Spread of drug-resistant Streptococcus pneumoniae in Asian countries: Asian Network for Surveillance of Resistant Pathogens (ANSORP) Study

Antimicrobial susceptibility of 996 isolates of Streptococcus pneumoniae from clinical specimens was investigated in 11 Asian countries from September 1996 to June 1997. Korea had the greatest frequency of nonsusceptible strains to penicillin with 79.7%, followed by Japan (65.3%), Vietnam (60.8%), Thailand (57.9%), Sri Lanka (41.2%), Taiwan (38.7%), Singapore (23.1%), Indonesia (21.0%), China (9.8%), Malaysia (9.0%), and India (3.8%). Serotypes 23F and 19F were the most common. Pulsed-field gel electrophoresis (PFGE) of 154 isolates from Asian countries showed several major PFGE patterns. The serotype 23F Spanish clone shared the same PFGE pattern with strains from Korea, Japan, Singapore, Taiwan, Thailand, and Malaysia. Fingerprinting analysis of pbp1a, pbp2x, and pbp2b genes of 12 strains from six countries also showed identical fingerprints of penicillin-binding protein genes in most strains. These data suggest the possible introduction and spread of international epidemic clones into Asian countries and the increasing problems of pneumococcal drug resistance in Asian countries for the first time.

In vitro comparison of elongation of the anterior cruciate ligament and single- and dual-tunnel anterior cruciate ligament reconstructions

This study evaluated strain in the normal anterior cruciate ligament (ACL) and compared it to four different double-strand hamstring tendon reconstructive techniques. Seventeen fresh-frozen knees from 11 cadavers were tested. The strain in the anteromedial and posterolateral bands of the native ACL and their equivalents in four autograft techniques were measured using differential variable reluctance transducers. The anteromedial band of the intact ACL shortened from 0 degree -30 degrees of flexion, then lengthened to 120 degrees; the posterolateral band of the intact ACL shortened from 0 degree - 120 degrees of flexion. Following ACL excision, these knees underwent reconstruction with double-strand hamstring tendons with either single tibial and femoral tunnels, single tibial and dual femoral tunnels, dual tibial and single femoral tunnels, or dual tibial and dual femoral tunnels. With the exception of the dual-band, dual-tunnel technique, all of the procedures placed greater strain on the reconstructive tissues than was observed on the native ACL, after approximately 30 degrees of flexion. These results indicate that dual-band hamstring tendon reconstructions placed with single tibial and femoral tunnels do not address the complexity of the entire ACL. Rather, these procedures appear to only duplicate the effect of the anteromedial band, while perhaps overconstraining the joint as a result of its inability to reproduce the function of the posterolateral band. During rehabilitation following ACL reconstruction, therefore, only from 0 degree - 30 degrees of the graft tissues are not significantly strained. Dual tibial and femoral tunnel techniques should be evaluated further to more closely recreate knee kinematics following ACL reconstruction.

Preterm infant thermal care: differing thermal environments produced by air versus skin servo-control incubators

OBJECTIVE

Incubator thermal environments produced by skin versus air servo-control were compared.

STUDY DESIGN

Infant abdominal skin and incubator air temperatures were recorded from 18 infants in skin servo-control and 14 infants in air servo-control (26- to 29-week gestational age, 14 +/- 2 days postnatal age) for 24 hours. Differences in incubator and infant temperature, neutral thermal environment (NTE) maintenance, and infant and incubator circadian rhythm were examined using analysis of variance and scatterplots.

RESULTS

Skin servo-control resulted in more variable air temperature, yet more stable infant temperature, and more time within the NTE. Circadian rhythm of both infant and incubator temperature differed by control mode and the relationship between incubator and infant temperature rhythms was a function of control mode.

CONCLUSION

The differences between incubator control modes extend beyond temperature stability and maintenance of NTE. Circadian rhythm of incubator and infant temperatures is influenced by incubator control.

Measures of disease control in Medicare beneficiaries with diabetes mellitus

OBJECTIVE

To investigate measures of disease control for Medicare beneficiaries with diabetes and their outpatient care in the fee-for-service setting.

DESIGN

Retrospective cohort study.

SETTINGS

Office practices in Alabama, Iowa, and Maryland of 293 primary care physicians (PCPs) who volunteered to participate in the Ambulatory Care Quality Improvement Project.

PARTICIPANTS

A total of 5980 patients with an average age of 75.2 years.

