PCR amplification of the fimA gene sequence of Salmonella typhimurium, a specific method for detection of Salmonella spp

The goal of this study was to evaluate the suitability of the fimA gene amplification by PCR as a specific method for detection of Salmonella strains. Salmonella typhimurium and other pathogenic members of the family Enterobacteriaceae produce morphologically and antigenically related, thin, aggregative, type 1 fimbriae. A single gene, fimA, encodes the major fimbrial unit. In order to obtain higher specificity, we have selected a series of primers internal to the fimA gene sequence and have developed a PCR method for detecting Salmonella strains. A collection of 376 strains of Salmonella comprising over 80 serovars, isolated from animals and humans in Canada, have been used to evaluate this PCR method. Forty non-Salmonella strains were also tested by the same procedure. Cultures were screened by inoculating a single colony of bacteria directly into a PCR mixture containing a pair of primers specific for the fimA gene. The specific PCR product is an 85-bp fragment which was visualized by polyacrylamide gel electrophoresis and ethidium bromide staining. All Salmonella strains gave positive results by the PCR. Feed and milk samples contaminated by Salmonella strains were also detected by this procedure. The detection of all Salmonella strains tested and the failure to amplify the fragment from non-Salmonella strains confirm that the fimA gene contains sequences unique to Salmonella strains and demonstrate that this gene is a suitable PCR target for detection of Salmonella strains in food samples.

Two serologic markers to monitor the engraftment, growth, and treatment response of human leukemias in severe combined immunodeficient mice

We have investigated human lactate dehydrogenase (LDH) isoenzymes and human nuclear matrix protein 41/7 (NMP 41/7) as potential serologic markers to monitor the course of human leukemia in severe combined immunodeficient (SCID) mice. Following the transplantation of 10(6) human acute lymphoblastic leukemia (ALL) Nalm-6 cells, human specific LDH isoenzymes were measurable in the serum of SCID mice as early as 7 days after transplantation, although serum total LDH increased in some animals as early as 5 days after transplantation. Human NMP 41/7 was measurable in all animals at day 15 after leukemia cell injection. Serum levels of total LDH, human specific LDH and NMP 41/7 increased progressively over time, reaching total LDH levels as high as 50,000 U/L at day 25 after transplantation. To determine whether the levels of LDH and NMP 41/7 in serum were a reflection of human tumor burden, we studied these serologic markers in SCID mice bearing measurable subcutaneous human neuroblastoma tumors, or compared the serum levels of these markers with the number of human leukemia CD10+ cells in the bone marrow of the SCID mice. The serum levels of total LDH, human specific LDH isoenzymes, and NMP 41/7 correlated well with tumor burden, and they drastically decreased or disappeared from serum after the human leukemia or neuroblastoma cells were selectively killed with a single intravenous (IV) injection of 1 to 3 micrograms diphtheria toxin (DT) (the cellular receptor for DT is present on human cells, but not on mouse cells). Paraplegic mice with central nervous system leukemia completely recovered after DT treatment. We conclude that measurements of serum levels of total LDH, human LDH isoenzymes, and NMP 41/7 are sensitive, quantitative, rapid, and easy to perform serologic methods useful to monitor the engraftment, progression, and treatment response of human leukemia in SCID mice.

Factors predicting change in prescription and nonprescription drug use in a community-residing black and white elderly population

The current study identifies characteristics that predict change in use of prescription and nonprescription drugs over a period of 3 years. A modified health care services use model was applied to information obtained from a probability-based sample of black (n = 1778) and white (n = 1446) community-resident elderly, interviewed in 1986-1987 and 1989-1990. Analysis was by means of logistic and ordinary least-squares regression, with sample weights and design effects taken into account. The number of users and average number of prescription drugs used increased over the 3 years, and was best predicted by extent of prior drug use, older age, white race, poorer health, and number of health care visits. Conversely, nonprescription drug use declined significantly, and was best predicted by prior use, white race, and female gender. The reduced use of prescription drugs by blacks as compared to whites is of concern, suggesting that attention is needed to assure equitable access to prescription drugs.

Is medication use by community-dwelling elderly people influenced by cognitive function?

