Reductions in spice lead levels in the republic of Georgia: 2020-2022

Spice adulteration using yellow lead chromate-based pigments has been documented as a growing global health concern. Spices from the Republic of Georgia with extremely high levels of lead, up to an order of magnitude higher than any other spices worldwide, have been implicated as sources of child lead poisoning. The objectives of this study were to 1) evaluate lead concentrations in spices sampled across the country of Georgia between 2020 and 2022, and 2) assess factors associated with spice adulteration, specifically the role of spice quality and regulatory enforcement. Spice samples were collected from 29 cities nationwide. The most populous cities were selected in each administrative region as well as those of importance to the spice supply chain. Sampling was carried out at the largest spice bazaars in each city. The regions of Adjara and Imereti were the focus of qualitative interviews conducted in 2021 with key businesspeople selling spices with very high and low levels of lead. The same cities and bazaars were visited at each of three sampling periods between 2020 and 2022. In total, 765 spice samples were collected. Lead concentrations in spices decreased over time, with a maximum of 14,233 μg/g in 2020 down to 36 μg/g in the final sampling round of 2022. A logistic regression determined that sampling round, region and spice type were associated with elevated lead in samples. Samples from Adjara and those containing marigold had the highest lead levels. Interviews with eighteen prominent spice vendors revealed difficulties sourcing sufficient quantities of high quality, brightly colored marigold, and concerns about adulteration. Interviews with two authorities from the National Food Authority highlighted the increased attention on regulating lead in spices since 2018. Continued monitoring and periodic regulatory enforcement may adequately disincentivize further adulteration with lead chromate in the spice industry in Georgia.

Paraneoplastic gastrointestinal dysmotility due to non-Hodgkin diffuse large B cell lymphoma: a case report

Paraneoplastic gastrointestinal dysmotility is a rare entity which occurs in association with malignancy. We present the second case associated with lymphoma, characterised by generalised gastrointestinal dysmotility with constipation, malnutrition, weight loss, and capsule endoscope retention. This case highlights the importance of maintaining a high index of suspicion for malignancy in patients with unexplained gastrointestinal dysmotility.

Rapid Market Screening to assess lead concentrations in consumer products across 25 low- and middle-income countries

Lead exposure can have serious consequences for health and development. The neurological and behavioral effects of lead are considered irreversible. Young children are particularly vulnerable to lead poisoning. In 2020, Pure Earth and UNICEF estimated that one in three children had elevated blood lead levels above 5 µg/dL. The sources of lead exposure vary around the world and can range from household products, such as spices or foodware, to environmental pollution from nearby industries. The aim of this study was to analyze common products from markets in low- and middle-income countries (LMICs) for their lead content to determine whether they are plausible sources of exposure. In 25 LMICs, the research teams systematically collected consumer products (metal foodware, ceramics, cosmetics, paints, toys, spices and other foods). The items were analyzed on site for detectable lead above 2 ppm using an X-ray fluorescence analyzer. For quality control purposes, a subset of the samples was analyzed in the USA using inductively coupled plasma mass spectrometry. The lead concentrations of the individual product types were compared with established regulatory thresholds. Out of 5007 analyzed products, threshold values (TV) were surpassed in 51% for metal foodware (TV 100 ppm), 45% for ceramics (TV 100 ppm), and 41% for paints (TV 90 ppm). Sources of exposure in LMICs can be diverse, and consumers in LMICs lack adequate protection from preventable sources of lead exposure. Rapid Market Screening is an innovative, simple, and useful tool to identify risky products that could be sources of lead exposure.

Drug-induced liver injury from selective androgen receptor modulators, anabolic-androgenic steroids and bodybuilding supplements in Australia

BACKGROUND

Reports of DILI due to herbal and dietary supplements have been increasing over time.

AIMS

To characterise clinical, laboratory and histopathological phenotypes and outcomes of drug-induced liver injury (DILI) due to anabolic-androgenic steroids (AAS), selective androgen receptor modulators (SARMs), and bodybuilding supplements (BBS) in Australia.

METHODS

Retrospective case series. Patients presented to nine Australian tertiary hospitals, 2017-2023. DILI was defined biochemically and patients were included if their treating physician attributed DILI to preceding use of AAS, SARMs or BBS. Primary endpoint was time to normalisation of liver biochemistry. Secondary endpoints were hospitalisation for investigation or management of DILI, death attributable to liver injury, and liver transplantation.

RESULTS

Twenty-three cases of DILI were identified, involving 40 drugs: 18 AAS, 14 SARMs and eight BBS. Patients were predominantly male (22/23), with median age 30 years (IQR 26-42). Most were symptomatic (21/23). Median latency of onset was 58 days (IQR 28-112 days) from drug commencement. Most patients (17/23) were admitted to hospital. Based on updated Roussel Uclaf Causality Assessment Method, DILI was possible in 17/23, probable in 2/23 and unlikely in 4/23. Median time to normalisation of liver biochemistry was 175 days (IQR 70-292 days) from presentation. Three (3/23) were treated with corticosteroids, 14/23 were treated for itch, and one (1/23) underwent liver transplantation. There were no deaths.

CONCLUSIONS

The prognosis of DILI from AAS, SARMs and BBS is good although liver transplantation may rarely be required. A detailed drug history is important in uncovering DILI due to these supplements.

Substance use during hospitalisation requiring an urgent clinical response: an opportunity for intervention

BACKGROUND

There are few reports on drug use in patients while hospitalised and none regarding management or clinical outcomes.

