Dextromethorphan in Cough Syrup: The Poor Man's Psychosis

Dextromethorphan (3-methoxy-N-methylmorphinan), also known as "DXM" and "the poor man's PCP," is a synthetically produced drug that is available in more than 140 over-the-counter cough and cold preparations. Dextromethorphan (DXM) has overtaken codeine as the most widely used cough suppressant due to its availability, efficacy, and safety profile at directed doses. However, DXM is subject to abuse. When consumed at inappropriately high doses (over 1500 mg/day), DXM can induce a state of psychosis characterized by Phencyclidine (PCP)-like psychological symptoms, including delusions, hallucinations, and paranoia. We report a noteworthy case of severe dextromethorphan use disorder with dextromethorphan-induced psychotic disorder in a 40-year-old Caucasian female, whose symptoms remitted only following treatment with a combination of an antipsychotic and mood stabilizer. While some states have begun to limit the quantity of DXM sold or restrict sales to individuals over 18-years of age, there is currently no federal ban or restriction on DXM. Abuse of DXM, a readily available and typically inexpensive agent that is not detected on a standard urine drug screen, may be an under-recognized cause of substance-induced psychosis. It is imperative that clinicians are aware of the potential psychiatric sequelae of recreational DXM use.

Reduced toxicity with gradual initiation of trimethoprim-sulfamethoxazole as primary prophylaxis for Pneumocystis carinii pneumonia: AIDS Clinical Trials Group 268

Trimethoprim-sulfamethoxazole (TMP/SMX) is recognized as the superior agent for Pneumocystis carinii pneumonia (PCP) prophylaxis but a high incidence of adverse drug reactions, which may be due to toxic drug metabolites, limits its use. AIDS Clinical Trials Group protocol 268 was a randomized, double-blind, controlled two-arm trial designed to determine whether gradual initiation of TMP/SMX suspension reduced the incidence of treatment-limiting adverse drug reactions compared with routine initiation of double-strength (DS; 160 mg/800 mg) tablets. In all, 372 HIV-1-infected study subjects with a CD4+ cell count <250 x 10 cells/mm3 who had not previously received TMP/SMX for PCP prophylaxis were randomized to receive either daily TMP/SMX DS tablets or a gradually increasing dose of TMP/SMX suspension. The suspension dose was increased to reach the equivalent of a DS tablet by study day 13. During the first 2 weeks, study subjects also received a matching placebo tablet/suspension. After week 2, all study subjects received TMP/SMX tablets for the next 10 weeks. There were significantly fewer study subjects who discontinued prophylaxis during the first 12 weeks when TMP/SMX therapy was initiated gradually (17%) than when initiated in DS tablet formulation (33%) (p =.0002). Gradual initiation was also associated with significantly fewer adverse drug reactions. Gradual initiation of TMP/SMX for primary PCP prophylaxis reduces the incidence of its treatment-limiting adverse effects.

Grazing methods and stocking rates for direct-seeded alfalfa pastures: I. Plant productivity and animal performance

A 4-yr study was conducted to determine the effects of two grazing methods (GM) at two stocking rates (SR) on alfalfa pasture plant productivity and animal performance and to ascertain the effect of grazing systems on subsequent performance of steers fed a high-concentrate diet. Eight pasture plots (.76 ha) were seeded in 1988 with alfalfa (Medicago sativa L. var. WL225) and divided into two blocks of four pastures each. Grazing methods consisted of a traditional four-paddock or an intensive 13-paddock system. Pastures were managed to allow a 36-d rest period with an average grazing season of 110 d. The low and high SR were 5.9 vs 11.7, 5.3 vs 10.5, 5.3 vs 7.9, and 5.3 vs 7.9 steers/ha for years 1989 to 1992, respectively. Following the grazing season, steers were placed in a feedlot and fed a high-concentrate diet (81% high-moisture corn, 14% corn silage, 5% protein-mineral supplement) for an average of 211 d. There was no effect of GM on herbage mass, pasture phase ADG, or live weight gain/hectare. Increasing the number of paddocks was beneficial when herbage mass was limited and stocking rate was above 7.9 steers/ha. Increasing SR above 7.9 steers/ha decreased herbage mass and pasture-phase ADG. As forage allowance increased, pasture-phase ADG increased quadratically (R2 = .82, P < .001), reached a plateau, and then decreased. Previous grazing system did not influence the performance of steers in the feedlot or their carcass characteristics. Optimum SR is dependent on herbage mass produced.