To determine whether medication use differs by cognitive status among community dwelling elderly, a survey was made of a stratified random sample of 4110 black and white participants, aged 65 or older from the Duke Established Populations for Epidemiologic Studies of the Elderly in five adjacent urban and rural counties in the Piedmont area of North Carolina. Main outcome measures were usage of prescription medications, non-prescription medications, and medicines within therapeutic classes in the previous 2 weeks as determined during an in-home interview; and total number of prescription and non-prescription medicines used in the previous 2 weeks. Multivariate analyses, using weighted data adjusted for sampling design, were conducted to assess the association between drug use patterns and cognitive status, as assessed by the Short Portable Mental Status Questionnaire, while adjusting for demographic, health status, and access to health care factors. Participants with cognitive impairment (13.7% of sample) were less likely to use any prescription medications (Adjusted OR = 0.66, 95% CI = 0.48-0.90) or any non-prescription medications (Adjusted OR = 0. 71, 95% CI = 0.56-0.89) than cognitively intact subjects. Both groups took a similar number of prescription and non-prescription medications. Those who were cognitively impaired were less likely to take analgesics (Adjusted OR = 0.66, 95% CI = 0.52-0.83), but were more likely to take central nervous drugs (Adjusted OR = 1.55, 95% CI 1.18-2.04) than those who were cognitively intact. We conclude that drug use patterns by community-dwelling elderly people differ with cognitive status. Future research needs to examine medication use by specific causes of cognitive impairment.

A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy

PURPOSE

To evaluate the effect of sustained clinical pharmacist interventions involving elderly outpatients with polypharmacy and their primary physicians.

PATIENTS AND METHODS

Randomized, controlled trial of 208 patients aged 65 years or older with polypharmacy (> or = 5 chronic medications) from a general medicine clinic of a Veterans Affairs Medical Center. A clinical pharmacist met with intervention group patients during all scheduled visits to evaluate their drug regimens and make recommendations to them and their physicians. Outcome measures were prescribing appropriateness, health-related quality of life, adverse drug events, medication compliance and knowledge, number of medications, patient satisfaction, and physician receptivity.

RESULTS

Inappropriate prescribing scores declined significantly more in the intervention group than in the control group by 3 months (decrease 24% versus 6%, respectively; P = 0.0006) and was sustained at 12 months (decrease 28% versus 5%, respectively; P = 0.0002). There was no difference between groups at closeout in health-related quality of life (P = 0.99). Fewer intervention than control patients (30.2%) versus 40.0%; P = 0.19) experienced adverse drug events. Measures for most other outcomes remained unchanged in both groups. Physicians were receptive to the intervention and enacted changes recommended by the clinical pharmacist more frequently than they enacted changes independently for control patients (55.1% versus 19.8%; P <0.001).

CONCLUSIONS

This study demonstrates that a clinical pharmacist providing pharmaceutical care for elderly primary care patients can reduce inappropriate prescribing and possibly adverse drug effects without adversely affecting health-related quality of life.

Extracellular glutathione peroxidase in human lung epithelial lining fluid and in lung cells

The epithelial cells of the lower respiratory tract are exposed to high levels of inhaled oxygen and other oxidants. We hypothesized that lung cells would secrete the antioxidant enzyme, extracellular glutathione peroxidase (eGPx), into epithelial lining fluid (ELF). To investigate this hypothesis, we used specific immunoprecipitations of GPx enzymes from ELF, specific immunoprecipitations of 75Se metabolically labeled proteins from lung cells in culture, and in situ hybridization, Northern blot, and reverse transcription-polymerase chain reaction (RT-PCR) analyses. Fifty-seven percent of ELF GPx activity was due to eGPx and 40% was due to cellular GPx (cGPx). Primary bronchial epithelial cells (BEC), primary alveolar macrophages (AM), and two human bronchial epithelial cell lines, BEP2D and A549, synthesized both eGPx and cGPx and secreted eGPx into the medium. Freshly isolated human AM and BEC expressed eGPx mRNA, while freshly isolated rabbit type 2 pneumocytes did not. In lung tissue, eGPx mRNA was found mainly in interstitial cells of tissue surrounding airways. It is concluded that more than half of GPx activity in BAL is due to eGPx, and that BEC, AM, and interstitial cells are potential sources of pulmonary eGPx.

Do older women use estrogen replacement? Data from the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE)

OBJECTIVES

The primary purpose of this study was to determine the prevalence of current and past estrogen use among older, community-dwelling, postmenopausal women. The secondary purpose was to describe factors associated with estrogen use in this population.

DESIGN

A survey.

SETTING

The Piedmont region of North Carolina.

PARTICIPANTS

The sample included 2602 community-dwelling women over the age of 65 who were interviewed for the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE).

MEASUREMENTS

Current and past use of estrogen.