AIMS

To describe cases of drug use by inpatients requiring an urgent clinical response.

METHODS

We retrospectively reviewed cases at a teaching hospital in Sydney, Australia, from February 2019 to March 2021.

RESULTS

Thirty cases were identified, with no deaths. Two patient groups were identified: (i) substance use disorders, using illicit drugs and (ii) self-harm history, using prescribed or over-the-counter drugs. Management involved cardiac monitoring (40%), intensive care (30%), charcoal (20%), antidotes (20%) and intubation (13%). Discharge was planned in 22 of 30 patients, against medical advice in four and directed by medical staff in four.

CONCLUSIONS

Inpatient drug use requiring an urgent clinical response was infrequently recognised but presents a risk of harm to patients and staff and increases service utilisation and costs. Both harm reduction and systematic approaches guided by institutional policy are recommended. Using these events as reachable moments to address driving factors may modify patients' risk from future events.

Alcohol-Associated Liver Disease: Evolving Concepts and Treatments

Alcohol is a prominent cause of liver disease worldwide with higher prevalence in developed nations. The spectrum of alcohol-associated liver disease (ALD) encompasses a diverse range of clinical entities, from asymptomatic isolated steatosis to decompensated cirrhosis, and in some cases, acute or chronic liver failure. Consequently, it is important for healthcare practitioners to maintain awareness and systematically screen for ALD. The optimal evaluation and management of ALD necessitates a collaborative approach, incorporating a multidisciplinary team and accounting for concurrent medical conditions. A repertoire of therapeutic interventions exists to support patients in achieving alcohol cessation and sustaining remission, with complete abstinence being the ultimate objective. This review explores the existing therapeutic options for ALD acknowledging geographical discrepancies in accessibility. Recent innovations, including the inclusion of alcohol consumption biomarkers into clinical protocols and the expansion of liver transplantation eligibility to encompass severe alcohol-associated hepatitis, are explored.

Bovine lead exposure from informal battery recycling in India

We provide an estimate of annual bovine lead exposure and attributable mortality at informal lead acid battery recycling sites in India. We use Pure Earth's Toxic Sites Identification Program database, the FAO's Gridded Livestock dataset, and a Poisson plume model of lead particle air dispersion to estimate site-level mortality. We calculate that India suffers 2370 excess bovine fatalities each year, resulting in more than USD $2.1 million of economic damage. The distribution of damages by location is highly skewed. While we find most sites (86.3%) induce no mortalities, 6.2% of sites induce minor damage (1 to 5 fatalities), 4.1% induce moderate damage (6 to 20 fatalities), and 3.4% induce severe damage (21 + fatalities). These findings highlight the importance of geospatial data to prioritize mitigation efforts and identify a previously unquantified burden on the rural poor.

Hippocampal ischaemia from accidental 5-Hydroxytryptophan (5-HTP) overdose case report

We report severe reversible hippocampal ischaemia following an accidental 5-Hydroxytryptophan (5-HTP) overdose. Serious consequences from 5-HTP overdose have not been reported. A 44-year-old previously well man ingested ten times the recommended dose of 5-HTP powder. After four hours he developed marked antegrade and retrograde amnesia, disorientation and confusion in the absence of loss of consciousness, seizure activity or features of serotonin toxicity. Magnetic resonance imaging (MRI) of the brain on day two revealed extensive symmetrical restricted diffusion bilaterally in the hippocampi, suggestive of ischaemia or seizure. Electroencephalogram was normal. Short and long-term memory improved sufficiently to return to work after two months. MRI at eleven months was normal. The most likely mechanism is drug-induced hippocampal ischaemia resulting from marked increase in 5-HTP.

Prevalence of elevated blood lead levels and risk factors among children living in Patna, Bihar, India 2020

Childhood lead exposure remains a key health concern for officials worldwide, contributing some 600,000 new cases of intellectually disabled children annually. Most children affected by high exposure to lead live in low- and middle-income countries. The leaded gasoline phase out in India was completed in 2000. Yet, in 2020, an estimated 275 million children aged 0 to 9 years had blood lead levels (BLLs) ≥ 5 μg/dL known to adversely affect intelligence and behavior. Lead sources reported in India include spices, cookware, paint, traditional medicines and cosmetics, and lead-acid battery recycling and repair. However, their relative contribution has not been characterized. More than 200 lead pollution sites related to battery recycling and repair activities were identified in Bihar and Jharkhand, India. Ninety percent of the recycling sites had soil lead concentrations exceeding the US Environmental Protection Agency's standards. We compared blood and environmental lead levels in two groups of children in Patna, Bihar. Households in proximity to battery recycling operations (Proximal n = 67) versus households distal to these operations (Distal n = 68). The average age of children was 40 months; 46% were female. Overall, the geometric mean (GM) BLL was 11.6 μg/dL. GM BLLs of children in Proximal and Distal households were not significantly different (10.2 μg/dL vs. 13.1 μg/dL respectively; p≤0.07). About 87% children, 56 Proximal and 62 Distal had BLLs ≥5 μg/dl. Lead concentrations in environmental samples were significantly higher in Proximal households (soil mean 9.8 vs. 1.6 μg/ft2; dust mean 52.9 vs. 29.9 μg/ft2 p<0.001; Proximal vs. Distal respectively) whereas concentrations in all spices were higher in Distal households (mean 46.8 vs 134.5 ppm p<0.001; Proximal vs. Distal respectively), and turmeric (mean 59.4 vs. 216.9 ppm Proximal vs. Distal respectively). In multivariate analyses for all children lead in spices and turmeric and number of rooms in the house were significant while for the Proximal group only lead in spices remained in the model. The predictive value of these models was poor. For the Distal group, a model with lead concentration in spices, turmeric and soil and number of rooms in the house was a much better fit. Of the 34 water samples collected, 7 were above the Indian standard of 10 ppb for lead in drinking water (2 in the Proximal area, 5 in the Distal area). Children in Patna, Bihar, India are exposed to multiple sources of lead, with lead levels in house dust and loose, locally sourced spices the most likely to increase blood lead levels. A holistic approach to blood lead testing and source identification and remediation are necessary to prevent lead exposure.