Grazing methods and stocking rates for direct-seeded alfalfa pastures: III. Economics of alternative stocking rates for alfalfa pastures

A framework that permits estimation of economically optimal stocking rates for alternative economic parameters and alfalfa forage allowance was developed and applied to a controlled grazing experiment conducted with Holstein steers (243 kg) placed on direct-seeded alfalfa pastures in central Michigan. Responses of ADG to alternative levels of forage allowance (FA) were summarized by a quadratic function and the associated gains/hectare were calculated. The standard stocking rate (SSR; standard livestock units/ha) that maximized gain/hectare increased with FA and was greater than that which maximized ADG. Net returns to fixed resources(NRFR)/hectare were calculated for alternative SSR and economically optimal SSR were identified under various levels of herbage mass (kg/d). The SSR that maximized NRFR were between the SSR that maximized ADG and gain/hectare. Magnitude of the sale price discount for heavier calves, the slide, influenced the optimal SSR and the sensitivity of net return to SSR. The economically optimal SSR increased as the slide increased because animals stocked under higher SSR weighed less off pasture and therefore received a lower price discount.

Parents' predicted transmitting abilities are not associated with culling prior to second lactation of Michigan, USA dairy cows

The objective of this study was to test the association between parents' predicted transmitting abilities (PTAs) for milk, fat and protein and subsequent culling of heifers during rearing or first lactation. The data from 1992 to 1996 consisted of the culling outcome of 5619 Michigan Holstein heifers during rearing or first lactation, and the heifers' parents' PTAs from the period in which the heifers were born. Fixed-effect probit models (both dichotomous and ordered) estimated the relationships between culling and parents' PTAs. Herd effect was modeled as a fixed-effect. There was no association between PTAs of milk, fat, and protein for each heifer's parents and subsequent culling of the heifer during rearing or first lactation. Weak evidence for the necessity of modeling the herd effect as fixed was present. The lack of association between parents' PTAs and reason-specific culling (voluntary versus involuntary)--coupled with the counter-intuitive effects of parents' PTAs on the probability of being culled for each of the reasons--raised questions about the utility of classifying culling reasons according to the voluntary nature of the culling decision. We concluded that Michigan producers are not using parents' genetics in heifer-culling decisions.

A comparison of profitability and economic efficiencies between management-intensive grazing and conventionally managed dairies in Michigan

A retrospective cohort study was designed to determine differences in profitability, asset efficiency, operating efficiency, and labor efficiency between Michigan dairy farms implementing management-intensive grazing (MIG) and conventionally managed dairy farms. Financial information and labor use data for the calendar year 1994 were collected with surveys and personal interviews from 35 MIG dairies and 18 conventionally managed dairies. Because the geographic distribution of MIG and conventionally managed farms in this study did not include Michigan's "dairy belt," extrapolation of these results to an average Michigan or Midwest dairy should be made with care. Within the areas represented, however, multivariate linear regression indicated that MIG dairies had more economic profit than conventionally managed dairies. They captured this profit by being more efficient in asset use, operating practices, and labor use. These results suggest that MIG could provide a sustainable alternate management tool for portions of Michigan's dairy industry.

Itraconazole prophylaxis for fungal infections in patients with advanced human immunodeficiency virus infection: randomized, placebo-controlled, double-blind study. National Institute of Allergy and Infectious Diseases Mycoses Study Group

In a prospective, randomized, double-blind trial, 149 patients with advanced human immunodeficiency virus (HIV) infection were randomized to receive itraconazole capsules (200 mg daily) and 146 to receive a matched placebo. Both groups were monitored for evidence of fungal infections. Baseline characteristics of the two groups were similar. Failure of prophylaxis occurred in 29 (19%) of the itraconazole recipients and 42 (29%) of the placebo recipients (P = .004; log-rank test). There were 6 invasive fungal infections in the itraconazole group (4, histoplasmosis; 1, cryptococcosis; 1, aspergillosis) and 19 in the placebo group (10, histoplasmosis; 8, cryptococcosis; 1, aspergillosis) (P = .0007; log-rank test). Itraconazole significantly delayed time to onset of histoplasmosis (P = .03; log-rank test) and cryptococcosis (P = .0005; log-rank test). Prophylaxis failure due to recurrent or refractory mucosal candidiasis occurred with similar frequency in the two groups (itraconazole, 15%; placebo, 16%). A survival benefit was not demonstrated. Itraconazole generally was well tolerated. Primary prophylaxis with itraconazole capsules prevents histoplasmosis and cryptococcosis in patients with HIV infection.