MEASUREMENTS

For an 18-month period (1/1/94-6/30/95), medical records were abstracted for clinical parameters, including up to four blood glucose values; two blood pressure measurements; one total cholesterol value; two serum creatinine values; medication use, including antihypertensives, angiotensin-converting enzyme (ACE) inhibitors, and lipid-lowering agents; and frequency of glycosylated hemoglobin (GHb) determinations.

RESULTS

During the study, 44% of patients received at least one GHb determination, 94% received at least one blood glucose, 68% at least one total serum cholesterol, 74% at least one serum creatinine test, and 97% at least one blood pressure measurement. Ten percent of patients had mean blood glucose levels > or = 250 mg/dL. Eighty-five percent had evidence of hypertension. Of this group of hypertensive patients with blood pressure readings available, 70% had blood pressure readings > or = 140/90 mm Hg, even though there were on medication that could have been prescribed for hypertension. Thirty-six percent of those who had evidence of hypertension were taking an ACE inhibitor. Thirty-two percent of those taking lipid-lowering medication had a total serum cholesterol value > or = 240 mg/dL. Statistically significant differences were noted for age and gender, with men and patients more than 85 years old generally having better measures of disease control.

CONCLUSIONS

Many older Medicare patients with diabetes did not achieve recommended target levels of blood glucose, blood pressure, and lipids. GHb and serum cholesterol are not being monitored at recommended intervals. Significant opportunities exist to improve diabetes care for this population.

Prenatal diagnosis of human cytomegalovirus by culture and polymerase chain reaction: 98 pregnancies leading to congenital infection

Human cytomegalovirus (HCMV) is the most common cause of viral intra-uterine infection. The experience with prenatal diagnosis remains limited and is based on few reports of small numbers of cases. It is thus difficult to compare the accuracy of the different tests because the groups studied were small and heterogeneous. We describe here our experience on a series of 98 pregnancies leading to HCMV congenital infection, among which 71 have been tested by amniotic fluid (AF) sampling followed by culture and/or polymerase chain reaction (PCR). Independently of the delay between AF sampling and the first HCMV IgM positive result, the mean sensitivity of both culture and PCR was around 70 per cent. The best sensitivity (95.5 per cent) was obtained after a delay > or = 6 weeks in late pregnancy (> or = 23 weeks). The present study demonstrated clearly that the delay between AF puncture and the presumed date of seroconversion is more important for sensitivity than the technique used for the diagnosis (PCR or culture). However, even in the best diagnostic conditions, negative results of HCMV culture or PCR in AF cannot formally exclude intra-uterine infection.

Development and implementation of a breast and cervical cancer screening program in urban and rural Alaska

Early detection of breast and cervical cancers represents the single best strategy to effect the reduction of associated morbidity and mortality. The State of Alaska identified a need to establish a service delivery system which would assure the availability of breast and cervical cancer screening services for women who are low income, under- and uninsured, and from racial/ethnic minorities. In March 1995 the Alaska Breast and Cervical Cancer Early Detection Program (AK-BCCEDP) began funding breast and cervical cancer screening services through the Centers for Disease Control and Prevention, National Breast and Cervical Cancer Early Detection Program. The purpose of AK-BCCEDP is to establish a comprehensive service delivery strategy which includes screening, tracking, referral, follow-up, public education, quality assurance, surveillance, coalition building/partnering, and evaluation. During the first year of services (March 1, 1995, to February 29, 1996) 651 women were screened for breast and cervical cancer. Higher than expected numbers of breast cancer were detected. Of the 651 women screened, four were diagnosed with invasive breast cancer and three were diagnosed with high-grade squamous intraepithelial lesions.

Glucose concentration in human subcutaneous adipose tissue: comparison between forearm and abdomen

There is still controversy about the relation between the glucose concentration in the subcutaneous (sc.) adipose tissue and the blood plasma. Depending on the technique applied, the glucose concentration in sc. tissue varies between 50% and 100% of the plasma glucose concentration. In the present study the sc. glucose concentration of forearm and abdomen in seven healthy volunteers was compared with plasma glucose by applying the microdialysis technique with very low flow rates. A microdialysis probe implanted into the subcutaneous tissue of abdomen and forearm was perfused with a flow rate of 1 microl/4 min. The dialysate was sampled in three 2-h-fractions in the fasting state and in one 2-h-fraction during a hyperglycemic clamp (216.9+/-3.4 mg/dl) (mean +/- SEM). The mean recoveries of the plasma glucose were 91.1+/-4.1% in the forearm and 82.7+/-18.0% in the abdomen. The recoveries in the sc. tissue of abdomen and arm were not significantly different. However, the arm showed significantly (p < 0.014) less interindividual variance (range 73.2- 103.2%) than the abdomen (range 50.6-117.1%) and appears to be the preferable implantation site. The recovery remained constant during the investigation.

