A Segmental Approach from Molecular Profiling to Medical Imaging to Study Bicuspid Aortic Valve Aortopathy

Bicuspid aortic valve (BAV) patients develop ascending aortic (AAo) dilation. The pathogenesis of BAV aortopathy (genetic vs. haemodynamic) remains unclear. This study aims to identify regional changes around the AAo wall in BAV patients with aortopathy, integrating molecular data and clinical imaging. BAV patients with aortopathy (n = 15) were prospectively recruited to surgically collect aortic tissue and measure molecular markers across the AAo circumference. Dilated (anterior/right) vs. non-dilated (posterior/left) circumferential segments were profiled for whole-genomic microRNAs (next-generation RNA sequencing, miRCURY LNA PCR), protein content (tandem mass spectrometry), and elastin fragmentation and degeneration (histomorphometric analysis). Integrated bioinformatic analyses of RNA sequencing and proteomic datasets identified five microRNAs (miR-128-3p, miR-210-3p, miR-150-5p, miR-199b-5p, and miR-21-5p) differentially expressed across the AAo circumference. Among them, three miRNAs (miR-128-3p, miR-150-5p, and miR-199b-5p) were predicted to have an effect on eight common target genes, whose expression was dysregulated, according to proteomic analyses, and involved in the vascular-endothelial growth-factor signalling, Hippo signalling, and arachidonic acid pathways. Decreased elastic fibre levels and elastic layer thickness were observed in the dilated segments. Additionally, in a subset of patients n = 6/15, a four-dimensional cardiac magnetic resonance (CMR) scan was performed. Interestingly, an increase in wall shear stress (WSS) was observed at the anterior/right wall segments, concomitantly with the differentially expressed miRNAs and decreased elastic fibres. This study identified new miRNAs involved in the BAV aortic wall and revealed the concomitant expressional dysregulation of miRNAs, proteins, and elastic fibres on the anterior/right wall in dilated BAV patients, corresponding to regions of elevated WSS.

Metabolic Syndrome and COVID-19 Mortality Among Adult Black Patients in New Orleans

OBJECTIVE

Coronavirus disease 2019 (COVID-19) mortality is high in patients with hypertension, obesity, and diabetes. We examined the association between hypertension, obesity, and diabetes, individually and clustered as metabolic syndrome (MetS), and COVID-19 outcomes in patients hospitalized in New Orleans during the peak of the outbreak.

RESEARCH DESIGN AND METHODS

Data were collected from 287 consecutive patients with COVID-19 hospitalized at two hospitals in New Orleans, LA from 30 March to 5 April 2020. MetS was identified per World Health Organization criteria.

RESULTS

Among 287 patients (mean age 61.5 years; female, 56.8%; non-Hispanic black, 85.4%), MetS was present in 188 (66%). MetS was significantly associated with mortality (adjusted odds ratio [aOR] 3.42 [95% CI 1.52-7.69]), intensive care unit (ICU) (aOR 4.59 [CI 2.53-8.32]), invasive mechanical ventilation (IMV) (aOR 4.71 [CI 2.50-8.87]), and acute respiratory distress syndrome (ARDS) (aOR 4.70 [CI 2.25-9.82]) compared with non-MetS. Multivariable analyses of hypertension, obesity, and diabetes individually showed no association with mortality. Obesity was associated with ICU (aOR 2.18 [CI, 1.25-3.81]), ARDS (aOR 2.44 [CI 1.28-4.65]), and IMV (aOR 2.36 [CI 1.33-4.21]). Diabetes was associated with ICU (aOR 2.22 [CI 1.24-3.98]) and IMV (aOR 2.12 [CI 1.16-3.89]). Hypertension was not significantly associated with any outcome. Inflammatory biomarkers associated with MetS, CRP, and lactate dehydrogenase (LDH) were associated with mortality (CRP [aOR 3.66] [CI 1.22-10.97] and LDH [aOR 3.49] [CI 1.78-6.83]).

CONCLUSIONS

In predominantly black patients hospitalized for COVID-19, the clustering of hypertension, obesity, and diabetes as MetS increased the odds of mortality compared with these comorbidities individually.