Escalating multiple-dose safety and tolerance study of oral WR 6026 in HIV-infected subjects: AIDS clinical trials group 173

WR 6026 is an 8-aminoquinoline with activity against Pneumocystis carinii in vitro and in an animal model of P. carinii pneumonia that has predicted the clinical utility of related compounds. This study was conducted to assess the safety and tolerance of WR 6026 given once daily for 21 days to HIV-infected subjects with CD4 counts <500 cells/microl. This double-blind, placebo-controlled study employed WR 6026 doses starting at 30 mg once daily and increasing to 60, 90, 120, or 150 mg once daily. Weekly visits for clinical and laboratory monitoring were conducted. Forty-nine study subjects, including 25 subjects with CD4 counts <200 cells/microl and 12 subjects with CD4 counts <100 cells/microl, entered the study. The maximum tolerated dose was 120 mg/day. Dose-limiting methemoglobinemia (>20%) was seen in 3 of 6 study subjects who received 150 mg/day for > or =19 days. Methemoglobin level was correlated with peak plasma WR 6026 concentrations. Three other study subjects developed skin rashes that may have been drug-related, and two developed asymptomatic serum triglyceride levels >1000 mg/dl. We conclude that WR 6026 is well tolerated at doses up to 120 mg/day for 21 days in HIV-infected volunteers including those with CD4 counts <200 cells/microl. Methemoglobinemia appears to be the primary dose-limiting toxicity.

Comparison of three regimens for treatment of mild to moderate Pneumocystis carinii pneumonia in patients with AIDS. A double-blind, randomized, trial of oral trimethoprim-sulfamethoxazole, dapsone-trimethoprim, and clindamycin-primaquine. ACTG 108 Study Group

OBJECTIVE

To compare the tolerability and efficacy of three oral regimens for the treatment of patients with the acquired immunodeficiency syndrome (AIDS) and Pneumocystis carinii pneumonia.

DESIGN

A randomized, double-blind study.

SETTING

24 U.S. academic medical centers.

PATIENTS

181 patients with morphologically confirmed P. carinii pneumonia and alveolar-arterial oxygen differences (PAO2-PaO2) of 45 mm Hg or less.

INTERVENTION

Patients were randomly assigned to receive trimethoprim-sulfamethoxazole, dapsone-trimethoprim, or clindamycin-primaquine for 21 days. Patients with a PAO2-PaO2 of 35 to 45 mm Hg at study entry also received prednisone.

MEASUREMENTS

Serial clinical and laboratory evaluations for therapeutic response and toxicity. Therapeutic failure at day 21 was defined by any of the following: increase in PAO2-PaO2 of greater than 20 mm Hg; no remission of baseline signs and symptoms; and change in antipneumocystis therapy for reasons other than toxicity, intubation, or death. Dose-limiting toxicity was defined as discontinuation of therapy by the primary physician because of one or more adverse reactions.

RESULTS

No statistically significant differences were seen among treatment groups in the proportions of patients who had dose-limiting toxicity (P=0.2), therapeutic failure (P>0.2), or a complete course of therapy (P>0.2). Survival during therapy or for 2 months thereafter did not differ among the three groups (P>.02). However, elevation of serum aminotransferase levels to more than five times the baseline levels was more frequent in the trimethoprim-sulfamethoxazole group (P=0.003), and one or more serious hematologic toxicities (neutropenia, anemia, thrombocytopenia, or methemoglobinemia) occurred more frequently in the clindamycin-primaquine group (P=0.01).

CONCLUSIONS

The rates of dose-limiting toxicity, therapeutic failure, and survival did not differ among patients with AIDS who were receiving oral trimethoprim-sulfamethoxazole, dapsone-trimethoprim, or clindamycin-primaquine for mild to moderate P. carinii pneumonia. However, the limited sample size prevents the unequivocal demonstration of the equality of these three regimens. Differences in expected categories of toxicities associated with each regimen should guide the clinician in choosing first-line therapy, particularly for patients with baseline hepatic insufficiency or myelosuppression.

