SNAP-II and SNAPPE-II: Simplified newborn illness severity and mortality risk scores

OBJECTIVES

Illness severity scores for newborns are complex and restricted by birth weight and have dated validations and calibrations. We developed and validated simplified neonatal illness severity and mortality risk scores. The primary outcome was in-hospital mortality.

STUDY DESIGN

Thirty neonatal intensive care units in Canada, California, and New England collected data on all admissions during the mid 1990s; patients moribund at birth or discharged to normal newborn care in <24 hours were excluded. Starting with the 34 data elements of the Score for Neonatal Acute Physiology (SNAP), we derived the most parsimonious logistic model for in-hospital mortality using 10,819 randomly selected Canadian cases. SNAP-II includes 6 physiologic items; to this are added points for birth weight, low Apgar score, and small for gestational age to create a 9-item SNAP-Perinatal Extension-II (SNAPPE-II). We validated SNAPPE-II on the remaining 14,610 cases and optimized the calibration.

RESULTS

In all birth weights, SNAPPE-II had excellent discrimination and goodness of fit. Area under the receiver operator characteristic curve was .91 +/- 0.01. Goodness of fit (Hosmer-Lemeshow) was 0.90.

CONCLUSIONS

SNAP-II and SNAPPE-II are empirically validated illness severity and mortality risk scores for newborn intensive care. They are simple, accurate, and robust across populations.

Activity-guided isolation of antioxidative constituents of Cotinus coggygria

Six constituents (1-6) were isolated from EtOAc-soluble partitions of two separate collections of the whole plants of Cotinus coggygria, namely, disulfuretin ¿2,2'-[1,2-bis(3,4-dihydroxyphenyl)-1, 2-ethanedylidene]bis[6-hydroxy-3(2H)-benzofuranone] (1)¿, sulfuretin (2), sulfurein (3), gallic acid (4), methyl gallate (5), and pentagalloyl glucose (6). The structure of the novel biaurone 1 was determined by spectral and chemical methods. Compounds 1-6 were found to be potent antioxidants in a 1,1-diphenyl-2-picrylhydrazyl free-radical scavenging assay.

Reconstituted basement membrane induces glandular-like morphogenesis but no difference in ACTH synthesis of anterior pituitary cells

Basement membrane, a thin extracellular matrix, promotes tissue integrity and differentiated phenotype. This study was performed in order to investigate the effect of basement membrane components on adrenocorticotropin (ACTH) synthesis and to observe its relationship with cell morphology. Rat anterior pituitary cells were cultured on plastic culture plate coated with either Matrigel or poly-D-lysine. Phase-contrast microscopy and scanning electron microscopy showed that cells cultured on Matrigel appeared as a three-dimensional glandular-like cell aggregate, while those cultured on plastic showed a flat, confluent monolayer. Reverse-transcription polymerase chain reaction (RT-PCR) and Northern blot analysis revealed that ACTH synthesis in the Matrigel culture was not significantly different from that in the plastic culture. Our results suggest that the relationship between the morphological changes caused by cell-substrate interaction and pituitary hormone synthesis does not exist in all pituitary cell types and that other factors associated with cell-substrate interaction influence the hormone synthesis of some pituitary cells.

Clinical associations of anti-endothelial cell antibodies in patients with systemic lupus erythematosus

The aim of this study was to define the clinical associations of anti-endothelial cell antibody (AECA) in systemic lupus erythematosus (SLE) patients by measuring serum AECA titers to correlate with the disease activity and clinical manifestations. Forty-one SLE patients and 27 controls were studied. Serum samples were collected at the time of patient presentation with disease exacerbation and 4 weeks after the start of treatment. The disease activity was evaluated by the SLE Disease Activity Index (SLEDAI). AECA was detected by enzyme-linked immunosorbent assay (ELISA) methods with the surface antigen of the immortalized human microvascular endothelial cell line (HMEC-1). The mean immunoglobulin (Ig)G-AECA and IgM-AECA optical densities (ODs) were significantly higher in patients with SLE compared with controls [mean +/- standard deviation (SD), 0.32 +/- 0.15 vs 0.18 +/- 0.16 and 0.29 +/- 0.14 vs 0.21 +/- 0.09, respectively]. There was a positive correlation between IgG-AECA and the SLEDAI scores. The positivity rate of AECA in the groups with digital vasculitis, neuropsychiatric lupus, and anti-cardiolipin antibody was significant. In conclusion, AECA may be involved in the pathogenesis of SLE and was correlated with the disease activity. It was also associated with clinical manifestations such as digital vasculitis, neuropsychiatric lupus, and anti-cardiolipin antibody positivity.