Drug-induced liver injury in Australia, 2009-2020: the increasing proportion of non-paracetamol cases linked with herbal and dietary supplements

OBJECTIVE

To compare the characteristics and outcomes of drug-induced liver injury (DILI) caused by paracetamol and non-paracetamol medications, particularly herbal and dietary supplements.

DESIGN

Retrospective electronic medical record data analysis.

SETTING, PARTICIPANTS

Adults admitted with DILI to the Gastroenterology and Liver Centre at the Royal Prince Alfred Hospital, Sydney (a quaternary referral liver transplantation centre), 2009-2020.

MAIN OUTCOME MEASURES

90-day transplant-free survival; drugs implicated as causal agents in DILI.

RESULTS

A total of 115 patients with paracetamol-related DILI and 69 with non-paracetamol DILI were admitted to our centre. The most frequently implicated non-paracetamol medications were antibiotics (19, 28%), herbal and dietary supplements (15, 22%), anti-tuberculosis medications (six, 9%), and anti-cancer medications (five, 7%). The number of non-paracetamol DILI admissions was similar across the study period, but the proportion linked with herbal and dietary supplements increased from 2 of 13 (15%) during 2009-11 to 9 of 19 (47%) during 2018-20 (linear trend: P = 0.011). Despite higher median baseline model for end-stage liver disease (MELD) scores, 90-day transplant-free survival for patients with paracetamol-related DILI was higher than for patients with non-paracetamol DILI (86%; 95% CI, 79-93% v 71%; 95% CI, 60-82%) and herbal and dietary supplement-related cases (59%; 95% CI, 34-85%). MELD score was an independent predictor of poorer 90-day transplant-free survival in both paracetamol-related (per point increase: adjusted hazard ratio [aHR], 1.19; 95% CI, 1.09-3.74) and non-paracetamol DILI (aHR, 1.24; 95% CI, 1.14-1.36).

CONCLUSION

In our single centre study, the proportion of cases of people hospitalised with DILI linked with herbal and dietary supplements has increased since 2009. Ninety-day transplant-free survival for patients with non-paracetamol DILI, especially those with supplement-related DILI, is poorer than for those with paracetamol-related DILI.

Fentanyl and Driving Impairment

The incidence of fentanyl in forensic toxicology analyses in the USA has dramatically increased over the past several years. The increase in death cases has been well studied; however, little has been reported on the impact to drug impaired driving. Fentanyl driving while under the influence of drugs (DUID) case data from 2014 to 2019 is presented. The data were obtained from three toxicology laboratories in the Northeast, Southeast, and Midwest regions of the USA. Fentanyl whole blood concentrations ranged from 0.1 to 157 ng/mL in living drivers with a 466% to 524% increase in fentanyl-positive DUID cases from 2014 to 2019, depending on the US region. The vast majority of fentanyl cases involved poly-drug use. Twenty case histories are presented where fentanyl was the only drug identified. The mean (standard deviation) fentanyl concentration for these cases was 5.2 ± 3.8 ng/mL with a median of 3.7 ng/mL, and the concentrations ranged from 2.0 to 16 ng/mL. Naloxone administration was documented in exactly half of these cases similar to another study involving carfentanil-impaired driving. The case histories also demonstrate that some recreational opioid users may display limited signs of impairment either due to tolerance or naloxone administration. The top three observations in common among the cases were the driver was found unresponsive behind the wheel, the vehicle left the travel lane or roadway, and the driver was involved in a crash. The increase in fentanyl use not only poses a risk for overdose and death, but is also a significant concern for traffic safety. This study supports the movement of fentanyl from a Tier II drug to Tier I due to its significant potential for impairment and increase in prevalence in impaired driving cases.

Child lead exposure near abandoned lead acid battery recycling sites in a residential community in Bangladesh: Risk factors and the impact of soil remediation on blood lead levels