Skin disorders of the lower extremity in adults as reported in the current literature

This article represents a synthesis of the literature from 1960 to the present. The authors refocused their assigned topic from geriatric skin disorders to adult skin disorders. The distinction between adult and nonadult is clearer than the distinction between geriatric and nongeriatric. The topics covered are divided broadly into malignant and nonmalignant entities.

Comparative X-ray structures of the major binding protein for the immunosuppressant FK506 (tacrolimus) in unliganded form and in complex with FK506 and rapamycin

FK506 (tacrolimus) is a natural product now approved in the US and Japan for organ transplantation. FK506, in complex with its 12 kDa cytosolic receptor (FKBP12), is a potent agonist of immunosuppression through the inhibition of the phosphatase activity of calcineurin. Rapamycin (sirolimus), which is itself an immunosuppressant by a different mechanism, completes with FK506 for binding to FKBP12 and thereby acts as an antagonist of calcineurin inhibition. We have solved the X-ray structure of unliganded FKBP12 and of FKBP12 in complex with FK506 and with rapamycin; these structures show localized differences in conformation and mobility in those regions of the protein that are known, by site-directed mutagenesis, to be involved in calcineurin inhibition. A comparison of 16 additional X-ray structures of FKBP12 in complex with FKBP12-binding ligands, where those structures were determined from different crystal forms with distinct packing arrangements, lends significance to the observed structural variability and suggests that it represents an intrinsic functional characteristic of the protein. Similar differences have been observed for FKBP12 before, but were considered artifacts of crystal-packing interactions. We suggest that immunosuppressive ligands express their differential effects in part by modulating the conformation of FKBP12, in agreement with mutagenesis experiments on the protein, and not simply through differences in the ligand structures themselves.

Paronychia

Paronychia is defined most often in terms of inflammation and is classified as congenital, acute-acquired, or chronic-acquired. The cause for acquired paronychia usually is trauma, and middle-aged women are at greatest risk. Chronic paronychia has been associated with numerous occupations where fluids are the common denominator. Mixed infections usually are found in chronic paronychia, including bacteria, fungus, and yeast. Depending upon the type of paronychia and associated organisms, therapy includes footgear considerations, pharmacology measures, and surgical measures.

Clindamycin and primaquine therapy for mild-to-moderate episodes of Pneumocystis carinii pneumonia in patients with AIDS: AIDS Clinical Trials Group 044

The objective of this prospective, noncomparative study was to assess the safety and efficacy of clindamycin and primaquine therapy for mild-to-moderate pneumocystis pneumonia (defined as a difference of < 40 mm Hg between the alveolar and the arterial oxygen determinations) in patients with AIDS. In the first part of the study, 22 patients were treated with iv clindamycin (900 mg every 8 hours) for the first 10 days, and then their therapy was switched to oral clindamycin (450 mg every 6 hours) for an additional 11 days. In the second part of the study, 38 patients were treated entirely with oral clindamycin (600 mg every 8 hours). All patients were treated with oral primaquine base (30 mg once daily). Fifty-five (92%) of 60 patients responded to the study treatment. Forty-six (77%) of 60 patients completed a full course of therapy. Of the nine patients with treatment-limiting toxic effects, four had only a mild rash. This study indicates that the combination of clindamycin and primaquine is an effective and well-tolerated therapy for mild-to-moderate pneumocystis pneumonia in patients with AIDS. Entirely oral therapy appears to be as effective as initial therapy with iv clindamycin.

Infection prevention in severely myelosuppressed patients: a comparison between ciprofloxacin and a regimen of selective antibiotic modulation of the intestinal flora

PURPOSE

To study whether oral ciprofloxacin would be as effective in preventing bacterial infections in severely myelosuppressed patients as selective antibiotic modulation of the gut flora with neomycin/polymyxin B sulfate/nalidixic acid (NPN).

PATIENTS AND METHODS

One hundred and five patients undergoing allogeneic or autologous bone marrow transplant, or induction therapy for acute leukemia in 1988 and 1989 were studied. Patients were stratified according to the type of therapy, and randomized in a ratio of 2:1 to either oral ciprofloxacin 500 mg BID, or a combination of oral neomycin 250 mg QID, polymyxin-B 100 mg QID, and oral nalidixic acid 1,000 mg BID. Treatment began on admission and continued until the absolute granulocyte count was greater than 500/mm3 for 3 consecutive days.