The Homeless Hospital Liaison Program: An Interprofessional Program to Improve Students' Skills at Facilitating Transitions of Care for Patients Experiencing Homelessness

PROBLEM

Traditional medical school curricula lack specific training on caring for individuals experiencing homelessness, and the literature suggests that medical students' attitudes toward these individuals become increasingly negative during medical school.

APPROACH

To increase discharge planning support for individuals experiencing homelessness, the Homeless Hospital Liaison (HHL) program was developed at the University Medical Center New Orleans in January 2017-May 2017. Student liaisons are recruited from all 4 years of medical school and a graduate-level social work program. Liaisons administer a social needs questionnaire to assess patients' connections to services and identify gaps in care, coordinate with hospital social workers to avoid duplicating work, coordinate with the medical team, help patients complete any needed documentation or applications for social benefits, provide patients with referrals to outpatient resources, and provide patients assistance with a variety of basic needs.

OUTCOMES

As of December 2017, HHL has trained 70 students (65 medical students and 5 social work students) to serve as liaisons and has enrolled 99 patients. For the majority of these patients, student liaisons were able to facilitate successful referrals to community-based services.

NEXT STEPS

Future directions of the HHL program include developing a formal, staffed consult service at the hospital (e.g., the HHL program was awarded hospital funding for 2 full-time staff in the summer of 2019, which will increase the HHL's capacity); assessing the program's effect on student knowledge, attitudes, and proficiency related to individuals experiencing homelessness and/or interprofessional collaboration; and assessing the impact of the program on patients' experiences.

Strength and conditioning in adolescent female athletes

Despite evidence that strength and conditioning (S&C) programs decrease injury risk and increase sport performance, young females are rarely offered S&C programs comparable to those of their male counterparts. The purpose of this study was to evaluate the current body of available literature regarding S&C in adolescent female athletes, describe potential benefits, and generate recommendations for S&C programs for female adolescent athletes. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Systematic searches of the PubMed and Google Scholar databases were conducted using the following keywords: 'female athletes,' 'injury prevention,' 'adolescent,' 'physical fitness,' 'strength,' 'female adolescent,' and 'conditioning.' Studies included in this review evaluated the effectiveness of S&C protocols and/or the habits and attitudes of coaches and athletic trainers working with female adolescent athletes. Seven articles evaluating S&C programs for the adolescent female athlete were used as the basis for this systematic review. These articles described current protocols and/or factors that should be taken into account when designing S&C programs. The identified articles focused on improving the strength of adolescent female athletes, decreasing the risk of injury, and exposing female athletes to the benefits of S&C that are routinely afforded to their male counterparts. Despite the critical potential benefits of S&C training, such as improved landing mechanics, coaches and athletic trainers do not routinely implement S&C programs for female adolescent athletes. The lack of such programs is largely due to misconceptions surrounding female athletes, such as the perception that females fear bulking up. S&C programs for adolescent female athletes should incorporate stretching of the hip adductors, targeted hamstring, gluteal and quadriceps strengthening, and a synergistic adaptation model, which tailors training protocols to an athlete's pubertal stage.

Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients

BACKGROUND

Various scoring systems have been developed to predict need for massive transfusion in traumatically injured patients. Assessments of Blood Consumption (ABC) score and Shock Index (SI) have been shown to be reliable predictors for Massive Transfusion Protocol (MTP) activation. However, no study has directly compared these two scoring systems to determine which is a better predictor for MTP activation. The primary objective was to determine whether ABC or SI better predicted the need for MTP in adult trauma patients with severe hemorrhage.

METHODS

This was a retrospective cohort study which included all injured patients who were trauma activations between January 1, 2009 and December 31, 2013 at an urban Level I trauma center. Patients <18 years old or with traumatic brain injury (TBI) were excluded. ABC and SI were calculated for each patient. MTP was defined as need for >10 units PRBC transfusion within 24h of emergency department arrival. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) were used to evaluate scoring systems' ability to predict effective MTP utilization.

RESULTS

A total of 645 patients had complete data for analysis. Shock Index ≥1 had sensitivity of 67.7% (95% CI 49.5%-82.6%) and specificity of 81.3% (95% CI 78.0%-84.3%) for predicting MTP, and ABC score ≥2 had sensitivity of 47.0% (95% CI 29.8%-64.9%) and specificity of 89.8% (95% CI 87.2%-92.1%). AUROC analyses showed SI to be the strongest predictor followed by ABC score with AUROC values of 0.83 and 0.74, respectively. SI had a significantly greater sensitivity (P=0.035), but a significantly weaker specificity (P<0.001) compared to ABC score.