Lead is a potent neurotoxin that is particularly detrimental to children's cognitive development. Batteries account for at least 80% of global lead use and unsafe battery recycling is a major contributor to childhood lead poisoning. Our objectives were to assess the intensity and nature of child lead exposure at abandoned, informal used lead acid battery (ULAB) recycling sites in Kathgora, Savar, Bangladesh, as well as to assess the feasibility and effectiveness of a soil remediation effort to reduce exposure. ULAB recycling operations were abandoned in 2016 due to complaints from residents, but the lead contamination remained in the soil after operations ceased. We measured soil and blood lead levels (BLLs) among 69 children living within 200 m of the ULAB recycling site once before, and twice after (7 and 14 months after), a multi-part remediation intervention involving soil capping, household cleaning, and awareness-raising activities. Due to attrition, the sample size of children decreased from 69 to 47 children at the 7-month post-intervention assessment and further to 25 children at 14 months. We conducted non-parametric tests to assess changes in soil lead levels and BLLs. We conducted baseline surveys, as well as semi-structured interviews and observations with residents throughout the study period to characterize exposure behaviors and the community perceptions. We conducted bivariate and multivariate regression analyses of exposure characteristics to determine the strongest predictors of baseline child BLLs. Prior to remediation, median soil lead concentrations were 1400 mg/kg, with a maximum of 119,000 mg/kg and dropped to a median of 55 mg/kg after remediation (p < 0.0001). Among the 47 children with both baseline and post-intervention time 1 measurements, BLLs dropped from a median of 21.3 μg/dL to 17.0 μg/dL at 7 months (p < 0.0001). Among the 25 children with all three measurements, BLLs dropped from a median of 22.6 μg/dL to 14.8 μg/dL after 14 months (p < 0.0001). At baseline, distance from a child's residence to the nearest abandoned ULAB site was the strongest predictor of BLLs and baseline BLLs were 31% higher for children living within 50 m from the sites compared to those living further away (n = 69, p = 0.028). Women and children spent time in the contaminated site daily and relied on it for their livelihoods and for recreation. Overall, this study highlights the intensity of lead exposure associated with the ULAB recycling industry. Additionally, we document the feasibility and effectiveness of a multi-part remediation intervention at a contaminated site embedded within a residential community; substantially reducing child BLLs and soil lead concentrations.

Blood lead levels in low-income and middle-income countries: a systematic review

BACKGROUND

Since the global phase-out of leaded petrol, reports have suggested that lead exposure remains substantial or is increasing in some low-income and middle-income countries (LMICs). However, few studies have attempted to systematically assess blood lead levels over the full range of LMICs. We aimed to describe values for blood lead level in LMICs.

METHODS

In this systematic review, we searched PubMed for studies published between Jan 1, 2010, and Oct 31, 2019, that reported blood lead levels in the 137 countries in World Bank LMIC groupings. Studies were reviewed for inclusion if they contained blood lead level data from human populations residing in any given country; comprised at least 30 participants; presented blood lead level data derived from venous, capillary, or umbilical cord samples of whole blood; had data that were collected after Dec 31, 2004; and were published in English. Data on blood lead level were extracted and pooled, as appropriate, to make country-specific estimates of the distribution of background blood lead levels among children and adults, along with information on specific sources of exposure where available. This study is registered with PROSPERO, number CRD42018108706.

FINDINGS

Our search yielded 12 695 studies, of which 520 were eligible for inclusion (1100 sampled populations from 49 countries comprising 1 003 455 individuals). Pooled mean blood lead concentrations in children ranged from 1·66 μg/dL (SD 3·31) in Ethiopia to 9·30 μg/dL (11·73) in Palestine, and in adults from 0·39 μg/dL (1·25) in Sudan to 11·36 μg/dL (5·20) in Pakistan. Background values for blood lead level in children could be pooled in 34 countries and were used to estimate background distributions for 1·30 billion of them. 632 million children (95% CI 394 million-780 million; 48·5%) were estimated to have a blood lead level exceeding the US Centers for Disease Control's reference value of 5 μg/dL. Major sources of lead exposure were informal lead acid battery recycling and manufacture, metal mining and processing, electronic waste, and the use of lead as a food adulterant, primarily in spices.

INTERPRETATION

Many children have a blood lead level exceeding 5 μg/dL in LMICs, despite leaded petrol phase-outs. Given the toxicity of lead, even at low amounts of exposure, urgent attention is required to control exposures and to expand population-based sampling in countries with no or scant data.

FUNDING

This work was supported by the United States Agency for International Development (Cooperative Agreement number AID-OAA-A-16-00019).

Short-term and long-term cardiovascular risk, metabolic syndrome and HIV in Tanzania

OBJECTIVE

To compare short-term and long-term cardiovascular disease (CVD) risk scores and prevalence of metabolic syndrome in HIV-infected adults receiving and not receiving antiretroviral therapy (ART) to HIV-negative controls.

METHODS

A cross-sectional study including 151 HIV-infected, ART-naive, 150 HIV-infected on ART and 153 HIV-negative adults. Traditional cardiovascular risk factors were determined by standard investigations. The primary outcome was American College of Cardiology/American Heart Association Atherosclerotic CVD (ASCVD) Risk Estimator lifetime CVD risk score. Secondary outcomes were ASCVD 10-year risk, Framingham risk scores, statin indication and metabolic syndrome.

RESULTS

Compared with HIV-negative controls, more HIV-infected adults on ART were classified as high lifetime CVD risk (34.7% vs 17.0%, p<0.001) although 10-year risk scores were similar, a trend which was similar across multiple CVD risk models. In addition, HIV-infected adults on ART had a higher prevalence of metabolic syndrome versus HIV-negative controls (21.3% vs 7.8%, p=0.008), with two common clusters of risk factors. More than one-quarter (28.7%) of HIV-infected Tanzanian adults on ART meet criteria for statin initiation.

CONCLUSIONS

HIV-infected ART-treated individuals have high lifetime cardiovascular risk, and this risk seems to develop rapidly in the first 3-4 years of ART as does the development of clusters of metabolic syndrome criteria. These data identify a new subgroup of low short-term/high-lifetime risk HIV-infected individuals on ART who do not currently meet criteria for CVD risk factor modification but require further study.