RESULTS

The 96 evaluable patients were evenly distributed over the 3 treatment groups; 63 patients received ciprofloxacin and 33 received NPN. Fever developed in 92% of patients on ciprofloxacin and in 97% of patients on NPN. (P = 0.66), 6.6 +/- 5.8 and 7.2 +/- 5.3 days from the start of prophylaxis, respectively. Twenty-five patients on ciprofloxacin developed 29 microbiologically documented infections, fewer than the 26 infections in the 22 patients on NPN (P = 0.02). Patients on ciprofloxacin had fewer bacteremias (33%) than did the NPN patients (55%) (P = 0.05). Gram-negative bacteremias were very rare (2 cases; no Enterobacteriaceae), but streptococcal bacteremias were frequent in both arms (27 cases). Side effects were not significantly different, but compliance with ciprofloxacin was better.

CONCLUSIONS

Ciprofloxacin is at least as effective as the combination of neomycin/polymyxin/nalidixic acid in the prophylaxis of bacterial infections in myelosuppressed patients, and is better tolerated. Additional agents to prevent streptococcal infections are needed.

A simple method for isolating alpha 2 macroglobulin-cytokine complexes

There is the need for a simple, effective procedure for separating alpha 2 macroglobulin-cytokine complexes from free cytokine in order that the nature and possible immunological significance of cytokine-binding by alpha 2 macroglobulin (alpha 2-M) might be further investigated. This presentation describes a method which exploits the presence of zinc-binding sites on alpha 2-M which permit the isolation of complexes from other proteins by zinc-affinity chromatography. Furthermore the method may be used in either a column or batch format.

Preliminary analysis of multiple crystal forms of the bovine cyclophilin-cyclosporin A complex

The immunosuppressant cyclosporin-A (CsA) has been crystallized in complex with the bovine form of its major receptor protein cyclophilin (CyP) in three different forms by the hanging-drop vapor diffusion method. A hexagonal crystal form (P6(1)22 or P6(5)22; a = b = 110 A, c = 440 A) diffracts to 4 A resolution. Orthorhombic (P2(1)2(1)2(1) or P2(1)2(1)2; a = 154.3 A, b = 163.3 A, c = 94.7 A), and monoclinic (P2(1); a = 70.0 A, b = 162.5 A, c = 94.7, beta = 100.0 degrees) forms diffract to 2.2 A resolution. Self-rotation function analysis of the orthorhombic and monoclinic forms shows 52 point group local symmetry for both. A previously reported tetragonal crystal form of the complex also shares this local symmetry, suggesting that the observed motif may pre-exist in solution.

Successful allogeneic bone marrow transplantation in an adult with aplastic anemia following orthotopic liver transplantation for non-A, non-B, non-C hepatitis

A 29-year-old male patient presented with acute liver failure from non-A, non-B and non-C hepatitis, necessitating orthotopic liver transplantation. After operation he developed progressive pancytopenia on the basis of aplastic anemia, which was probably hepatitis associated. After therapy with GM-CSF had failed, he underwent allogeneic BMT from his HLA genotypically identical brother following a conditioning regimen of CY 50 mg/kg x 4 and 500 cGy total lymphoid irradiation. He engrafted promptly but transfusion dependency did not resolve until CMV viremia was treated with ganciclovir. The patient is alive and well 2 years after BMT.

Nutrient requirements versus supply in the dairy cow: strategies to account for variability

Dairy producers must overcome substantial challenges to achieve milk outputs > 14,000 kg of milk/yr per cow within the next decade. To obtain high productivity, a more complete comprehension of the dynamics of metabolism, nutrient utilization, and nutrient absorption will enable better prediction of the efficiency of utilization of these nutrients. A better understanding of the dynamics of rumen function and a more accurate prediction of nutrient flow from the rumen are necessary. Grouping strategy and group feeding behavior influence cow productivity and farm profitability. Understanding of the variance of individual cow responses to management practice is critical. Feeding system design and management and diet formulation techniques need to be developed that recognize the dynamic nature of cow physiology and the variability in feedstuffs and cow requirements. These concepts need to be integrated into total farm management and require the use of new computer modeling technologies.

Comparative evaluation of ofloxacin and metronidazole in the treatment of bacterial vaginosis

BACKGROUND AND OBJECTIVES

The epidemiology and etiology of bacterial vaginosis is poorly understood. Many antimicrobial agents have been studied and suggested as treatment alternatives for this infection. Fluoroquinolones have in vitro activity against some of the organisms associated with bacterial vaginosis and may provide another treatment option.