CONCLUSION

ABC score and Shock Index can both be used to predict need for massive transfusion in trauma patients, however SI is more sensitive and requires less technical skill than ABC score.

Scleritis and multiple systemic autoimmune manifestations in chronic natural killer cell lymphocytosis associated with elevated TCRalpha/beta+CD3+CD4-CD8- double-negative T cells

BACKGROUND/AIMS

Chronic natural killer lymphocytosis (CNKL) has been associated with systemic autoimmunity; however, its association with scleritis or ocular autoimmunity has not been characterised. The natural killer (NK) cell function and immunophenotype of a patient with CNKL who developed bilateral scleritis and multiple systemic autoimmune findings were evaluated.

METHODS

The ophthalmic records of a patient with CNKL and scleritis were reviewed over a 6-year period. Flow cytometry was performed to evaluate T cell, NK and B cell populations. NK cellular functions (ie, NK cytotoxicity and cytokine/chemokine production following interleukin 2 (IL2) stimulation) were evaluated.

RESULTS

A 56-year-old woman with vitiligo, psoriatic arthritis, thyroiditis, erythema nodosum, bilateral anterior scleritis and Sjogren syndrome was managed with multiple immunosuppressive medications, including prednisone, mycophenolate mofetil and methotrexate. Flow cytometry showed a persistent elevation of CD56(+)CD3(-) NK cells greater than 40%, which was consistent with CNKL. NK cell cytotoxicity assay identified a deficiency of K562 cell lysis in the patient (1.46 mean-fold greater in control vs patient). NK cytokine/chemokine production following IL2 stimulation was also deficient (2.5-32.5-fold greater in control). Cytokines/chemokines assessed included pro-inflammatory (interferon gamma, tumor necrosis factor alpha, IL1, monocyte chemotactic protein 1) and immunoregulatory cytokines (IL4, IL5 and IL10). An abnormal elevation of TCRalpha/beta(+) CD3(+)CD4(-)CD8(-) T cells suggestive of autoimmune lymphoproliferative syndrome was observed; however, apoptosis dysfunction was not found.

CONCLUSION

The association of increased but dysfunctional NK cells in the context of multiple systemic and ocular manifestations suggests a role of NK cells in the pathogenesis of our patient's disease. Further studies regarding NK cell dysfunction and ocular autoimmunity are needed.

Arsenic release and attenuation in low organic carbon aquifer sediments from West Bengal

High arsenic concentrations in groundwater are causing a humanitarian disaster in Southeast Asia. It is generally accepted that microbial activities play a critical role in the mobilization of arsenic from the sediments, with metal-reducing bacteria stimulated by organic carbon implicated. However, the detailed mechanisms underpinning these processes remain poorly understood. Of particular importance is the nature of the organic carbon driving the reduction of sorbed As(V) to the more mobile As(III), and the interplay between iron and sulphide minerals that can potentially immobilize both oxidation states of arsenic. Using a multidisciplinary approach, we identified the critical factors leading to arsenic release from West Bengal sediments. The results show that a cascade of redox processes was supported in the absence of high loadings of labile organic matter. Arsenic release was associated with As(V) and Fe(III) reduction, while the removal of arsenic was concomitant with sulphate reduction. The microbial populations potentially catalysing arsenic and sulphate reduction were identified by targeting the genes arrA and dsrB, and the total bacterial and archaeal communities by 16S rRNA gene analysis. Results suggest that very low concentrations of organic matter are able to support microbial arsenic mobilization via metal reduction, and subsequent arsenic mitigation through sulphate reduction. It may therefore be possible to enhance sulphate reduction through subtle manipulations to the carbon loading in such aquifers, to minimize the concentrations of arsenic in groundwaters.

General practitioners' attitudes to patients who have learning disabilities

BACKGROUND

Previous research suggests that the inadequate primary health care received by people with learning disabilities may be the result of general practitioners' (GPs) negative attitudes. Few studies have investigated the evidence for this assumption. This study uses psychological theory to inform an investigation of the attitudes and emotions experienced by GPs when working with learning disabled patients, as assessed by reliable and valid measures.