Primary hyperparathyroidism in pregnancy leading to hypercalcaemic crisis and uraemic encephalopathy

Primary hyperparathyroidism is rare during pregnancy. Recognition may be challenging as symptoms overlap with those of other common disorders of pregnancy. Furthermore, physiological changes of pregnancy affecting calcium homoeostasis mean awareness of the condition and careful interpretation of results in the light of pregnancy are essential for diagnosis. Maternal complications of primary hyperparathyroidism include nephrolithiasis, pancreatitis, cardiac arrhythmias, hypertension and peptic ulcers. At its most severe, hypercalcaemic crisis may occur, presenting with acute neurological disturbance. Most commonly, the underlying aetiology is a solitary parathyroid adenoma whereby parathyroidectomy is the only cure. A 30-year-old Caucasian woman booked under Consultant care presented at 32 weeks gestation with vomiting and right-sided loin pain. Following presentation, she was diagnosed with renal calculi. She was delivered by caesarean section (CS) due to deterioration in renal function. Post-CS, she had a grand mal seizure. She was found to have hypercalcaemia with underlying hyperparathyroidism.

Employment in adults with cystic fibrosis

BACKGROUND

Chronic ill-health may significantly impact on an individual's ability to work. This not only relates to disease severity but also to psychosocial factors such as illness perception and coping strategies.

AIMS

To explore the factors associated with employment status in adults with cystic fibrosis (CF).

METHODS

Subjects recruited from adult CF clinics in Aberdeen, Birmingham and Newcastle completed questionnaires assessing health-related quality of life (HRQoL), workplace productivity (presenteeism) and employment. Clinical data indicative of disease severity were also recorded.

RESULTS

A total of 254 subjects were recruited, 41 from Aberdeen, 63 from Birmingham and 150 from Newcastle. Sixty-five per cent of subjects were in employment or education. If employed/self-employed, median hours worked was 37.3h/week. Forty per cent reported stopping a job due to CF; 47% felt CF had affected career choice and 24% changed duties because of CF. Ten per cent had taken a pay cut and 23% reported workplace discrimination due to CF. Multivariate modelling demonstrated that employment status was independently associated with educational attainment, centre and the HRQoL domains of role and health perception and is independent of clinical parameters of disease severity.

CONCLUSIONS

Adults with CF reported that CF impacted on their ability to work. Employment appeared to be most strongly associated with educational attainment, locality and HRQoL domains and not clinical parameters of severity. Specific guidance is needed for both adults with CF and potential employers, with appropriate targeted interventions aimed at improving health perceptions and coping strategies.

The history of OSHA's asbestos rule makings and some distinctive approaches that they introduced for regulating occupational exposure to toxic substances

The Occupational Safety and Health Administration (OSHA) has regulated occupational exposure to asbestos since 1971. Since issuing its first asbestos standard, OSHA has modified it several times in response to new information about the health risk of exposure and concern expressed by workers and public health groups. As each modification has reduced worker exposure and disease risk, each also has introduced new concepts including emphasis on ancillary provisions in standards regulating occupational exposure to toxic substances to enhance worker health; medical removal protection; two attempts at emergency temporary standards; use of historical and objective exposure data to assess worker exposure; the need to eliminate significant risk of disease posed by asbestos; and the presumption of hazard in absence of exposure information. These and other advances have affected all subsequent OSHA standards aimed at reducing occupational exposure to toxic substances.

Antiretroviral prophylaxis of health care workers at two urban medical centers

We examined the influence of job category, source patient HIV status, and exposure type as predictors of whether health care workers initiated antiretroviral prophylaxis after potential blood-borne pathogen exposures. Of 639 exposures over an 18-month period, 82 individuals (13%) elected to receive prophylaxis, of whom 66% took medications for fewer than 96 hours and 12% completed a 4-week course. Reasons for early drug discontinuation included confirmation of source patient HIV-negative serological status (65%), gastrointestinal side effects (13%), headache (4%), and personal decision after counseling/other input (18%). Individuals exposed to HIV-positive source patients were more likely to initiate prophylaxis (odds ratio [OR], 5.1; 95% confidence interval [CI] 2.6 to 9.9). Licensed nurses were less likely than others to accept prophylaxis (OR, 0.5; 95% CI, 0.3 to 0.8), whereas physicians and medical students were more likely to accept prophylaxis (OR, 1.9; 95% CI, 1.1 to 3.3).

Comparative effects of potassium chloride and bicarbonate on thiazide-induced reduction in urinary calcium excretion

BACKGROUND

The chronic low-grade metabolic acidosis that occurs in various renal disorders and in normal people, and that is related both to dietary net acid load and age-related renal functional decline, may contribute to osteoporosis by increasing urine calcium excretion. Administration of potassium (K) alkali salts neutralizes acid and lowers urine calcium excretion. Urine calcium excretion also can be reduced by the administration of thiazide diuretics, which are often given with supplemental K to avoid hypokalemia. We determined whether the K alkali salt potassium bicarbonate (KHCO3) and the thiazide diuretic hydrochlorothiazide (HCTZ) combined is more effective in reducing urinary calcium than KHCO3 alone or HCTZ combined with the conventionally coadministered nonalkalinizing K salt potassium chloride (KCl).

METHODS

Thirty-one healthy men and women aged 50 or greater were recruited for a four-week, double-blind, randomized study. After a baseline period of 10 days with three 24-hour urine and arterialized blood collections, subjects were randomized to receive either HCTZ (50 mg) plus potassium (60 mmol daily) as either the chloride or bicarbonate salt. Another 19 women received potassium bicarbonate (60 mmol) alone. After two weeks, triplicate collections of 24-hour urines and arterialized bloods were repeated.