Change in activity of the sympathetic nervous system in diet-induced obese rats

We investigated the change in activity of the sympathetic nervous system (SNS) in high-sucrose diet (HSD)-induced obese rats compared with controls. Power spectral analyses of R-R interval variability were performed to obtain the low frequency (LF, 0.04-0.699 Hz) and high frequency (HF, 0.7-3.0 Hz) powers. The percents of fat mass to body weight (%F/BW) and fat to muscle ratios (F/M) were significantly increased in HSD-fed rats. Plasma glucose, leptin, and triglyceride concentrations in rats fed with HSD were significantly increased. LF in normalized units (LFn), which represents both sympathetic and parasympathetic activities, was significantly increased whereas HF in normalized unit (HFn), which represents parasympathetic activity, was significantly decreased in HSD-fed rats. LF/HF, which represents sympathetic activity, was significantly increased in HSD-fed rats and was correlated with leptin (r=0.549, p<0.023), %F/BW (r=0.513, p<0.035), F/M (r=0.536, p<0.038), and triglyceride (r=0.497, p<0.042). When adjusted for leptin concentrations, however, LF/HF of HSD-fed rats was significantly decreased. In conclusion, HSD-induced obese rats showed increased LF/HF, which was significantly decreased by adjustment for leptin concentrations. We suggest that stimulating effect of leptin on SNS is reduced, which might play a role in induction of obesity by HSD.

Visual working memory revealed by repetitive transcranial magnetic stimulation

We evaluated whether repetitive transcranial magnetic stimulation (rTMS) could be utilized for studying the hemispheric lateralization and anatomical localization of the cortical areas of the visual system that are concerned with object-related visual working memory. In eight normal volunteers, visual working memory was tested during rTMS delivery over nine regions in each hemisphere. Visual working memory was significantly disturbed by rTMS over the right hemisphere compared with the left (P<0.05). The disturbance in visual working memory by rTMS was significant over the right inferior frontal (F8), inferior temporal (T8), and middle parietal (P4) areas compared with the control region (P<0.05). This study suggests that visual working memory is lateralized to the right hemisphere and localized in the right inferior frontal, inferior temporal, and middle-parietal areas. As a non-invasive tool, rTMS may be useful for the functional localization of the working memory system.

A validation study of the Siriraj Stroke Score

A cross-sectional study was conducted on 160 Malaysian patients to validate the usefulness of the Siriraj Stroke Score (SSS) for differentiating intracerebral haemorrhage and infarction following acute strokes. Our results indicate that the score lacks sensitivity and specificity. It should thus not be used in epidemiological studies to determine stroke types in a community. More importantly, in the absence of information from neuroimaging of the brain, it cannot be used safely by physicians to assess the need or otherwise of thrombolytic and/or anticoagulant therapy after an acute stroke.

Presence of circulating autoantibodies against bronchial epithelia cell in patients with nonatopic asthma

Allergic response to common environmental agents has been regarded as a main pathogenetic mechanism of bronchial asthma. However, allergic sensitization (atopy) can not be detected in a siginificant number of adult asthmatic patients. The etiology of nonatopic asthma has not yet been defined. To evaluate the possible involvement of autoimmune response against bronchial mucosa in the pathogenesis of nonatopic asthma, we performed indirect immunofluorescence staining of fresh frozen human bronchial mucosa tissue using serum samples from patients with atopic and nonatopic asthma, healthy controls, and patients with systemic lupus erythematosus. On immunostaining, circulating IgG autoantibodies against bronchial mucosa were detected in 2 (9.1%) of 22 patients with nonatopic asthma and in none of 22 patients with atopic asthma and of 22 healthy controls. IgG autoantibodies from the two patients with nonatopic asthma predominantly stained the cytoplasmic membrane of basal cells in bronchial epithelium. Serum samples from 10 patients with systemic lupus erythematosus immunostained the nucleus of epithelial cells in whole layer of bronchial epithelium. This study showed the presence of circulating IgG autoantibodies against the bronchial epithelial cell in a small portion of patients with nonatopic asthma. Further studies may be necessary to evaluate the possible involvement of autoimmune mechanism in the pathogenesis of nonatopic asthma.