METHOD

A questionnaire comprising an attitude measure and emotion measure was developed and tested for reliability and validity. This was mailed out to a total of 613 GPs registered with three Health Authorities, 310 questionnaires (51%) were returned.

RESULTS

GP respondents held positive attitudes to working with patients who have learning disabilities. However, they were less positive about adapting their behaviour. Attitudes varied according to respondents' age and frequency of professional contact with this patient group. There was a strong association between attitudes and emotional experience. Attitudes were unaffected by learning disability training and non-professional contact.

CONCLUSIONS

Negative perceptions about working with patients with learning disabilities do not fully explain the inadequate healthcare provided to this group. Other factors may include insufficient awareness of the benefits of adapting the format of a consultation, and the quality of the interface between the GP and the carer accompanying the patient.

Credentialling Australian critical care nurses: the pilot study

In October 1998, the Australian College of Critical Care Nurses (ACCCN) launched a model to credential specialist level critical care nurses. This model was 'road tested' during a pilot study, when experienced critical care nurses were invited to apply to become the first Australian credentialled critical care nurses. The pilot study was designed to ensure all individuals taking part in the process were surveyed regarding adequacy of the credentialling package and the credentialling process. Applicants were required to provide evidence of practise at the specialist level, as described in the Competency Standards for Specialist Level Critical Care Nurses. Evidence was presented via curriculum vitae, professional journal and supported by three peer reviewers and two referees. Each application was sent to a three-person assessor panel, which assessed the evidence in the application against the Competency Standards for Specialist Level Critical Care Nurses. A total of six applications from five states and one territory were received by April 1999. Five of the applicants were assessed to have met the Competency Standards and were awarded the credential, Australia Credentialled Critical Care Nurse (ACCN), which they will hold for a period of 3 years. Feedback from assessors, applicants, peer reviewers and referees involved in the pilot study has resulted in the further refinement of the credentialling package and processes. Australian critical care nurses will now have the opportunity to seek to be credentialled four times per year.

Precision error of fan-beam dual X-ray absorptiometry scans at the spine, hip, and forearm

The current study investigated short-term precision of fan-beam dual X-ray absorptiometry scans using a sample of subjects typically seen in a routine practice. Seventy-two women were scanned twice each in array fan-beam mode at the lumbar spine and 71 at the hip on a Hologic QDR 2000. Sixty-five were scanned at the forearm on a Hologic QDR 4500A in array mode. Each of the two scans was analysed without reference to its companion scan (independent analysis). The second assessment was also reanalyzed using the manufacturer's "Compare" function (compared analysis). Coefficients of variation (CVs) were calculated for the two forms of analysis at all the sites measured. Paired t-tests were performed to see whether the "Compare" function improved precision. The CV at the lumbar spine was 1.1% in both forms of analysis. The "Compare" function did not improve precision significantly at this site. The highest precision at the hip was found at the (Total) site of the hip (1.2-1.0%, independent and compared analyses, respectively) and the lowest at Ward's triangle. The Compare function significantly improved precision at Ward's triangle. The forearm had the best precision of all the sites measured with the Total site of the forearm being highest (0.5-0.7%) and the ultradistal site lowest (1.6-1.8%). The Compare function significantly decreased precision at the mid-distal and Total sites of the forearm. In conclusion, the highest precision was found at the Total site of the hip, the Total site of the forearm, and the spine. The Compare function did not significantly improve precision at the spine or hip (with the exception of Ward's triangle) and decreased precision at the forearm.