STUDY DESIGN

Women who presented with symptomatic bacterial vaginosis were randomly assigned to receive either oral ofloxacin 300 mg twice a day or oral metronidazole 500 mg twice a day for seven days. Twenty-seven of the 31 patients who were enrolled in this double-blinded study were evaluable.

RESULTS

Fourteen women received ofloxacin. At follow-up, four had no residual symptoms, seven noted a reduction in symptoms, and three had no change in symptoms. Eight (57%) of the 14 women who received ofloxacin had secretions at follow-up that satisfied the criteria for the diagnosis of bacterial vaginosis. Thirteen women received metronidazole. Nine had no residual symptoms and four noted a reduction in symptoms. Eleven (85%) of the 13 women had normal vaginal secretions and two (15%) had secretions that were improved. None of the women who received metronidazole had secretions at follow-up that met the criteria for the diagnosis of bacterial vaginosis.

CONCLUSION

We conclude that ofloxacin is less effective than metronidazole in the treatment of bacterial vaginosis.

Heel pain in the older patient

Older Americans are the fastest growing segment of the US population. For this group, mobility is a significant factor in individual well-being. Heel pain is primarily a symptom found in adults, and like most health problems, increased age has a compounding effect on most disease processes. If heel pain becomes the cause of immobility in an older patient, significant consequences may arise. The true prevalence of heel pain in older individuals is not known precisely. The frequency may lie between 12.5% and 15% on the basis of reports in the literature. The scientific basis of these figures, however, is open to question. No one method of organizing heel pain according to a causative agent or condition is accepted universally. A review of the literature, however, reveals that most reporters ultimately include the same elements in whatever schema they use. In general terms, management of heel pain, regardless of the cause, can be organized according to noninvasive to invasive treatment methods. The authors have found the categories of mechanical, pharmacologic, and surgical to be useful. Selection of a therapeutic method is based on the patient's specific physical circumstance and social situation.

Warfarin sodium. Practitioner beware

The use of warfarin sodium in the US has increased dramatically over the last 40 years. Warfarin sodium or Coumadin is the most popular oral anticoagulant used in the US. The podiatric physician frequently encounters patients taking this agent and therefore needs to understand its potential impact. This article will familiarize the reader with the history, pharmacology, clinical applications, side effects, and frequent drug interactions encountered with warfarin sodium.

Salvage therapy with clindamycin/primaquine for Pneumocystis carinii pneumonia

Clindamycin/primaquine is effective for treating mild-to-moderate cases of Pneumocystis carinii pneumonia (PCP) in patients with AIDS. We retrospectively reviewed our experience with this combination among patients in whom conventional therapy had failed or was not tolerated. Twenty-six patients who experienced 28 episodes of PCP received salvage therapy with clindamycin/primaquine at two university-affiliated medical centers. Clindamycin was administered intravenously, (usually 900 mg every 8 hours), after which oral therapy was instituted. Primaquine (30 mg) was given orally to all patients except three; two of these patients received 15 mg of the drug daily and another 30 mg of drug on alternate days. In 11 of the episodes, the patients received clindamycin/primaquine as initial therapy for PCP because of previous intolerance of conventional therapy. In 13 of the episodes, conventional therapy had failed or the patients were unable to tolerate the regimen, while in four episodes conventional therapy failed and the patients were unable to tolerate their therapeutic regimens. Twenty-four (86%; 95% confidence interval, 73%-99%) of 28 episodes were successfully treated with clindamycin/primaquine. The most common adverse effect was the development of an erythematous rash. Clindamycin/primaquine appears to be an attractive alternative for patients in whom standard therapy for PCP has failed or cannot be tolerated.

Ration formulation using linear programming

A combination spreadsheet-LP ration formulation program offers tremendous advantages for dairy nutritionists. The spreadsheet format provides the framework for flexibility in describing feeds and in formulating a realistic and practical ration. The LP module can solve for a complicated set of nutrient requirements to give a relatively well-balanced ration. This "first-cut" ration can then be reworked in the spreadsheet mode to meet the needs of the individual farm based on other biologic and management considerations.