RESULTS

Of the women surveyed, 6.1% reported current estrogen use, and 18.5% reported past use. Approximately half of the participants reported using estrogen for more than 2 years. Multivariate analysis demonstrated that current estrogen users were younger, more affluent, had smaller families, and were more likely to be white and to live in an urban area than were never users. Current users were also more likely to drink alcohol and to take calcium supplements; and compared with past estrogen users, they were more likely to be white, have smaller families, and to drink alcohol.

CONCLUSION

Estrogen replacement therapy is used by a small minority of older women, especially blacks. Moreover, although women with some risk factors for osteoporosis are more likely to use estrogen, the chief determinants of estrogen utilization are socioeconomic.

Religious coping and cognitive symptoms of depression in elderly medical patients

The investigators examined associations between depressive symptom type and religious coping in 832 consecutively admitted older medical inpatients. Cognitive symptoms of depression, but not somatic symptoms, were related to religious coping. Boredom, loss of interest, social withdrawal, feeling downhearted and blue, restlessness, feeling like a failure, feeling hopeless, or feeling that other people were better off were all significantly less common among religious copers. Difficulty initiating new activities was the only somatic symptom related to this coping behavior. Religious coping, a strategy heavily dependent on cognitive processes, is associated with fewer cognitive but not somatic symptoms of depression in medically ill older patients

Tumor necrosis factor, natural killer activity and other measures of immune function and inflammation in elderly men with heart failure

OBJECTIVE

To determine the status of tumor necrosis factor (TNF) and other measures of immunity and inflammation in chronic heart failure (CHF) in the elderly.

DESIGN

Comparative survey study of subjects with heart failure and age-matched controls.

SETTINGS

University affiliated tertiary care VA Medical Center, Heart Failure Clinic.

PATIENTS

Twenty men with New York Class II and III heart failure and 17 age-matched controls.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Levels of lymphocyte mitogenesis, TNF, natural killer (NK) cell activity, elastase-alpha 1-antitrypsin (E/alpha) and cross-linked fibrin D-dimers (XDP).

RESULTS

TNF levels (p = 0.27), NK activity (p = 0.56), and lymphocyte mitogenesis (p = 0.67) were similar in patients and controls. E/alpha levels were somewhat lower in CHF patients (p = 0.05) and XDP were similar (p = 0.59). However, TNF levels were significantly related to NK activity and to E/alpha activity in elderly men with heart failure but not controls. XDP were positively related to NK in heart failure patients but not controls.

CONCLUSION

TNF and other measures of immune function and inflammation do not appear to be significantly elevated in elderly patients with heart failure of moderate severity. However, significant relationships exist between TNF, NK activity, XDP and E/alpha in the heart failure patients only, suggesting that immune activation and subclinical inflammation does exist in these patients.

Assessing health-related quality of life in elderly outpatients: telephone versus face-to-face administration

OBJECTIVE

While health-related quality of life (HRQOL) is increasingly being used as an outcome in clinical trials, it is unknown whether HRQOL assessments are influenced by the method of administration. Within the context of a randomized, controlled trial evaluating a pharmacist intervention for elderly outpatients prescribed at least five medications, we compared telephone and face-to-face administration of the SF-36, a widely used HRQOL measure.

DESIGN

Survey.

SETTING

General Medicine Clinic, Veterans Affairs Medical Center.

PATIENTS

At entry, participants in the randomized trial received continuous care from a general medicine clinic physician, were > or = 65 years of age, and were prescribed > or = 5 regularly scheduled medications. Patients were excluded if they were cognitively impaired and had no caregiver available to participate in the study as a proxy or if they resided in a nursing home.

MEASUREMENTS

Subjects completed the SF-36 by telephone at closeout and face-to-face at clinic visits within 1 month (mean = 16.7 days).

MAIN RESULTS

Telephone administration required significantly less time than face-to-face interviews (10.2 vs 14.0 minutes, P < 0.001). Although systematic differences between modes of administration were generally small, there were substantial nonsystematic discrepancies for all eight SF-36 scales (mean absolute difference scores ranged from 10.8 to 30.1). Discrepancies were greatest for emotional role functioning, physical role functioning, social functioning, and bodily pain; these four scales also demonstrated low to moderate correlations (.33 to .58).

CONCLUSIONS

The two modes of administration may not produce interchangeable results. Researchers should be cautious when mixing modes of administration to elderly patients.

Appropriateness of medication prescribing in ambulatory elderly patients

OBJECTIVE

To assess the quality of medication prescribing in ambulatory elderly patients on multiple medications using the Medication Appropriateness Index (MAI).