Steaming of ginseng at high temperature enhances biological activity

The present study was performed to evaluate the effect of steaming ginseng at a temperature over 100 degrees C on its chemical constituents and biological activities. Raw ginseng was steamed at 100, 110, and 120 degrees C for 2 h using an autoclave. The ginseng steamed at 120 degrees C was more potent in its ability to induce endothelium-dependent relaxation. Steaming the raw ginseng at 120 degrees C also remarkably increased the radical-scavenging activity. Ginsenosides F(4), Rg(3), and Rg(5), which were not present in raw ginseng, were produced after steaming. Ginsenosides Rg(3) and Rg(5) were the most abundant ginsenosides in the ginseng steamed at 120 degrees C, accounting for 39% and 19% of all ginsenosides, respectively.

Seroepidemiological study of Toxoplasma gondii infection in the rural area Okcheon-gun, Korea

There have been some reports about the prevalence of anti-Toxoplasma gondii antibody among Koreans, and most of all data were taken from patients visiting hospitals. However, the epidemiological data of the community-based study in Korea are rare. This study was performed to evaluate the seroprevalence of toxoplasmosis among the inhabitants of the rural area Okcheon-gun, Korea. A total of 1,109 serum samples (499 males, 610 females) were examined for the IgG antibodies by ELISA. To set up the cut-off point for ELISA, we used a commercial latex agglutination (LA) kit. The sensitivity and specificity of ELISA against LA test were 89.5%, and 98.6% respectively. Among 1,109 sera, 6.9% showed seropositivity by ELISA. The positive rates of males and females were 6.0% and 7.2%, respectively. However, there were no significant differences between sexes. Comparing the age groups, the highest seropositive rate showed in the seventies or higher, and their rates had a tendency to increase with age (0.05 < p < 0.3). These results revealed that the seroprevalence of toxoplasmosis in rural inhabitants is similar to previous reports in Korea; however we need further investigation to clarify the prevalence of toxoplasmosis in the general population.

Hypersensitivity pneumonitis caused by Fusarium napiforme in a home environment

BACKGROUND

We report a case of hypersensitivity pneumonitis (HP) in a 17-year-old male student caused by Fusarium napiforme found in his home environment.

METHODS

The patient was diagnosed according to history, chest radiograph, spirometry, high-resolution chest CT, and transbronchial lung biopsy. To identify the causative agent, cultured aeromolds were collected by the open-plate method. From the main fungi cultured, fungal antigens were prepared, and immunoblot analysis with the patient's serum and each fungal antigen was performed.

RESULTS

Five fungal species were isolated from the patient's home. Immunoblotting analysis with the patient's serum demonstrated more than 10 IgG-binding fractions to F. napiforme extract only, while little binding was noted with the other fungal antigens.

CONCLUSIONS

We should be aware that HP may be caused by F. napiforme in the home environment.

Modulation of Nad(P)H:quinone oxidoreductase (NQO1) activity mediated by 5-arylamino-2-methyl-4,7-dioxobenzothiazoles and their cytotoxic potential

Synthesized 5-arylamino-2-methyl-4,7-dioxobenzothiazoles 3a-3o were evaluated for modulation of NAD(P)H: quinone oxidoreductase (NQO1) activity with the cytosolic fractions derived from cultured human lung cancer cells and their cytotoxicity in cultured several human solid cancer cell lines. The 4,7-dioxobenzothiazoles affected the reduction potential by NQO1 activity and showed a potent cytotoxic activity against human cancer cell lines. The tested compounds 3a, 3b, 3g, 3h, 3n and 3o were considered as more potent cytotoxic agents, and comparable modulators of NQO1 activity.