Metal ions play a passive role in the hairpin ribozyme catalysed reaction

The hairpin ribozyme is an example of a small catalytic RNA which catalyses the endonucleolytic transesterification of RNA in a highly sequence-specific manner. The hairpin ribozyme, in common with all other small ribozymes such as the hammerhead, requires the presence of a divalent metal ion co-factor (typically magnesium) for the reaction to take place. To investigate the role of magnesium ions in the hairpin catalysed reaction we have synthesised two epimeric modified substrates in which a phosphorothioate replaces the scissile phosphodiester bond. Previously, Burke and co-workers have reported that no thio-effect is observed with the Rp-phosphorothioate isomer. We observe the absence of a thio-effect with both diastereomeric phosphorothioate hairpin substrates. Furthermore we report that inert cobalt (III) complexes are capable of supporting the hairpin ribozyme reaction, with a similar efficiency to Mg2+,even in the presence of EDTA. Variation of the net charge on the inert cobalt complex does not change the observed rate of reaction. These results suggest that metal ions play a passive role in the hairpin ribozyme catalysed reaction and are probably required for structural purposes only. This places the hairpin ribozyme in a different mechanistic class to other small ribozymes such as the hammerhead.

[Preperitoneal pelviscopic Burch colposuspension using the "Nottingham needle"]

By 40 women with stress incontinence II.-III. degrees we performed a preperitoneal pelviscopic colposuspension (Burch) modified by Gill with the "Nottingham Needle". An urodynamic and sonographic assessment before and 6-9 months after the pelviscopic operation were done. In 38 cases from the 40 women (95%) we saw a good result. The new modification of the pelviscopic colposuspension showed us a low intra- and postoperative morbidity and we consider it a big advantage for obese women.

[A new surgical aid--the "endo-stitch disposable suture device"--for pelviscopic pre-peritoneal Burch incontinence operation. A pilot study]

OBJECTIVE

It is the therapeutical aim of urogynecology to correct urinary incontinence. Which advantages offers the use of the Endo-Stitch needle in Burch's pelviscopic colposuspension?

METHODS

When extending the field of pelviscopic surgery, in a prospective study we performed Burch's pelviscopic preperitoneal colposuspension using the disposable Endo-Stitch suture instrument in 12 patients with stress incontinence grades 2 or 3. Clinical and urodynamic evaluations were performed before and 8.5 months after the pelviscopic operation.

RESULTS

Clinical and urodynamic follow-up examinations revealed continence in 10 (83%) out of 12 patients.

CONCLUSIONS

Our preliminary experience suggests that the pelviscopic incontinence operation by means of the Endo-Stitch needle is a good alternative to abdominal colposuspension. Follow-up results of a large number of patients will have to prove advantages in contrast to conservative surgery.

Bleeding complications after CASH

We assessed the frequency and studied the possible mechanisms of bleeding after classic abdominal Semm hysterectomy (CASH) in a retrospective, nonrandomized review of 70 women (47 premenopausal) undergoing the procedure with 1-year minimum follow-up. In several women CASH was associated with adhesiolysis, and in more than 50% with bilateral oophorectomy. Of the 47 patients who were menstruating prior to surgery, 6 (13%) reported postoperative menstruation. Two additional patients required repeat surgery, and one required transfusion. Endometrial glands were present in one excised specimen, suggesting the possibility that menstruation and hematometra may occur.

Histopathologic findings in synthetic and biologic explanted grafts used in peripheral arterial reconstruction

Surgically explanted vascular grafts, including 47 autografts, 14 allografts, 103 chemically processed human umbilical vein (HUV) grafts, and 406 polytetrafluoroethylene (PTFE) grafts, were studied histopathologically. Autografts, HUV, and PTFE grafts were implanted mostly in the femoropopliteal position, whereas allografts were used as a blood access for hemodialysis. The main cause for explantation in autografts (53.6%), HUV (74.8%), and PTFE (61.3%) was thrombosis, whereas allograft failure was usually related to aneurysmal degeneration (72.7%). The infection rates of HUV (20.9%) and PTFE (25%) grafts were higher than those of autografts (4.8%) and allografts (9.1%). Furthermore, bacterial colonization occurred more frequently in HUV (63.9%) and PTFE (64.7%) than in autografts (6.7%) and allografts (0%). Leukocyte infiltration was detected mostly in HUV (39.4%) and PTFE (27%) explants. Autografts and allografts both showed a 7.1% rate of lipid uptake, whereas lipid retention was observed in 84.9% of HUV and 79.8% of PTFE grafts. These results suggest that biologic vascular grafts are to be used preferentially in small diameter arterial reconstruction because of their resistance to bacterial colonization and lipid uptake.

Noise and the classical musician

OBJECTIVES

To test the hypothesis that noise exposure may cause hearing loss in classical musicians.