DESIGN

Cross-sectional study.

SETTING

General Medical Clinic of the Durham VA Medical Center.

PATIENTS

208 elderly outpatients on five or more regularly scheduled medications.

MEASUREMENTS

Medication prescribing appropriateness was measured with the MAI, a reliable method that employs 10 implicit criteria. A weighted MAI score (range 0-18 per drug) served as a summary measure of appropriateness.

RESULTS

There were 1644 medications evaluated; 26% received no inappropriate ratings, 37% had one, 19% had two, and 18% had three or more. Of 16,440 ratings, 2295 (14%) were evaluated as inappropriate. The percentage of inappropriate ratings varied across prescribing dimensions: drug-drug interactions, 0%; drug-disease interactions, 1.4%; medication effectiveness, 4.7%; therapeutic duplication, 5.7%; indication, 11.5%; duration of treatment, 16.5%; dosage, 17.3%; practical directions, 20.3%; cost, 29.7%; and correct directions, 32.4%. The mean MAI score for all medications was 2.2 +/- 2.1 (range 0-10) and varied by therapeutic class. MAI scores were significantly lower for medications with a high potential for adverse effects compared with those with a low potential (MAI score of 1.8 vs 2.9, P < 0.001). Regression analysis revealed that no patient characteristics were associated with a higher likelihood of inappropriate prescribing.

CONCLUSIONS

Medication prescribing for elderly outpatients taking multiple medications was substantially appropriate. Prescribing dimensions with the most room for improvement were more exact directions, less expensive drugs, and practical directions. Drugs at high risk for adverse effects were prescribed more appropriately than those at low risk.

Variability of plasma IL-6 and crosslinked fibrin dimers over time in community dwelling elderly subjects

Because obtaining multiple blood samples from individuals involved in epidemiologic studies is difficult, conclusions must be drawn on the basis of one or two samples. In this study, the authors attempted to determine the variability of two plasma markers over time, namely IL-6 levels and crosslinked fibrin degradation products (D-Dimers), in 16 elderly community-dwelling individuals. The study group included both men and women and black and white subjects (four in each group). Eight blood samples were obtained from each subject over a period of 36 days. Blood was separated within 1 hour after collection and aliquots of plasma were stored at -70 degrees C until all samples were collected. All samples from an individual were analyzed at one time. IL-6 and D-Dimers were measured by commercially available ELISA kits. The variability in the levels of plasma IL-6 and D-Dimers was assessed by means of intra-class correlation coefficient (ICC). The estimates of the ICCs for one measurement of IL-6 and D-Dimers were .87 and .86, respectively. Reliability values of this magnitude indicate excellent reproducibility in the measurement. These values indicate that obtaining a single sample from a subject is fairly representative of that individual's IL-6 and D-Dimer levels over an extended period of time.

Alterations in L-selectin expression and elastase activity in neutrophils from patients receiving granulocyte colony-stimulating factor alone or in conjunction with high-dose chemotherapy with autologous bone marrow transplantation

We determined L-selectin expression and elastase levels in neutrophils obtained from patients receiving granulocyte colony-stimulating factor (G-CSF) either alone (given for increasing peripheral progenitor cells for harvest) or in combination with high-dose chemotherapy with autologous bone transplantation support (BMT). Administration of G-CSF alone for 3-5 days produced a decrease in L-selectin expression in neutrophils (25 +/- 4 versus 7 +/- 1, mean +/- SEM; mean channel fluorescence, n = 10) with no effect on neutrophil elastase activity (3.1 +/- 0.3 versus 3.4 +/- 0.6; micrograms elastase/million cells; n = 9). In contrast, in patients in the BMT group the L-selectin expression was increased (26 +/- 2 versus 38 +/- 3; n = 20) and elastase activity was markedly decreased (2.9 +/- 0.2 versus 1.4 +/- 0.2, n = 12) compared with values before BMT. The changes in L-selectin expression correlated with the ability of neutrophils to adhere to human umbilical vein endothelial cells. The decrease in the neutrophil elastase activity was not associated with an increase in the plasma elastase/alpha 1-antitrypsin complex levels, indicating that the decrease in the neutrophil elastase activity is not caused by activation of neutrophils and release of the enzyme into the plasma. Administration of G-CSF alone did not cause a decrease in the neutrophil elastase activity but increased plasma elastase/alpha 1-antitrypsin complex levels. There was no change in CR3 expression on neutrophils under any of these conditions. These observations suggest that the changes seen in neutrophils during BMT are influenced by various factors associated with BMT other than the administered cytokine alone.(ABSTRACT TRUNCATED AT 250 WORDS)

Developmental and service needs of school-age children with human immunodeficiency virus infection: a descriptive study

OBJECTIVE

To describe the developmental functioning and service needs of a group of school-age children with human immunodeficiency virus (HIV) infection.