Vascular endothelial growth factor receptor KDR tyrosine kinase activity is increased by autophosphorylation of two activation loop tyrosine residues

Vascular endothelial growth factor is an important physiological regulator of angiogenesis. The function of this endothelial cell selective growth factor is mediated by two homologous tyrosine kinase receptors, fms-like tyrosine kinase 1 (Flt-1) and kinase domain receptor (KDR). Although the functional consequence of vascular endothelial growth factor binding to the Flt-1 receptor is not fully understood, it is well established that mitogenic signaling is mediated by KDR. Upon sequencing several independent cDNA clones spanning the cytoplasmic region of human KDR, we identified and confirmed the identity of a functionally required valine at position 848 in the ATP binding site, rather than the previously reported glutamic acid residue, which corresponds to an inactive tyrosine kinase. The cytoplasmic domain of recombinant native KDR, expressed as a glutathione S-transferase fusion protein, can undergo autophosphorylation in the presence of ATP. In addition, the kinase activity can be substantially increased by autophosphorylation at physiologic ATP concentrations. Mutation analysis indicates that both tyrosine residues 1054 and 1059 are required for activation, which is a consequence of an increased affinity for both ATP and the peptide substrate and has no effect on kcat, the intrinsic catalytic activity of the enzyme. KDR kinase catalyzes phosphotransfer by formation of a ternary complex with ATP and the peptide substrate. We demonstrate that tyrosine kinase antagonists can preferentially inhibit either the unactivated or activated form of the enzyme.

Advanced practice nursing in Texas: the interface of accreditation, regulation, and certification

The rapidity and degree of development of regulation by boards of nursing of advanced practice nurses (APNs) and programs for their preparation has varied from state to state over the past 20 years. In general, boards have authority only to regulate advanced practice through the recognition of APNs and the setting of standards and scope of their practice. In the early 1990s, lack of consistent APN educational program standards and experiences and criteria for recognition of APNs was problematic at the levels of accreditation, certification, and regulation. The interdependency of these concepts as well as the necessity and difficulty of linking them in a consistent, effective manner has become increasingly evident. The Texas Board of Nurse Examiners has been involved in deriving a model designed to ensure the education and recognition of APNs with emphasis on both professionalism and public safety. Because Texas is unique in size and geography, it mirrors many problems and issues of both large and small states.

Serotyping of Streptococcus pneumoniae by coagglutination with 12 pooled antisera

We report on the performance of a recently introduced commercial chessboard method using 12 antisera, in comparison with that of the 55-antiserum panel used in determining the serogroups and types (SGTs) of Streptococcus pneumoniae, both of which were carried out by a coagglutination technique. Of a total of 150 strains of S. pneumoniae studied, 135 (90%) belonged to the SGTs represented in the 23-valent pneumococcal vaccine; of these, 130 (96.3%) were identified as the same SGTs by both typing methods. The remaining five strains showed cross-reactivity with more than two pools by the chessboard method, but could be assigned to a single SGT by the Quellung test. The 96.3% concordance of the chessboard method suggests it can be adopted for determination of the SGTs of S. pneumoniae in laboratories.

Cerebral fungal infections in the immunocompromised host: a literature review and a new pathogen--Chaetomium atrobrunneum: case report

OBJECTIVE AND IMPORTANCE

A case of a cerebral abscess, occurring in a patient who had undergone bone marrow transplant, caused by a new pathogen, Chaetomium atrobrunneum, and a review of the literature are presented. Although Aspergillus species are by far the most common fungi found in cerebral abscesses in immunocompromised patients, an increasing number of fungi commonly found in nature but not usually associated with infections in humans have been isolated from cerebral abscesses in these patients.

CLINICAL PRESENTATION

A 31-year-old male patient, who had undergone a recent bone marrow transplantation for multiple myeloma, presented 3 months after transplantation with right-sided hemiplegia caused by a left parietal hemorrhagic lesion.

INTERVENTION

A biopsy guided by computed tomography showed that the abscess contained the fungus C. atrobrunneum. The final identification of the organism was based on cultures, scanning electron microscopic studies, and consultation with the Fungus Testing Laboratory at the University of Texas Health Science Center, San Antonio, TX. The patient was treated with several antifungal medications but developed uncontrolled cerebral edema, which led to further neurological deterioration and eventual death.

CONCLUSION

Cerebral abscesses in the immunocompromised patient may no longer be assumed to be caused solely by Aspergillus species. The literature reveals several rare cases of uncommon fungi found in these abscesses. Only four cases of cerebral infections caused by the genus Chaetomium have been reported. The case presented represents the first time a patient who had undergone a bone marrow transplant with a cerebral abscess was found to be caused by the pathogen C. atrobrunneum.