DESIGN

Comparison of hearing levels between two risk groups identified during the study by measuring sound levels.

SETTING

Symphony orchestra and occupational health department in the west Midlands.

MAIN OUTCOME MEASURES

Hearing level as measured by clinical pure tone audiometry.

RESULTS

Trumpet and piccolo players received a noise dose of 160% and 124%, respectively, over mean levels during part of the study. Comparison of the hearing levels of 18 woodwind and brass musicians with 18 string musicians matched for age and sex did not show a significant difference in hearing, the mean difference in the hearing levels at the high (2, 4, and 8 KHz) audiometric frequencies being 1.02 dB (95% confidence interval -2.39 to 4.43).

CONCLUSIONS

This study showed that there is a potential for occupational hearing loss in classical orchestral musicians.

[Pelviscopic hysterectomy--a prospective comparative study of 40 cases]

We review to date 20 pelviscopic extirpations of the uterus. This new method of hysterectomy shows some advantages over the common vaginal hysterectomy. Anatomy of the supporting ligaments of the uterus remains the same, recovery from the operation goes quicker. Morbidity rate seems to be less than in the case of vaginal hysterectomy.

[Struma ovarii maligna]

Benign and malignant struma ovarii are very rare ovarian teratomas. Specific therapy guidelines should be established. A case of a malignant struma ovarii is presented and results of therapy discussed.

An histo-morphological evaluation of ninety surgically excised human umbilical vein grafts

Morphological, histological, and scanning electron microscopy examinations were performed on 90 surgically excised human umbilical vein grafts. Most of the explanted grafts were removed because of thrombosis or infection and were removed typically from a patient in the mid 60s and after an average duration of implantation of 11 months. Multiple structural defects were found including deep folds, breaks on the luminal surface, and delamination. These areas as well as anastomotic sites represented potential areas for thrombotic accumulation. A higher incidence of infection was observed in grafts composed of 2 or 3 segments. Bacteria were often found in folds and could be seen invading the wall of the prosthesis. In addition, bacteremic colonization was often seen in noninfected grafts. The late aneurysmal formations were also of particular concern. The biodegradation of the wall and the disruption of the polyester mesh were the probable causes. The second generation Dardik Biograft aimed at reducing these formations. The success of this new processing remains to be evaluated.

Expanded polytetrafluoroethylene prostheses as secondary blood access sites for hemodialysis: pathological findings in 29 excised grafts

The popularity of expanded polytetrafluoroethylene (PTFE) arteriovenous fistulas for hemodialysis access is increasing. The low infection rate, low thrombogenicity and low body reactivity make it an important blood access for patients on routine hemodialysis. The authors examined 29 PTFE graft fistulas surgically excised from patients on hemodialysis for one or more of the following complications: infection 7, 2 with associated hemorrhage; thrombosis 9; aneurysm 11, 3 with associated thrombosis; stenosis 5, 3 with associated thrombosis; hemorrhage 4 and arterial steal 2. The explanted prostheses were reinforced Gore-tex in 20, Gore-tex thin wall in 1, Impra I in 4, Impra II in 3 and Vitagraft in 1. It was also noted that the implants failed in the short term mainly because of infection, in the medium term mainly because of thrombosis and stenosis, and in the long term usually because of aneurysm.

Biologic and structural evaluation of 80 surgically excised human umbilical vein grafts

Human umbilical vein is a valuable alternative to autogenous saphenous vein in lower-limb revascularization. However, the long-term patency is not as good. To understand better the reasons for this, the authors studied the biologic and structural changes occurring in 80 segments of human umbilical vein (HUV) grafts excised from 70 patients. Morphologic, histologic and scanning electron microscopy examinations were performed on each specimen. It was noted that increasing duration of implantation was associated with greater encapsulation and less surrounding inflammatory reaction. Twenty-six percent of clinically noninfected grafts were found to harbour bacteria. Bacteremic colonization was often in the folds of the luminal surface. As a result of these findings, the authors emphasize the need for complete excision of clinically infected grafts. Anastomoses between HUV segments are discouraged because they are associated with a high frequency of infection and a corresponding decrease in duration of implantation. Delamination of the wall was common, and such sites may represent areas at risk for further degradation. Continued surveillance of the biologic and structural changes occurring in excised grafts remains an important method in increasing our understanding of the evolutive complications of HUV grafts.

