Inter-rater Reliability of a Classification System for Hospital Adverse Drug Event Reports

Hospital pharmacovigilance systems frequently classify adverse drug event (ADE) reports on various axes such as severity and type of outcome in an attempt to better detect changes in the frequency of certain types of ADEs. The aim of this study was to measure the inter-observer reliability of an ADE classification system. Two pharmacists and two internal medicine physicians reviewed 150 pharmacist-generated ADE reports and used a structured form to classify reports on four domains: the presence or absence of process measures leading to ADE; the individual who initiated the process that potentially leads to ADE; the severity of ADE; and whether the ADE was related to dose. There was wide variation in inter-observer reliability of different elements in a classification system for ADEs. Agreement on specific processes associated with ADEs ranged from poor to moderate, which limits the ability to target accurately processes to improve drug utilization.

Standards for head injury management in acute hospitals: evidence from the six million population of the Eastern region

OBJECTIVES

To develop standards of care for head injury and thereby identify and prioritize areas of the service needing development; to report the findings from a survey of compliance with such standards in the Eastern region of UK.

METHODS

The standards were collaboratively developed through an inclusive and iterative process of regional surveys, multidisciplinary conferences, and working groups, following a method similar to that used by the Society of British Neurological Surgeons. The standards cover seven topics relating to all aspects of service delivery, with standards within each objective. Each standard has been designated a priority level (A, B, or C). The standards were piloted using a self-assessment questionnaire, completed by all 20 hospitals of the Eastern region.

RESULTS

Full compliance was 36% and a further 30% of standards were partially met across the region, with some areas of service delivery better than others. Seventy eight per cent of level A standards were either fully or partially met. Results were better in the north of the region compared with the south.

CONCLUSION

A survey of compliance with the head injury standards indicate that, with their whole systems approach and subject to further refinement, they are a useful method for identifying deficiencies in service provision and monitoring for quality of care both within organisations and regionally.

Virulence in Candida species

Candida species other than Candida albicans now account for up to 50% of deep candidiasis cases, yet little attention has been paid to the virulence attributes of these fungi. Adherence to host tissues, response to environmental changes and the secretion of hydrolases are all thought to be important in Candida virulence. The identification of virulence attributes unique to a particular Candida species could provide powerful insights into the pathogenic process but will require the use of genome-wide approaches such as transcript profiling, signature-tagged mutagenesis and in vivo expression technology.

Improving access to health care

It is a problem that has plagued the American health care system for years, and it is not getting any better. While the majority of our population enjoys ready access to the finest health care in the world, a steadily growing number are joining the ranks of the uninsured. Despite a strong economy throughout the last decade, the uninsured rate in Michigan is at a higher level today than it was in 1990, and more than one million residents currently have no health care insurance.

The pharmacodynamic characterization of an antisense oligonucleotide against monoamine oxidase-B (MAO-B) in rat brain striatal tissue

1. The aim of our work was to pharmacodynamically characterize an antisense oligonucleotide sequence (5'-GCC AAA CTT TTG CAT GAC-3') against MAO-B, using qualitative and quantitative analyses as assessment measures. 2. Qualitative analysis using histochemical staining revealed that intracerebroventricular (ICV) administered antisense (100 picomoles twice daily x 3.5 days) eliminated all visibly detectable histochemical staining for MAO-B throughout the striatum 1, 12, and 24 h after the last antisense treatment. 3. Qualitative analysis using RT-PCR of the time course of MAO-B mRNA expression in the rat striatum following ICV administration of the antisense sequence showed that 12-24 h after the last administration there was a dramatic reduction in MAO-B mRNA expression in the striatum. The reverse and scrambled sequences generated no change in MAO-B mRNA at 1 or 24 h after the last treatment. 4. Quantitative analysis using the MAO-B selective substrate 4-dimethylamino-phenethylamine (DMAPEA) showed that the antisense sequence reduced MAO-B activity by more than 40%, which was comparable to a single 2 mg/kg, ip dose of L-deprenyl. 5. Quantitative analysis of neurotransmitter levels 24 h after the last treatment suggested that the antisense sequence did not produce any significant changes in neurotransmitter levels. 6. Potential mechanisms for enhancing the antisense response and the speculated potential of an antisense against MAO-B for studying neurotoxicity, Parkinson's disease, and the aging process are also discussed.

Candida glabrata displays pseudohyphal growth

The ability to undergo morphological change has been reported as an advantageous trait in fungal pathogenesis. Here we demonstrate that Candida glabrata ATCC2001, like diploid Saccharomyces cerevisiae strains, forms elongated chains of pseudohyphal cells on solid nitrogen starvation media (SLAD). Constrictions were apparent between adjoining cells; no parallel-sided hyphae were seen and pseudohyphae invaded the agar. When SLAD was supplemented with ammonium sulfate both C. glabrata and diploid S. cerevisiae strains lost their ability to undergo pseudohyphal growth. However, on this media C. glabrata yeast cells invaded the agar in a similar fashion to the invasive growth mode exhibited by haploid strains of S. cerevisiae cultured on rich media such as YPD. C. glabrata was not capable of invading YPD demonstrating that the process of filamentation is distinct in these two fungi. To our knowledge this is the first report to demonstrate that C. glabrata can undergo morphological change and grow as an invasive filamentous organism.