Transient expression of transglutaminase C during prenatal development of human muscles

Tissue transglutaminase (TGase C, TGase II) is known to participate in cellular processes during morphogenesis, differentiation, and development of various prenatal tissues and organs. The expression of TGase C during myoblast proliferation and attachment to external laminae was examined by immunohistochemical (IH) localization at 5-12 weeks of developmental stages of prenatal human muscle in 23 embryos. IH detection using a monospecific antibody to TGase C showed a prominent expression of TGase C in muscle cells as stage- and spatial-specific patterns during an early embryonal period. The myoblasts of intervertebral, tongue, and limb muscles, attached to adjacent cartilaginous skeletons or fibrous fascia, showed a pronounced expression of TGase C at 5-6, 6-7, and 7-8 weeks after fertilization, respectively. The most intense activity of TGase C was observed in some cardiac myoblasts infiltrating into endocardial mesenchyme at 6-7 weeks after fertilization. Although weak staining was detected until 14 weeks after fertilization, the level of TGase C expression in all muscles was significantly decreased after 6-7 weeks, with the exception that the smooth muscle cells of blood vessels and gastrointestinal tract showed diffusely intense staining of TGase C between 5 and 12 weeks after fertilization. Western blotting analysis of the cellular extracts of pooled samples showed a single strong band at 80 kD at 6 weeks after fertilization. This band became weaker after 8-10 weeks of prenatal development. These findings of transient expression of TGase C, which coincides with the development of myoblast anchoring and differentiation, suggest that TGase C plays a role in myoblast attachment to the extracellular laminae during the early embryonal period.

Tumor vessel: a valuable cholangioscopic clue of malignant biliary stricture

BACKGROUND

An irregularly dilated and tortuous vessel, the so-called tumor vessel, is considered to be one of the cholangioscopic features that suggest biliary malignancy. This is a prospective analysis of the presence of a tumor vessel as a finding that discriminates between benign and malignant biliary strictures.

METHODS

From August 1997 to August 1998, a total of 63 patients with biliary strictures diagnosed with endoscopic retrograde cholangiography or percutaneous transhepatic cholangiography obtained during percutaneous transhepatic biliary drainage tube placement were included in this study. Strictures were characterized as benign or malignant based on the observation of tumor vessels. The results were compared with those of percutaneous transhepatic cholangiography-guided biopsy and final diagnosis.

RESULTS

Forty-one patients were confirmed to have malignant strictures and 22 had benign biliary strictures. Cancer was confirmed by histopathologic evaluation of biopsies in 33 of 41 patients with malignancy (80.4%). Tumor vessel was seen in 25 of 41 patients with malignancy (61%). No patients with benign stricture had tumor vessels. Of the 8 patients with negative percutaneous transhepatic cholangioscopy-guided biopsies but with a final diagnosis of malignancy, 6 had tumor vessels. Combining the observation of tumor vessel and percutaneous transhepatic cholangiography-guided biopsy resulted in a diagnosis of malignancy in 39 of 41 patients (96%) and significantly increased the rate of preoperative diagnosis when compared with percutaneous transhepatic cholangiography-guided biopsy or presence of tumor vessel alone (p<0.05).

CONCLUSION

The presence of tumor vessel may be a valuable cholangioscopic finding that indicates the presence of a malignant biliary stricture. The combination of tumor vessel observation and percutaneous transhepatic cholangiography-guided biopsy may improve the preoperative diagnosis of malignancy.

Optical biosensing of nitrite ions using cytochrome cd1 nitrite reductase encapsulated in a sol-gel matrix