MRI of sickle cell cerebral infarction

Eleven patients with sickle cell disease and neurological symptoms underwent MRI examination. Cerebral infarcts of two types were found, those in the vascular distribution of the middle cerebral artery and those in the deep white matter. In the patient whose hydration and whose oxygenation of erythrocytes has been treated, MRI offers diagnostic advantages over arteriography and CT.

Expression of two G-6-PD genes in an XX phenotypic male

The glucose-6-phosphate dehydrogenase (G-6-PD) gene is located on the X-chromosome. Normal males have a single gene and produce a single G-6-PD type, while normal XX females may be heterozygotes for two different G-6-PD genes. We report the case of a phenotypic male who was found to be heterozygous for two G-6-PD enzymes. Cytogenetic analysis showed that he was a 46,XX male.

Streptococcal endocarditis: single vs. combination antibiotic therapy and role of various species

Forty-eight patients with 51 episodes of infective endocarditis caused by streptococci were studied in a comparison of the efficacy of single antibiotic therapy versus that of combination therapy. There was no statistical difference in terms of clinical course, toxicity, and mortality between the group given a single drug and that given combination therapy. However, one patient experienced two relapses, in both instances after high-dose penicillin therapy. The species and antibiotic susceptibilities of the infecting organisms were determined. The majority of isolates were alpha-hemolytic, with Streptococcus sanguis recovered most commonly. Streptococcus bovis and group B beta-hemolytic streptococci were the next most frequent isolates.

The Pennsylvania hemophilia program 1973-1978

In Pennsylvania, the prevalence of hemophilia is one per 10,000 males. Factor VIII deficiency is five times more frequent than Factor IX deficiency, and 34% of the patients have no relatives affected with the disease. The mean age is 23 years old, and 50% of the patients are less than 20 years old. Approximately one-third of the patients with Factor VIII deficiency and one fourth of the patients with Factor IX deficiency have levels of less than 0.01 mu/ml. By clinical criteria, 55% of those with Factor VIII deficiency are severe compared to 45% of those with Factor IX deficiency. Factor VIII-deficient patients are treated an average of 18 times per year compared to ten times per year for patients with Factor IX deficiency. Hemarthroses account for 70% of the hemorrhages treated and for 40% of the concentrate usage. Home therapy patients use an average of 45,950 Factor VIII units per year at a cost of ø170 per patient and their use accounts for 60% of the total Factor VIII usage of 1.7 million units. Less than five days per patient per year are lost from school or work because of bleeding, and patients are hospitalized for bleeding an average of only two to three days per patient year. Adverse immediate reactions to therapy are infrequent. Five percent of patients have persistence of the hepatitis B virus, and 7.5% have inhibitors. The mortality rate is 0.04% per year, with half of the deaths being hemophilia-related.

Failure of chloroquine in human babesiosis (Babesia microti): case report and chemotherapeutic trials in hamsters

The failure of a 3-week course of chloroquine to eliminate an infection of Babesia microti acquired on Martha's Vineyard led to tests of selected drugs in hamsters infected with the strain from this patient. The results showed response to several antitrypanosomal drugs (pentamidine and 4,4'-diazoaminobenzamidine) but not to antimalarial drugs (chloroquine, sulfadiazine, and pyrimethamine).

Increasing incidence of Gram-positive sepsis in cancer patients

A review of the agents causing septicemia in cancer patients during a nine-year period (1968--76) revealed that Gram-positive organisms (especially S aureus) have become the most frequent isolates during the last two years. This unanticipated increase (P less than 0.001) in the number of Gram-positive isolates could not be related to horizontal transmission nor to changes in patient characteristics or therapy.

Hemoglobin Lepore trait: globin synthesis in bone marrow and peripheral blood

There was decreased synthesis of the beta-globin chain in the peripheral blood, and equal synthesis of alpha- and non-alpha-chains in the bone marrow of three patients with hemoglobin Lepore trait, similar to the findings in patients with heterozygous beta-thalassemia. There is a relative instability of the synthetic mechanism for normal beta-chain in these patients.