RESULTS

Urinary calcium excretion decreased significantly in all groups. KHCO3 alone and HCTZ + KCl induced similar decreases (-0.70 +/- 0.60 vs. -0.80 +/- 1. 0 mmol/day, respectively). Compared with those treatments, the combination of HCTZ + KHCO3 induced more than a twofold greater decrease in urinary calcium excretion (-1.8 +/- 1.2 mmol/day, P < 0. 05). Both HCTZ + KHCO3 and KHCO3 alone reduced net acid excretion significantly (P < 0.05) to values of less than zero.

CONCLUSIONS

KHCO3 was superior to KCl as an adjunct to HCTZ, inducing a twofold greater reduction in urine calcium excretion, and completely neutralizing endogenous acid production so as to correct the pre-existing mild metabolic acidosis that an acid-producing diet usually induces in older people. Accordingly, for reducing urine calcium excretion in stone disease and osteoporosis, the combination of HCTZ + KHCO3 may be preferable to that of HCTZ + KCl.

Laparoscopic cholecystectomy for acute cholecystitis and the consequences of gallbladder perforation, bile spillage, and "loss" of stones

OBJECTIVE

To study the factors associated with accidental perforation of the gallbladder and spillage of bile and stones and to assess the consequences of these mishaps.

DESIGN

Prospective study with retrospective bacteriological evaluation.

SETTING

Teaching hospital, Israel.

SUBJECTS

189 Patients who were treated for clinical acute cholecystitis between January 1994 and August 1996.

INTERVENTIONS

Emergency laparoscopic cholecystectomy.

MAIN OUTCOME MEASURES

Incidence of accidental perforation of gallbladder and spillage of bile and stones and of conversion and complications in relation to preoperative and operative findings.

RESULTS

Bile was spilt in 65 (34%) and gall-stones were "lost" in 27 (14%), 44 (23%) required conversion to an open approach and 36 (19%) developed complications. Preoperative duration of symptoms >96 hours and a palpable gallbladder were associated with accidental perforation of the gallbladder and spillage of bile. A palpable gallbladder, gangrenous cholecystitis, and WBC > 15 x 10(9)/L were associated with stones "lost" in the peritoneum. A history of biliary disease was inversely related to "lost" stones. Conversion of laparoscopic to open cholecystectomy was associated with male sex, age >60 years, a non-palpable gallbladder, WBC > 15 x 10(9)/L, and a gangrenous gallbladder. Complications of surgery were more common among men and associated with fever of >38 degrees C. Neither the conversion nor the complications were associated with perforation of the gallbladder or "lost" stones.

CONCLUSION

Perforation of the gallbladder and intraperitoneal spillage of bile or stones during laparoscopic cholecystectomy for acute cholecystitis are not associated with undesirable events, are not indications for conversion, and are not associated with further complications. When patients are given appropriate antibiotics perioperatively and the spilt bile is properly aspirated and the peritoneum irrigated, the operative and postoperative courses are similar to those of patients with unperforated gallbladder.

Laparoscopic cholecystectomy for the various types of gallbladder inflammation: a prospective trial

Laparoscopic cholecystectomy (LC), the procedure of choice for elective cholelithiasis, is now also used in the management of acute cholecystitis. In the various types of gallbladder disease, favorable and unfavorable conditions may influence the conversion and complication rates. Information about these conditions may help elucidate the optimal circumstances for LC or indicate when the procedure is best avoided. We attempted to perform emergency LC on 215 patients with acute cholecystitis. The procedure was successful in 171 patients (79.5%), and conversion to open cholecystectomy (OC) was needed in 44 (20.5%). Complications occurred in 37 patients (17%). Uncomplicated acute cholecystitis was associated with age <50 years, duration of complaint <48 h, temperature <38.5 degrees C, a nonpalpable gallbladder, and an alkaline phosphatase >100 U/L. Acute gangrenous cholecystitis was associated with a negative gallbladder history, other associated diseases, temperature >38.5 degrees C, a palpable gallbladder, and serum bilirubin levels <1 mg/dl. Hydrops was associated with a temperature <38 degrees C and a leukocyte count of >12,000/cc3, and empyema of the gallbladder was associated with duration of complaint >48 h and a palpable gallbladder. The conversion rate of acute gangrenous cholecystitis (40%) was significantly higher than that of uncomplicated acute cholecystitis (8%) (p < 0.00001, odds ratio=7.7), as well as that of empyema of the gallbladder (12.5%) (p=0.005, odds ratio=4.7). The conversion from LC to OC in uncomplicated acute cholecystitis was associated with male sex and with duration of complaint >24 h, and in gangrenous cholecystitis with age >60 years, a nonpalpable gallbladder, and a leukocyte count of >15,000/cc3. The complication rates of acute cholecystitis, hydrops, empyema of the gallbladder, and gangrenous cholecystitis were 16%, 7%, 22%, and 21%, respectively (p = NS). The total complication rate in acute cholecystitis tended to be associated with a duration of complaint >48 h and in gangrenous cholecystitis with male sex, age >60 years, other associated disease, larger bile stones, and elevated serum bilirubin levels. Generally, LC is safe in all forms of cholecystitis, with acceptably low conversion and complication rates, excluding gangrenous cholecystitis. In gangrenous cholecystitis, a conversion rate of approximately 40% is expected. Predictors of conversion and complications may be particularly helpful in planning the laparoscopic approach to acute gangrenous cholecystitis. Patients >60 years of age, with a nonpalpable gallbladder and with a leukocyte count >15,000/cc3, frequently need conversion. In men >60 years old, with other associated disease, with larger bile stones, and with elevated serum bilirubin levels, complications are frequently expected. Under these conditions, laparoscopic approach should be undertaken by especially experienced teams, or OC should be considered.