Advance in the study of inhibin, activin and follistatin production in pregnant women

This review summarizes the new information on the studies of inhibin, activin, and follistatin production in the placenta during human pregnancy. Inhibin and activin exert suppressive and stimulatory effects, respectively, on the release of FSH in the pituitary. Follistatin is bound to inhibin and activin and indirectly modulates the FSH release. The placenta produces these three proteins. The serum levels of inhibin, activin, and follistatin are elevated in pregnant women and decrease after delivery. The trophoblast cells from term placenta secrete inhibin and activin in the primary cultures. The production and mRNA expression of inhibin and activin are regulated by several stimulatory and suppressive hormones and growth factors in placental tissues. cAMP, Ca2+, and protein kinase-C may be involved in intracellular signal transduction in trophoblasts. Activin receptors are present on placental cells. Follistatin inhibits the binding of activin to ActRII receptor. Abnormal levels of inhibin and activin in maternal serum are observed in problem pregnancies and gestational diseases. Inhibin, activin, and follistatin may play roles in the regulation of reproductive endocrinology in pregnant women and the embryo/fetal development.

PCR-Enzyme immunoassay for detection of Streptococcus pneumoniae DNA in cerebrospinal fluid samples from patients with culture-negative meningitis

A PCR-based assay was developed to amplify a conserved region of the pneumococcal autolysin gene. The amplified product was labelled with digoxigenin-labelled dUTP and was detected with a biotin-labelled probe in an enzyme immunoassay (EIA). The assay was initially tested with suspensions of various serotypes of Streptococcus pneumoniae and other gram-positive and gram-negative bacteria and was then applied to cerebrospinal fluid (CSF) specimens from patients with meningitis and those with other neurological disorders. The assay detected all the serotypes of S. pneumoniae tested, whereas all the other bacterial strains tested were negative. Seven of the 8 CSF specimens positive for pneumococcus by culture or latex agglutination (LA) were positive by PCR-EIA, whereas all 10 specimens positive for other organisms were negative. Among 11 patients with clinically diagnosed meningitis but with negative culture and LA results, 5 were positive by PCR-EIA. The assay was negative for all but one patient without meningitis; it was positive with the CSF from a child with immunodeficiency and pneumococcal abscesses on the scalp. PCR-EIA is a useful tool for the diagnosis of meningitis, especially when culture and LA are negative because of prior antibiotic treatment.

Uniform discrimination of pattern orientation by honeybees

To explore how honeybees, Apis cerana, discriminate the orientation of patterns, we trained workers to discriminate between a black stripe of a certain orientation on a white disc and a pure white disc. We tested trained bees for their ability to discriminate between the trained orientation and deviations from it. This was done either in a dual choice situation where the bees had to choose between the trained orientation and one deviation from it at a time, or in a multiple choice situation where bees had to choose simultaneously between the trained orientation and 11 successive deviations from it. In the dual choice situation, bees did not discriminate behaviourally between the trained orientation and deviations up to 25 degrees, whereas in a multiple choice situation, they discriminated between the trained orientation and a deviation of 15 degrees or more. Thus, orientation can be analysed more precisely in multiple choice experiments. The response of the bees was independent of the orientation of the trained orientation; the 12 different trained orientations all yielded identical results. This finding, considered together with a model that we present for orientation discrimination, suggests that at least three orientation-sensitive channels (a neuron or a set of neurons that respond maximally to a particular orientation) participate in the analysis of pattern orientation. (c) 1998 The Association for the Study of Animal Behaviour.

Role of EP2 receptors and cAMP in prostaglandin E2 regulated expression of type I collagen alpha1, lysyl oxidase, and cyclooxygenase-1 genes in human embryo lung fibroblasts