Clindamycin and primaquine as primary treatment for mild and moderately severe Pneumocystis carinii pneumonia in patients with AIDS

The combination of clindamycin and primaquine was investigated as primary treatment for mild or moderately severe Pneumocystis carinii pneumonia (alveolar-arterial oxygen gradient less than 40 torr) in 36 AIDS patients. All patients were treated with primaquine 30 mg (base) orally for 21 days. The first 22 patients were treated with clindamycin 900 mg i.v. q8h for the first 10 days, followed by clindamycin 450 mg q6h orally for 11 days. Twenty of these 22 patients (91%) showed a marked clinical response by day 7. Four patients were later withdrawn from the study due to toxicity. An additional 14 patients were treated with an entirely oral regimen of clindamycin and primaquine. Thirteen of the 14 patients (93%) showed a marked therapeutic response and 12 (86%) successfully completed treatment. The combination of clindamycin and primaquine appears to be an effective and well-tolerated treatment for mild to moderately severe Pneumocystis carinii pneumonia in AIDS patients.

Aggressive digital papillary adenoma: a case report

Aggressive digital papillary adenoma has only been identified as an entity within the past six years. Only forty patients have been reported in the literature with this lesion. The lesion is found three times more commonly on the hands than on the feet. The lesion typically enlarges slowly and is asymptomatic. Patients in half of the reported cases have experienced local recurrence after initial removal. The authors present a case of aggressive digital papillary adenoma of the foot.

Hepatitis. The forgotten disease

Hepatitis is a significant disease process for health care professionals. Because of the large number of procedures performed by podiatrists in the course of patient care, they are at particular risk. The variants of hepatitis are reviewed, and the modes of transmission are discussed. Recommendations are made on protective measures to reduce contraction of this disease.

Podiatric resident education at the James A. Haley Veterans Hospital

The Department of Veterans Affairs is the single largest source of podiatric resident education. The author describes the James A. Haley Veterans Hospital and discusses the development of the podiatric residency training program. A detailed description of all aspects of the training program is presented.

Peroneus longus tendon and peroneus brevis tendon dislocation. A case report

Trauma that produces recurrent dislocation of the peroneal tendons often is mistaken for an ankle sprain, or occurs in conjunction with an inversion ankle sprain. Self-diagnosis and self-treatment may preclude accurate diagnosis and management. The authors present a case that illustrates this scenario and review anatomical considerations, the mechanism of the injury, and therapeutic options.

Comparison of flurbiprofen and acetaminophen with codeine in postoperative foot pain

The purpose of this double-blind, randomized, parallel, multiple-dose study was to compare the efficacy and safety of flurbiprofen with acetaminophen with codeine phosphate in the 96-hr postoperative period following foot surgery. Analysis of mean pain intensity and mean pain relief for the patients not requiring rescue medication did not reveal any significant differences between treatment groups. There were also no significant differences between treatment groups with respect to patient and investigator global evaluations of therapy. The incidence of termination of the study because of side effects was higher for the acetaminophen with codeine group.

Symptomatic os supra naviculare. A case report

Accessory bones are common anomalies in the foot. They often may become symptomatic. The authors present such a case in which the patient was successfully treated by surgical incision of the accessory ossicle.

Multicenter, comparative study of enoxacin and ceftriaxone for treatment of uncomplicated gonorrhea

The efficacy of single dose enoxacin, 400 mg was compared to ceftriaxone, 250 mg IM for therapy of uncomplicated gonorrhea in 152 evaluable patients attending sexually transmitted disease clinics in Baltimore, Indianapolis and Seattle. Anogenital gonorrhea was cured in 75 (99%) of 76 patients treated with enoxacin and 73 (97%) of 75 patients treated with ceftriaxone. Three of three patients with pharyngeal gonorrhea were not cured by enoxacin while all three ceftriaxone treated cases of pharyngeal gonorrhea were cured. All cases of anogenital gonorrhea caused by beta-lactamase producing Neisseria gonorrheae (11 patients), gonococci with high-level, plasmid-mediated tetracycline resistance (11 patients), or gonococci with chromosomally mediated penicillin resistance (22 patients) were cured. The IC90 for enoxacin of N. gonorrhoeae isolated in this study was 0.06 microgram/ml. Enoxacin appears to be a well tolerated, efficacious alternative to currently recommended therapy for patients with uncomplicated, anogenital gonorrhea including cases potentially caused by antibiotic resistant N. gonorrhoeae.