Intussusception in adults

Adult intussusception is a rare condition, chronic and recurring in nature, and presenting as intermittent intestinal obstruction. Surgeons generally have limited experience with it. We present 13 cases that have been treated in our department over a period of 19 years. In most of the cases there is an identifiable cause and it is often a malignancy. Awareness, plain abdominal films, barium enema and CT are valuable tools for diagnosis. Resection without reduction is the treatment of choice in most cases. In instances where resection would necessitate a permanent stoma, attempts at manual reduction are justified. Timely treatment, properly carried out, should result in a good prognosis.

Laparoscopic versus open cholecystectomy in acute cholecystitis

Elective laparoscopic cholecystectomy is established as the treatment of choice for symptomatic cholecystolithiasis and is now proposed for the treatment of acute cholecystitis. We initiated the present study in order to clarify the question of safety of the procedure in the presence of an inflamed gallbladder, and to compare the results with those of a traditionally treated group with acute cholecystitis. We compared the preoperative, operative, and postoperative courses of 146 patients with acute cholecystitis, managed laparoscopically between 1994 and 1996, with those of 97 patients, treated traditionally by open cholecystectomy for the same diagnosis between 1992 and 1993. In the acute cholecystitis cases, when laparoscopic cholecystectomy was successfully performed, the operative and postoperative courses were superior to those of open cholecystectomy. The use of drains and NG tubes, the need for antibiotics and analgesia, the associated morbidity, and the hospital stay were significantly reduced. Following conversion, the postoperative course was similar to that of open cholecystectomy. Of the group of acute cholecystitis cases laparoscopically approached 39 (27%) needed conversion. Twenty-five complications occurred in 24 (16.5%) patients of the laparoscopic group, whereas 30 complications occurred in 25 (26%) patients of the traditionally operated group. Male sex, older patients, and larger bile stones were found to be associated with a higher conversion rate as well as a higher complication rate. A nonpalpable gallbladder and gangrenous cholecystitis were associated with conversion while fever was associated with complications. Laparoscopic cholecystectomy can be performed safely in selected cases of acute cholecystitis, with acceptable conversion and low complication rates. When laparoscopic cholecystectomy is successfully performed, the operative and postoperative courses are superior to those of open cholecystectomy. Following conversion, the postoperative course is similar to that of open cholecystectomy. According to this study, male sex, older age, large bile stones, a nonpalpable gallbladder, and gangrenous cholecystitis may be regarded as predictors of conversion, while male sex, older age, large bile stones, and fever may be regarded as predictors of complications. The timing of laparoscopic cholecystectomy should be within 96 h from onset of the inflammation.

Does the index operation influence the course and outcome of adhesive intestinal obstruction?

OBJECTIVE

To ascertain the incidence of obstruction after various operations and find out if the index operation influenced the course and outcome of adhesive small bowel obstruction.

DESIGN

Retrospective study.

SETTING

Teaching hospital, Israel.

SUBJECTS

190 of 248 patients who presented with small bowel obstruction between January 1980 and December 1994.

INTERVENTIONS

All patients were treated conservatively and operated on only if they did not improve or deteriorated.

MAIN OUTCOME MEASURES

Incidence of obstruction depending on site of index operation, and response to treatment.

RESULTS

46 Patients (24%) had undergone upper abdominal operations, 26 (14%) small bowel resection, 47 (25%) appendicectomy, 27 (14%) gynaecological operations, and 44 (23%) colonic resections. The annual incidence of obstructive complications among the 190 patients in the groups studied was highest after appendicectomy (3.1/year) and colonic resections (2.9/year) and lowest after operations on the gallbladder and pancreas (1.1/year). Postoperative adhesive obstruction presented earlier after operations on the small bowel (median 1 year, range 5.4-20) and colon (median 1 year, range 2.2-40) than after the other operations. 60 (32%) of patients with acute small bowel obstruction had a history of abdominal malignancy, and obstruction was more likely to be complete after small bowel resection (20/26, 77%) compared with 39/74 (53%) after appendicectomy or gynaecological surgery, 17/46 (37%) after upper abdominal surgery, and 15/44 (34%) after colonic resection. Patients who developed obstruction after colonic resection had the longest period of conservative treatment (median 60 hours, range 24-216) and had the highest morbidity (8/44, 18%) although only 2 required bowel resection. Two patients died, both after obstruction following upper abdominal operations.

CONCLUSIONS

Patients who present with obstruction after small bowel resection are extremely likely to be completely obstructed. Perhaps the morbidity associated with obstruction after colonic resection could be reduced if patients were operated on earlier.

Evaluation of three methods for improving mammography rates in a managed care plan

INTRODUCTION

Mammography has been shown to reduce breast cancer mortality among women 50 and older. Although mammography rates are increasing nationally, this effective screening tool remains underused. This study was conducted among 395 women who were members of a network model health maintenance organization (HMO) in Philadelphia in order to determine which of three methods was most effective in increasing mammography rates: (1) a birthday card reminder only (the standard method); (2) a personalized letter from the medical director and materials promoting mammography; and (3) a multicomponent phone call incorporating a reminder, counseling, and scheduling of appointments. An additional goal was to determine whether the interventions were more or less effective depending on a woman's readiness to get a mammogram, as measured by stage of change.