In a recent communication, we demonstrated that prostaglandin E2 (PGE2) lowers basal while it ablates interleukin-1beta((IL-1beta) and transforming growth factor-beta (TGFbeta) upregulated lysyl oxidase (LO) mRNA levels. Correspondingly, PGE2 increases cyclooxygenase-1 (COX1) mRNA in diploid, human embryo lung fibroblasts (IMR90) [Roy et al., 19961. We now report that these actions by PGE2 are routed through cAMP via the PGE2, EP2 receptor. Among the PGE2 receptor types, the IMR90 predominantly express the EP2 mRNA. These cells also express EP3 and EP4 mRNA at comparatively low levels. Northern blot analyses show that 11-deoxy PGE1, an EP2/EP4 agonist, emulates the action of PGE2. In a similar manner to PGE2, 11-deoxy PGE1 decreases basal and TGF-beta induced type I collagen alpha1 (COL) mRNA, basal and IL-1beta induced LO mRNA while it increases COX1 mRNA. Sulprostone, an EP3/EP1 agonist, has no effect on the expression of these three genes. Forskolin, an adenylate cyclase activator, acts in a very similar manner to PGE2 or 11-deoxy PGE1. It suppresses both basal and TGF-beta induced COL mRNA levels. Both PGE2 and 11-deoxy PGE1 increase cAMP to a level comparable with forskolin. The role of the EP2 receptor in controlling collagen production is further underscored in the immortalized Rat-1 fibroblasts, derived from Fischer rat embryos, which do not express detectable EP2 mRNA. In these cells, PGE2 has little effect on COL mRNA level, whereas forskolin increases it. Furthermore, forskolin increases cAMP level in Rat-1 cells, whereas PGE2 does not. Overall, these results illustrate that much of the PGE2 action on the expression of COL, LO, and COX1 genes is mediated through the EP2 receptor and a subsequent increase in intracellular cAMP.

Deriving a preference-based single index from the UK SF-36 Health Survey

This article presents the results of a study to derive a preference-based single index from the SF-36. The study was an attempt to reconcile a profile health status measure, the SF-36, with the "quality adjusted life years" approach. The study undertook a parsimonious restructuring of the SF-36 using explicit criteria to form the SF-6D health state classification. A sample of multidimensional health states defined by this classification were valued by a convenience sample of health professionals, managers, and patients, who responded to a set of visual analogue scale ratings and standard gamble questions, with highly complete and consistent answers. Statistical models were estimated to predict single index scores for all 9000 health states defined by the new classification. The resultant algorithms can be applied to existing SF-36 data sets and used in the assessment of the cost-effectiveness of health technologies. This preliminary work forms the basis of a larger study currently being undertaken in the UK.

Hybrid capture II, a new sensitive test for human papillomavirus detection. Comparison with hybrid capture I and PCR results in cervical lesions

AIM

To test a new assay for the detection of human papillomavirus (HPV) DNA, hybrid capture II (HC II), compared with the previous commercialized hybrid capture I (HC I) and polymerase chain reaction (PCR) results on cervical scrapes from fresh cone excision biopsy samples.

METHODS

The three methods were used on cervical scrapes from 42 fresh cone excision biopsy samples. There were nine metaplastic and inflammatory lesions, five low grade lesions, and 28 high grade lesions. PCR was performed using the general primers GP5+/GP6+. The viral load of high risk HPV DNA was estimated by the ratio of relative light units to positive control values in the samples.

RESULTS

The sensitivity of HC I for the detection of high grade lesions was 71.4%, while it was 92.8% for HC II and 96.4% for the PCR. Considering only the absence of detectable cervical in situ neoplasia, the specificity was 88.9% for HC I, 66.7% for HC II, and 66.7% for PCR. With HC II, for a ratio of cervical sample to normal control of > 200, the sensitivity for the detection of high grade lesion was only 34.6% with a specificity of 66.7%.

CONCLUSIONS

HPV detection with the HC II assay is more sensitive than the previous HC I and represents a more convenient and easier test than PCR for routine use. Nevertheless the viral load estimated with this test cannot be a reliable predictive indicator of high grade lesions.

A randomized double-blind sham-controlled study of intrathecal human anti-tetanus immunoglobulin in the management of tetanus

BACKGROUND

Tetanus is a major cause of mortality and morbidity in developing countries. Various modalities of treatment to prevent progression of the disease and alter its outcome have been tried. This study was designed to evaluate the role of intrathecal human anti-tetanus immunoglobulin (TIG) in the management of tetanus.

METHODS

Thirty-six adult patients presenting to an university-affiliated teaching hospital were stratified based on the severity of disease into mild and severe disease, and subsequently randomly allocated to receive either 250 i.u. of TIG intrathecally or a sham procedure mimicking the lumbar puncture.

RESULTS

In mild tetanus, TIG administration significantly retarded the rate of progression (p = 0.05), reduced the duration of hospital (p = 0.01) and intensive care unit stay (p = 0.05), need for tracheostomies (p = 0.03) and the dose of sedatives required for control of spasms (p = 0.01). In mild tetanus, the mortality rates were 20% and 30% in the treated and control groups, respectively.

CONCLUSION

We suggest that TIG is useful in reducing the morbidity, progression of disease and mortality in patients presenting with mild tetanus.