects of high glucose on retinal cell-associated proteoglycans were mimicked by PDBu added in a manner to stimulate protein kinase C activity. We conclude that cell-associated proteoglycans are present on retinal pericytes and endothelial cells. High glucose concentration and ascorbic acid affect cell-associated proteoglycans of these two cell types in opposite directions, whereas both suppress the growth of the two cell types. Therefore, it is not likely that high glucose concentration and ascorbic acid change the rate of retinal cell growth directly by affecting cell-associated proteoglycan levels.

High glucose concentration causes a decrease in mesangium degradation. A factor in the pathogenesis of diabetic nephropathy

Mesangium enlargement is a constant feature of diabetic nephropathy and is likely to be important in the pathogenesis of this diabetic complication. Whether decreased degradation of mesangium plays any role in causing the enlargement is uncertain. We developed a system of preparing radioactively labeled mesangium matrix from mesangial cell cultures to be used as substrates for studies of mesangium degradation. Degradation is commenced by growing mesangial cells on the labeled matrix and monitored by the release of radioactivity into the culture medium. High glucose concentration (30 mM), whether present 1) when the matrix is being made or 2) when the degradation is taking place, reduces the rate of mesangium degradation. The second but not the first of these two phenomena was abolished by aminoguanidine. Phorbol 12-myristate 13-acetate, added in a manner to antagonize the action of protein kinase C, inhibited mesangium degradation and was not able to nullify the effect of high glucose. Thus it appears unlikely that a high glucose concentration inhibits mesangium degradation by increasing mesangial cell protein kinase C activity. We conclude that decreased degradation of mesangium as a result of hyperglycemia may play a role in causing the mesangium enlargement that occurs in diabetic nephropathy.

Long-term visual morbidity of cytomegalovirus retinitis in patients with acquired immune deficiency syndrome

BACKGROUND

Patient survival with the acquired immune deficiency syndrome (AIDS) and cytomegalovirus (CMV) retinitis is increasing because of earlier diagnosis and improved medical therapy. Visual morbidity that occurs with prolonged survival has not been well described.

METHODS

To evaluate the progression of retinitis, ocular complications, and visual morbidity, the authors retrospectively reviewed the records of 22 patients who had tested positive for human immunodeficiency virus since December 31, 1987. Each patient had an ophthalmologic diagnosis of CMV retinitis and had survived for a minimum of 6 months after diagnosis of retinitis. Patients were treated with intravenous ganciclovir alone, ganciclovir followed by foscarnet, or foscarnet alone (1 patient).

RESULTS

Mean survival was 16.7 months after the diagnosis of retinitis. The retinitis progressed in 74% of eyes during therapy. Visual acuity of 20/70 or worse occurred in 79% of eyes at a mean of 7.6 months from diagnosis of CMV retinitis. No light perception occurred in 49% of eyes after a mean of 15 months patient survival. Eleven patients with visual acuity of 20/70 or worse in both eyes survived a mean of 11 months. In 39 eyes with CMV retinitis, the following complications occurred: retinal detachment (33%), papillitis (32%), branch retinal artery occlusion (10%), persistent iritis (5%), and cataract (2.5%).

CONCLUSION

Improved modalities of therapy will continue to increase the survival of patients with AIDS and CMV retinitis. Progression of the retinitis occurs with current therapeutic regimens in the majority of patients. As survival increases, significant visual loss and ocular complications may compromise patient care and quality of life.

Necrotizing cellulitis caused by Legionella micdadei

Legionella micdadei is primarily considered a pathogen of the pulmonary tract of immunocompromised patients, the majority of whom have been renal transplant recipients. We report the case of a necrotizing soft tissue infection in a cadaveric renal transplant recipient resulting in amputation of the left arm. Only one other extrathoracic bacteriologically documented L. micdadei infection has been reported in the literature.

Feasibility study for neonatal neuroblastoma screening in the United States

Urine was obtained from infants born at two large metropolitan Minneapolis/St. Paul, Minnesota hospitals to determine whether normal levels of urinary catecholamine metabolites in neonates can be used for subsequent neuroblastoma screening as well as to determine compliance with collecting such urine in a voluntary program. The results suggest that there are wide variations in raw values of urinary creatinine, homovanillic acid, and vanillylmandelic acid through the first 4 days of age, apparently because of maternal creatinine and catecholamine metabolite influences. Such maternal influences appear negligible by 3 weeks of age. Furthermore, the study suggests that voluntary compliance in the United States with collecting urine at home without rigorous public education and/or methods for reminding parents may be very poor.

Nocardia asteroides aortitis with perforation of the aorta

A 53-year-old man died of nocardial aortitis eight months after undergoing aortic valve replacement. Autopsy revealed vegetation in the area of a previous aortotomy incision and a small perforation of the aorta enclosed by pericardium immediately above the prosthetic valve ring. Prosthetic valve endocarditis was not present. Multiple splenic infarcts, microabscesses of both kidneys, and myocarditis were identified. Antemortem blood cultures and postmortem cultures of the aortic vegetation grew Nocardia asteroides.

Dengue with hemorrhagic manifestations: an imported case from the Middle East

We report a case of imported dengue with hemorrhagic manifestations seen in a patient who had recently returned from South Yemen. Conspicuous laboratory findings were marked thrombocytopenia and increase in the number of "transformed" lymphocytes. Hemagglutination-inhibition and complement-fixation antibody titers suggest a secondary heterotypic type of infection. Further studies should be done to establish the endemic nature of dengue throughout Yemen and adjacent countries on the Arabian peninsula.