DESIGN

Retrospective data were collected through chart reviews and follow-up telephone calls to primary care givers.

SETTING

A multidisciplinary team provided care at a developmental diagnostic and treatment center.

PATIENTS

Cases were 90 school-age children (ages 5 to 14 years) with presumed perinatally acquired HIV infection.

RESULTS

Forty-four percent of the 86 children on whom there were diagnoses were functioning in the low average to average range of intelligence, whereas 56% were functioning in the borderline range or lower. Fifty percent of the children demonstrated significant language impairments, with 28% also demonstrating an articulation disorder. Thirty-six of the children (42%) were formally diagnosed as having emotional/behavioral disorders. Eighty-six of the children were in school-based programs and of that group, 74% were in special education classes and receiving related services.

CONCLUSIONS

Most of the children in this study demonstrated deficits in the cognitive and learning areas, although they are clearly functioning better than earlier studies of children with HIV infection would have predicted. Their service needs include alternative living arrangements, remedial education, and psychotherapeutic interventions. The children's increasing longevity will place strains on the respective service systems.

The comprehensive assessment of community dwelling elderly: why functional status is not enough

The present study attempts to determine empirically the relationship of measures of functional status to other domains common to geriatric assessment, and to ascertain whether functional status can substitute for other domains of clinical assessment. A comprehensive research survey was administered in the home to a randomly selected population of 4163 community residents aged 65 and over in the Duke EPESE, one of the four sites of the National Institute on Aging-funded Established Populations for Epidemiologic Studies of the Elderly. Sample members were predominantly black (55%), female (65%), between 65 and 74 years of age (61%), and lived in five contiguous counties within the state of North Carolina. Measurements included three measures of functional status ranging from basic activities of daily living (ADL) to strenuous mobility items, and summary measures of cognition, depression, and overall physical health. The three functional status measures were inter-correlated. However, with the exception of cognitive status and performance of instrumental ADL, the functional status measures failed to show a clinically significant relationship with the domains of cognition, depression, or overall physical health status. Furthermore, even among those sample members impaired in all three domains, 8% could still perform strenuous activities, and over 50% could still perform the basic activities of daily living. The data show that functional status measures are not necessarily indicative of an elder's mental or physical health. Each domain of assessment contributes unique data, and no one area can fully substitute for another.

Biology of aging as related to cancer

The relationship of the biology of aging to cancer in older patients is of importance at several levels. The striking increase of cancer incidence with age may be related to a number of biologic factors. Potential age-related etiologic factors include decreased immune surveillance, longer duration of carcinogenic exposure, increased susceptibility of cells to carcinogens, decreased DNA repair, oncogene activation or amplification, and defects in tumor-suppressor genes. Moreover, at the cellular level, the uncontrolled proliferation characteristic of cancer and the reduced proliferation characteristic of senescence may be "opposite sides of the coin," governed by similar mechanisms of gene regulation. The biologic behavior of neoplasma, once initiated, may vary in different age groups depending on tumor type, immune system status, and alterations in other regulatory factors such as angiogenesis. In the clinical approach to the older cancer patient, attention to age-related biologic changes leading to decreased homeostatic reserve, especially in such areas as the hematopoietic, renal, immune, and cardiovascular systems, is essential to the designing of successful therapies.

A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity

Inappropriate medication prescribing is an important problem in the elderly, but is difficult to measure. As part of a randomized controlled trial to evaluate the effectiveness of a pharmacist intervention among elderly veterans using many medications, we developed the Medication Appropriateness Index (MAI), which uses implicit criteria to measure elements of appropriate prescribing. This paper describes the development and validation of a weighting scheme used to produce a single summated MAI score per medication. Using this weighting scheme, two clinical pharmacists rated 105 medications prescribed to 10 elderly veterans from a general medicine clinic. The summated score demonstrated acceptable reliability (intraclass correlation co-efficient = 0.74). In addition, the summated MAI adequately reflected the putative heterogeneity in prescribing appropriateness among 1644 medications prescribed to 208 elderly veterans in the same general medicine clinic. These data support the content validity of the summated MAI. The MAI appears to be a relatively reliable, valid measure of prescribing appropriateness and may be useful for research studies, quality improvement programs, and patient care.