METHODS

Eligible women were randomized into one of three treatment groups described earlier. Mammography rates were calculated on the basis of a claims review and follow-up phone interviews after a period of six months.

RESULTS

Women who received the telephone intervention were most likely to obtain a mammogram (28%); followed by the group that received the birthday card only (15%), and those who received the mailed intervention (9%).

CONCLUSIONS

These results indicate that a multicomponent phone intervention is significantly effective in promoting mammography in managed health care plan members. An analysis by women's stage of change found a difference in the effectiveness of the three interventions among contemplators only.

Laparoscopic cholecystectomy for acute cholecystitis: prospective trial

This prospective study determines the indications for and the optimal timing of laparoscopic cholecystectomy (LC) following the onset of acute cholecystitis. It also evaluates preoperative and operative factors associated with conversion from laparoscopic cholecystectomy to open cholecystectomy in the presence of acute cholecystitis. Having been established as the procedure of choice for elective cholelithiasis, LC is now also used for management of acute cholecystitis. Under these circumstances the procedure may be difficult and challenging. Certain favorable and unfavorable conditions may be present that influence the conversion and complication rates. Information about these conditions may be helpful for elucidating the optimal circumstances for LC or when the procedure is best avoided. We performed LC on an emergency basis as soon as the diagnosis was made on all patients presenting with acute cholecystitis from January 1994 to December 1995. All preoperative, operative, and postoperative data were collected on standardized forms. Of the 137 patients registered, 130 were eligible for the audit. Seven patients found by laparoscopic intraoperative cholangiography to have choledocholithiasis were converted for common bile duct exploration and were excluded from the study. Altogether 83 patients (72%) underwent successful LC and 37 (28%) needed conversion to open cholecystectomy. The conversion rate of acute gangrenous cholecystitis (49%) was significantly higher than that for uncomplicated acute cholecystitis (4.5%) (p < 0.00001) and for hydrops (28.5%) and empyema of the gallbladder (28.5%) (p = 0.004). The difference in conversion between the group with acute necrotizing (gangrenous) cholecystitis and the two groups with hydrops and empyema of the gallbladder was not statistically significant (p = 0.07). The complication rates of acute cholecystitis, hydrops, empyema of the gallbladder, and gangrenous cholecystitis were 9.0%, 9.5%, 14.0%, and 20.0%, respectively (p = NS). Patients with an operative delay of 96 hours or less from the onset of acute cholecystitis had a conversion rate of 23%, whereas a delay of more than 96 hours was associated with a conversion rate of 47% (p = 0.022). The complication rate was 8.5% in the laparoscopic group and 27% in the converted group (p = 0.013). Patients over 65 years of age, with a history of biliary disease, a nonpalpable gallbladder, WBC count over 13,000/cc, and acute gangrenous cholecystitis were independently associated with a high LC conversion rate; male patients, finding large bile stones, serum bilirubin over 0.8 mg/dl, and WBC count over 13,000/cc were independently associated with a high complication rate following laparoscopic surgery with or without conversion. Generally, LC can be performed safely for acute cholecystitis, with acceptably low conversion and complication rates. Different forms of cholecystitis carry various conversion and complication rates in selected cases. LC for acute cholecystitis should be performed within 96 hours of the onset of disease. Predictors of conversion and complications may be helpful when planning the laparoscopic approach to acute cholecystitis.

Possible association of the allele status of the CS.7/HhaI polymorphism 5' of the CFTR gene with postnatal female survival

Cystic fibrosis (CF) patients show a high degree of linkage disequilibrium between the CF transmembrane conductance regulator (CFTR) gene and polymorphisms 5' of that gene. To determine whether the region 5' of CFTR contains biologically important sequences, the allele frequencies of six CFTR-linked polymorphisms (metH/MspI, XV-2c/TaqI, CS.7/HhaI, KM19/PstI, MP6d9/MspI, J44/XbaI) were determined in 417 randomly selected elderly individuals (over 75 years of age) from the Czech population. The elderly individuals were considered "escapees" of strong selective pressures that had operated during their lifetime, prior to the introduction of modern health care since 1950. The pooled allele frequencies of the analyzed marker polymorphisms in the elderly did not significantly differ from published data. However, when analyzed by ex, the allele frequencies of markers CS.7/HhaI and KM19/PstI differed significantly (P < 0.05) between elderly females and males. The allele frequencies of the six polymorphisms were then determined in 646 newborns and 345 young adults of reproductive age; these individuals were selected in a similar manner and drawn from the same population. In these control groups, the studied marker polymorphisms exhibited no statistically significant differences between sexes and/or between individuals of the same sex, only between different age groups. A gradual relative increase in the frequency of allele "2" of marker CS.7/HhaI was observed from newborn females to elderly women, the overall difference in allele frequencies of this marker polymorphism between newborn females and elderly women reaching statistical significance (P < 0.05). Interestingly, allele "2" is the major constituent of the extended "B-haplotype", which is in strong linkage disequilibrium with common CF alleles. Taken together, our data suggest that the region spanning markers CS.7 and KM19 is associated with a genetic factor that influences postnatal female survival, providing a possible mechanism for increasing the frequency of particular mutations in the adjacent CFTR gene.