Nitrite is an important human health and environmental analyte. As such, the European Union (EU) has imposed a limit for nitrite in potable water of 0.1 mg l-1 (2.18 microM). In order to develop an optical biosensing system for the determination of nitrite ions in environmental waters, cytochrome cd1 nitrite reductase has been extracted and purified from the bacterium Paracoccus pantotrophus. The protein has been spectroscopically characterised in solution and important kinetic parameters of nitrite reduction of the cytochrome cd1 enzyme, i.e., Km, Vmax and kcat have been determined. The influence of pH on the activity of the cytochrome cd1 has been investigated and the results suggest that this enzyme can be used for the determination of nitrite in the pH range 6-9. Biosensing experiments with the cytochrome cd1 in solution suggested that the decrease in intensity of the absorption band associated with the d1 haem (which is the nitrite binding site), at 460 nm, with increasing nitrite concentrations would enable the measurement of this analyte with the optimum limit of detection. The cytochrome cd1 has been encapsulated in a bulk sol-gel monolith with no structural changes observed and retention of enzymatic activity. The detection of nitrite ions in the range 0.075-1.250 microM was achieved, with a limit of detection of 0.075 microM. In order to increase the speed of response, a sol-gel sandwich thin film structure was formulated with the cytochrome cd1. This structure enabled the determination of nitrite concentrations within ca. 5 min. The sol-gel sandwich entrapped cytochrome cd1 enzyme was found to be stable for several months when the films were stored at 4 degrees C.

Safety and usefulness of percutaneous transhepatic cholecystoscopy examination in high-risk surgical patients with acute cholecystitis

BACKGROUND

The aim of the present study was to evaluate the diagnostic and therapeutic usefulness of percutaneous transhepatic cholecystoscopy in high-risk surgical patients with acute cholecystitis.

METHODS

Between January 1992 and June 1998, there were 33 consecutive patients who underwent percutaneous transhepatic cholecystostomy and subsequent percutaneous transhepatic cholecystoscopy for the management of acute cholecystitis.

RESULTS

Percutaneous transhepatic cholecystostomy and subsequent percutaneous transhepatic cholecystoscopy were successfully accomplished in all 33 patients. During percutaneous transhepatic cholecystoscopy, minor complications (2 episodes of minor bleeding during electrohydraulic lithotripsy, 2 of tube dislodgement, and 1 of bile leakage to peritoneum) occurred in 5 patients. Percutaneous transhepatic cholecystoscopy revealed gallstones in 26 cases, sludge ball in 3, gallbladder carcinoma in 3, and 1 case of clonorchiasis related with acute cholecystitis. The 3 gallbladder cancers which were not identified radiologically were found incidentally during percutaneous transhepatic cholecystoscopy. For the 26 patients with gallstones, percutaneous transhepatic cholecystoscopy and concomitant stone removal were successful in 1 to 4 consecutive sessions (mean 2.2 sessions). Gallstones recurred in 3 of 22 patients (14%) during the mean follow-up period of 27 months. All of them remain asymptomatic.

CONCLUSION

Percutaneous transhepatic cholecystostomy may be justified in the management of acute cholecystitis in selected patients with high surgical risk.

Variations in practice and outcomes in the Canadian NICU network: 1996-1997

BACKGROUND

Previous reports of variations in outcomes among neonatal intensive care units (NICUs) examined only specific subpopulations of interest (eg, very low birth weight [VLBW] infants <1500 g of birth weight [BW]).

OBJECTIVES

We report on current practice and outcomes variations in a population-based national study of Canadian NICUs from January 8, 1996 to October 31, 1997.

METHOD

Information on 20 488 admissions to 17 tertiary level NICUs across Canada was prospectively collected by trained abstractors using a standard manual of operations and definitions. Data were verified and analyzed in concert with a steering committee comprising experienced researchers and neonatologists. Patient information included demographic information, antenatal history, mode of delivery, problems at delivery, status of infant and problems at birth, illness severity (Clinical Risk Index for Babies, Score for Neonatal Acute Physiology, Score for Neonatal Acute Physiology-Version II), therapeutic intensity (Neonatal Therapeutic Intensity Scoring System [NTISS]), selected NICU practices and procedures, use of technology and resources, and selected patient outcomes. Patients were tracked until death or discharge home.