Multicenter randomized study of single-dose ofloxacin versus amoxicillin-probenecid for treatment of uncomplicated gonococcal infection

The safety and efficacy of ofloxacin, 400 mg orally, were compared with those of amoxicillin, 3.0 g, plus probenecid, 1.0 g orally, as single-dose therapy in 201 heterosexual patients (101 men and 100 women) with uncomplicated gonococcal infection. Treatment groups were comparable in age, duration of symptoms, number of sexual partners within the previous month, and number of previous episodes of sexually transmitted diseases. The cure rate for men treated with ofloxacin was 98% (47 of 48), and that for women was 100% (52 of 52). Cure rates for both men and women treated with amoxicillin-probenecid were 96% (51 of 53 men; 46 of 48 women). All 13 patients with positive rectal cultures and 7 of 8 patients with positive pharyngeal cultures treated with ofloxacin were cured. Neither regimen reliably eradicated coexistent infection with Chlamydia trachomatis. The MIC of ofloxacin for all but two of 198 pretreatment isolates was 0.3 microgram/ml or less. The MIC of amoxicillin for 90% of isolates tested was 1.0 microgram/ml. Single oral doses of ofloxacin and of amoxicillin plus probenecid were equally effective for treatment of urethral and cervical gonorrhea. Ofloxacin appears promising as treatment for rectal and pharyngeal infection, but studies with larger numbers of patients with rectal or pharyngeal infection or both are required for confirmation. Relative contraindications in children and possibly pregnant women plus the potential for single-step, high-level resistance may limit the usefulness of quinolone therapy for gonorrhea.

Resistance to meningococcemia apparently conferred by anti-H.8 monoclonal antibody is due to contaminating endotoxin and not to specific immunoprotection

We evaluated the ability of a monoclonal antibody directed against the common H.8 antigen of pathogenic Neisseria sp. to confer passive protection against meningococcal disease in mice. The apparent protection conferred by antibody purified from tissue culture supernatant was actually the result of endotoxin contamination of buffers and tissue culture media. Endotoxin-free anti-H.8 antibody was not protective. The possibility of endotoxin contamination should be considered when evaluating immunity conferred by passively administered antibody in animal models.

The H8 antigen of pathogenic Neisseriae

We cloned and sequenced the H8 gene from N. meningitidis FAM18. The predicted amino acid sequence included a consensus lipoprotein signal sequence processing site, consistent with lipid modification that could account for the unusual electrophoretic and solubilization properties of H8. The amino acid sequence was rich in alanine and proline, especially in an imperfectly periodic region near the amino terminus, which encompassed the epitope recognized by available monoclonal antibodies. In a panel of neisserial strains, the presence of DNA homologous to the H8 gene correlated with the expression of an H8 protein. We cloned a gene from N. meningitidis JB515 that was distinct from the H8 gene but encoded a protein also recognized by an anti-H8 monoclonal antibody. Mice were not protected from meningococcemia by passive immunization with such an antibody.

Human immune response to iron-repressible outer membrane proteins of Neisseria meningitidis

Neisseria meningitidis grown under iron-limiting conditions in vitro expresses additional iron-repressible outer membrane proteins (FeRPs). To see which FeRPs were expressed and immunogenic in human infection, we examined purified membranes from four meningococcal disease isolates with Western blotting of patient sera. Convalescent serum from each patient contained immunoglobulin G (IgG) and IgM antibodies against the homologous 70-kilodalton (kDa) FeRP and IgG antibody to the homologous 94-kDa FeRPs. Three other immunoreactive FeRPs were identified in two or more strains. Neither acute-phase sera nor pooled normal human sera contained appreciable levels of these antibodies. Antigenic cross-reactivity among FeRPs was suggested by the observation that the convalescent sera of two patients contained IgG antibodies reactive with the 70- and 94-kDa FeRPs and IgM antibodies reactive with the 70-kDa FeRPs from all four strains. Additionally, rabbit antiserum against the 70-kDa FeRP from one of these disease isolates contained IgG and IgM antibodies that reacted in Western blots with the 70-kDa FeRPs in all four strains. These results demonstrate that meningococcal FeRPs are expressed and immunogenic in vivo and that certain of these proteins are immunologically cross-reactive.

Rheumatic dermatoarthropathies

Drs. Black and Fenske have presented a topic that fits in very well with the discussions provided by Dr. Graff concerning overall patient evaluation and the understanding that skin diseases may be external expressions of internal disease. As podiatrists, we are frequently exposed to patients who present with skin conditions secondary to rheumatic diseases or other forms of connective tissue disease. This review, with illustrations, will help us to improve our diagnostic abilities.