An outbreak of gentamicin-resistant Klebsiella pneumoniae: analysis of control measures

In April 1978, a strain of gentamicin-resistant Klebsiella pneumoniae (GRK) was introduced into the neonatal intensive care unit of Henry Ford Hospital. An additional ten cases of GRK occurred over the subsequent 16 months and intestinal colonization occurred in up to 91% of admissions per month. All GRK were susceptible to amikacin and were capsular serotype 19. Though hand contamination of hospital personnel with GRK was documented, increased handwashing practices did not reduce colonization rates of neonates with the epidemic strain. Intestinal carriage persisted for up to ten months and could not be eradicated by administering oral colistin sulfate. Discontinuation of gentamicin and utilization of amikacin were associated with a significant reduction in colonization with GRK (p less than 0.05). However, the only control measure that prevented both new cases and colonization with the epidemic strain was the utilization of a strict cohort system.

Osteomyelitis of the pubis. Report of seven cases

Seven cases of osteomyelitis of the pubis are reported. Predisposing factors leading to osteomyelitis included parenteral drug abuse in six patients and pelvic surgery in one patient. The average duration of symptoms before diagnosis was three weeks. Needle aspiration of the symphysis pubis was performed in five patients, and culture results were positive in three of them. Two patients with negative cultures of needle aspirates had positive cultures from open biopsy specimens of the symphysis pubis. Blood cultures were done in all patients, and results were positive in two of them. Pseudomonas aeruginosa was the responsible pathogen in five patients, Escherichia coli in one, and Staphylococcus aureus in one. Most patients required several weeks of antibiotic therapy. None required surgical debridement.

Ceforanide: in vitro and clinical evaluation

Ceforanide, a new cephalosporin antibiotic with a long half-life (3 h), can be administered twice daily. We evaluated its antimicrobial activity, pharmacology, and clinical efficacy. Twenty-seven patients with infections due to susceptible organisms received ceforanide, 0.5, 1, or 2 g, intramuscularly or intravenously every 12 h for 6 to 28 days. In vitro studies with the clinical isolates from 27 patients treated plus 263 additional isolates showed that ceforanide was active against cephalothin-susceptible gram-positive and gram-negative microorganisms. In addition, ceforanide inhibited 65% of cephalothin-resistant Escherichia coli and 65% of Enterobacter spp. at </=12.5 mug/ml. After a single 1-g intramuscular dose, the mean peak plasma concentration at 1 h was 48.9 mug/ml and that at 12 h was 4.7 mug/ml. Plasma accumulation occurred in some patients. The infections included 10 pneumonias, 3 with bacteremia and 1 with empyema; 11 soft tissue infections, 4 with abscesses and 3 with sepsis; and 3 urinary tract infections. One case each of endocarditis, osteomyelitis, and septic thrombophlebitis, all due to Staphylococcus aureus, were treated. Clinical response was satisfactory in all patients; bacteriological response was satisfactory in 26 of 27 patients. Ceforanide was well tolerated. Three patients developed mild increases in liver enzymes, and one developed slight eosinophilia. In another case, the antibiotic was discontinued because of a fivefold rise in serum glutamic-oxalacetic transaminase (aspartate aminotransferase) and serum glutamic-pyruvic transaminase (alanine aminotransferase) and a twofold rise in lactic acid dehydrogenase and alkaline phosphatase.

Optometric education in Nigeria

A 3-year optometry program was established at the University of Benin, Nigeria in 1973. The program is considered from the standpoint of curriculum, faculty, clinical instruction, and grading. Some background is given about Nigeria itself. Present eye care facilities are reviewed as well as the increasing requirements of a developing nation. The need of strong support from established optometry schools is indicated.

Parenteral cephalothin therapy for pelvic gonococcal infections

The efficacy of intravenous cephalothin was studied prospectively in 20 patients with acute pelvic inflammatory disease, all of whom presented with lower abdominal pain, cervical and adnexal tenderness, fever, and leukocytosis. Blood, cervical, and cul-de-sac cultures were obtained on admission. The latter was transported anaerobically and inoculated in routine and prereduced medium. Transgrow medium with trimethoprim was used for endocervical cultures. Neisseria gonorrhoeae was isolated from the endocervix in 15 patients and from the cul-de-sac in four patients. All received intravenous cephalothin, 2 gm every four hours for seven days. Clinical improvement was observed in 48 to 78 hours. The cervical cultures were negative for N. gonorrhoeae after 48 hours, at the completion of treatment, and two weeks post-treatment. The drug was well tolerated. It was concluded that cephalothin intravenously is an acceptable alternative antibiotic for the treatment of gonococcal pelvic infection.

Comparative biliary concentrations of cephazolin and cephalothin in patients with biliary tract disease

The concentration of cephazolin in the serum, gall bladder bile, common duct bile, and gall bladder wall were consideredably higher than cephalothin especially with IV administration and indicate that cephazolin should be a useful antibiotic in the surgical treatment of acute cholecystitis.

Clinical studies of cefazolin and comparison with other cephalosporins

Cefazolin, a new cephalosporin derivative, was studied in the treatment of 105 hospitalized patients with a variety of infections including endocarditis, pneumonia, and urinary and soft tissue infections, and was found to be effective in 104 patients. Cefazolin was also tested in vitro and shown to be effective against staphylococci, pneumococci, Escherichia coli, Klebsiella sp., and Proteus mirabilis by agar dilution method. It was shown to produce high serum levels when administered in a 250- to 1,000-mg intramuscular dose and was well tolerated and free from renal toxicity. Comparison of the results of this study with those from our prior studies on cephaloridine revealed equivalent antibiotic potency, good tolerance to both the agents when given intramuscularly, superior, average blood levels with cefazolin, equal clinical efficacy, and absence of renal toxicity with cefazolin (unlike cephaloridine). Similarly, the results of treatment of pneumococcal pneumonia with intramuscular cefazolin were found to be superior to those for oral cephalexin.