RESULTS

The mean number of annual admissions to an NICU was 657, with 26% outborn infants. Fifty-three percent were <2500 g BW, 20% were <1500 g BW (VLBW), and 65% were preterm (<38 weeks' gestational age [GA]). Only 2% of mothers received no prenatal care. Antenatal steroids were given to 58%, but there was wide variation in use (23%-76%). Congenital anomalies were present in 14%, and 4% were small for GA (less than the third percentile). Admission illness severity was lowest among infants 33 to 37 weeks of GA and correlated with risk of death. Ninety-six percent of patients survived until discharge, but fewer survived at lower GA. No infant <22 weeks' GA survived. Seven percent of infants had at least 1 episode of infection, but 75% received antibiotics in the NICU. Forty-three percent received respiratory support, and 14% received surfactant. Nitric oxide was given to 150 term infants and to 102 preterm infants. Selected outcomes of VLBW infants were: survival rate (87%); chronic lung disease (26%); >/=stage 3 retinopathy of prematurity (ROP; 11%); >/=grade 3 intraventricular hemorrhage (IVH; 10%); nosocomial infection (22%); necrotizing enterocolitis (NEC; 7%). Sixty-nine percent of VLBW infants survived without major morbidity (>/=grade 3 IVH, chronic lung disease, NEC, >/=grade 3 ROP). The mean duration of NICU stay was 19 days. Forty-seven percent of infants were discharged from the hospital, and 43% were retrotransferred to a community facility before discharge home. Significant variation in practices and outcomes were observed in all aspects of NICU care.

CONCLUSION

This study provides population-based information about NICU outcomes. Significant variation in NICU practices and outcomes was observed despite Canada's universal health insurance system. This national database provides valuable information for planning research, allocating resources, designing health and public policy, and serving as a basis for longitudinal studies of NICU care in Canada.

Cholangioscopic findings in bile duct tumors

BACKGROUND

Cholangioscopy has been used in the treatment of bile duct stones and the diagnosis of various bile duct tumors. However, the cholangioscopic characteristics of the various types of bile duct tumors have not been clearly described. We analyzed the results of cholangioscopic examinations and classified the findings according to tumor histology.

METHODS

Cholangioscopic findings from 111 patients with benign or malignant bile duct tumors were reviewed. The mucosal changes, the presence of neovascularization, and the patterns of luminal narrowing were analyzed and compared with the histologic diagnosis.

RESULTS

Bile duct adenocarcinoma can be classified into 3 different types according to the cholangioscopic findings: nodular, papillary, and infiltrative. Bile duct adenoma, hepatocellular carcinoma and other types of bile duct cancer such as mucin-hypersecreting cholangiocarcinoma, biliary cystadenocarcinoma, and squamous cell carcinoma also presented unique cholangioscopic characteristics.

CONCLUSIONS

Bile duct tumors exhibit characteristic cholangioscopic findings and cholangioscopy seems to be useful for differential diagnosis.

Neurogenic intermittent claudication related to spinal stenosis

BACKGROUND

The pathophysiology of neurogenic intermittent claudication (NIC) is not very well understood. We examined the theory of "two-level" spinal stenosis as the pathologic cause of NIC.

METHODS

Forty-five consecutive patients with NIC were chosen for the study group and another 45 patients with chronic low back pain, but without NIC, were consecutively chosen for the control group. All the patients were examined using several methods that included a personal history survey, physical examination, X-ray studies, computed tomography (CT) and magnetic resonance imaging (MRI).

RESULTS

Two-level central canal stenosis was found on MRI in 88.9% of the study group compared to only 37.8% of the control group (Fisher's exact two-tailed test, P = 0.0000). In the study group, 77.8% of the patients had severe or moderate facet joint degeneration on CT. The remaining 22.2% of patients had mild facet joint degeneration. In the control group, 40% of the patients had severe or moderate facet joint degeneration, while it was mild or normal in the remaining 60% (Fisher's exact two-tailed test, P = 0.0005). On X-ray, 42.2% of the study group compared with 17.7% of the control group had spondylolisthesis (Fisher's exact two-tailed test, P = 0.0129). In 35% of the study group compared with 11.1% of the control group, X-ray findings showed scoliosis (Fisher's exact two-tailed test, P = 0.0115). The lumbosacral angle in the study group was 35.8 degrees +/- 6.1 degrees compared to 33.1 degrees +/- 7.5 degrees in the control group (independent Student's two-tailed t-test, P > 0.05).

CONCLUSIONS

Our study strongly supports pathophysiology for NIC that is closely related to two-level spinal canal stenosis. Degenerative joint disease, spondylolisthesis and scoliosis of the lumbar spine are predisposing factors of NIC.