Candida glabrata shuttle vectors suitable for translational fusions to lacZ and use of beta-galactosidase as a reporter of gene expression

The functionality of beta-galactosidase encoded by the E. coli lacZ gene as a reporter of gene expression in C. glabrata was investigated. C. glabrata/E. coli shuttle vectors were constructed, containing both a C. glabrata CEN-ARS cassette, to allow regular segregation and episomal replication of the plasmids, and the lacZ coding sequence of E. coli. The functionality of beta-galactosidase in C. glabrata was verified by inserting the promoter and the 5' coding region of the HIS3 gene from C. glabrata directionally upstream of the lacZ gene. By fusing the promoter of the copper-controlled MTII gene to the lacZ reporter, we showed that beta-galactosidase activity can be differentially induced in C. glabrata. beta-galactosidase reporter activities were detected qualitatively by an indirect filter assay and quantitatively from permeabilized cells.

Patients as peer preceptors for orthopedic oncology rehabilitation patients

This article describes a peer preceptor program that trains patients who have experienced limb preservation surgeries and managed long-term rehabilitative therapy to support and teach newly diagnosed patients through their rehabilitation. This preceptor program was designed to complement the professional counseling and support that rehabilitation staff provide to patients and their families. Training includes communication techniques, practice sessions using videotaped scenes of patients and their families, as well as role-playing. Experienced patients who became preceptors as a result of this program were orthopedic oncology patients who had completed limb preservation surgery, chemotherapy, grafting, and physical therapies. After their training, preceptors exhibited improved communication skills in terms of empathy, listening, and voice expressions. Initiatives designed to make the preceptor program self-sustaining by having staff nurses manage the training still have to be tested.

Molecular and phenotypic analysis of Candida dubliniensis: a recently identified species linked with oral candidosis in HIV-infected and AIDS patients

The discovery and characterisation of a novel species of Candida, termed Candida dubliniensis, associated with oral candidosis in HIV-infected individuals is described. These organisms share several phenotypic characteristics in common with Candida albicans and Candida stellatoidea, including the ability to produce germ tubes and chlamydospores. However, in contrast to these latter two species, C. dubliniensis isolates produce abundant chlamydospores, which are often arranged in contiguous pairs, triplets and other multiples suspended from a single suspensor cell. They belong to C. albicans serotype A and exhibit atypical substrate assimilation profiles. Genomic DNA fingerprinting analysis with the C. albicans-specific probe 27A and five different oligonucleotide probes consisting of short repeat sequence-containing motifs, demonstrated that C. dubliniensis has a distinct genomic organisation relative to C. albicans and C. stellatoidea. This was confirmed by karyotype analysis and random amplified polymorphic DNA (RAPD) analysis. Comparison of 500 bp of the V3 variable region of the large ribosomal subunit genes from 14 separate C. dubliniensis isolates and the corresponding sequences from C. albicans, C. stellatoidea, C. tropicalis, C. glabrata, C. parapsilosis, C. kefyr and C. krusei demonstrated that the C. dubliniensis isolates formed a homogenous cluster (100% similarity), representing a discrete taxon within the genus Candida that was significantly different from the other species analysed.

Widespread geographic distribution of oral Candida dubliniensis strains in human immunodeficiency virus-infected individuals

Candida dubliniensis is a recently identified chlamydospore-positive yeast species associated with oral candidiasis in human immunodeficiency virus (HIV)-infected (HIV+) patients and is closely related to Candida albicans. Several recent reports have described atypical oral Candida isolates with phenotypic and genetic properties similar to those of C. dubliniensis. In this study 10 atypical chlamydospore-positive oral isolates from HIV+ patients in Switzerland, the United Kingdom, and Argentina and 1 isolate from an HIV-negative Irish subject were compared to reference strains of C. albicans and Candida stellatoidea and reference strains of C. dubliniensis recovered from Irish and Australian HIV+ individuals. All 11 isolates were phenotypically and genetically similar to and phylogenetically identical to C. dubliniensis. These findings demonstrate that the geographical distribution of C. dubliniensis is widespread, and it is likely that it is a significant constituent of the normal oral flora with the potential to cause oral candidiasis, particularly in immunocompromised patients.

Persistence, replacement, and microevolution of Cryptococcus neoformans strains in recurrent meningitis in AIDS patients

Six separate human immunodeficiency virus-positive patients with cryptococcal meningitis were each found to have been infected with a unique strain of Cryptococcus neoformans on the basis of genomic DNA finger-printing analysis with the microsatellite sequence-containing oligonucleotide probe (GGAT)4 and by random amplification of polymorphic DNA. Two patients (A and B) experienced a recurrent episode of infection. Between 12 and 16 single-colony isolates recovered from primary isolation media (> 50% of C. neoformans colonies recovered) from cerebrospinal fluid specimens were fingerprinted from both patients during each episode. The fingerprints of both isolate collections from patient B were very similar, although minor polymorphisms were evident in both sets of profiles. The fingerprints of the isolate collection from the initial episode of infection in patient A were also identical to each other, apart from minor polymorphisms, but they were clearly different from the corresponding profiles of the isolate collection from the recurrent episode, the latter of which were completely identical, apart from minor polymorphisms in a single isolate. Furthermore, prolonged storage and in vitro subculture of the isolates did not alter the fingerprint profiles. These results provided convincing evidence that patients A and B were each infected with a single C. neoformans strain during each episode of infection and that in patient B, the same strain persisted and caused both episodes, while in patient A, a different strain was responsible for each episode. The prevalence of polymorphisms in multiple single-colony isolates from both patients also suggested that C. neoformans populations may undergo microevolution.

Retrospective evaluation of a latex agglutination test for diagnosis of invasive aspergillosis in immunocompromised patients

A commercial latex agglutination (LA) test for the detection of circulating Aspergillus galactomannan was evaluated in sera obtained from 121 immunocompromised patients, including 19 with proven invasive pulmonary aspergillosis. Patient urine (the specimen of choice for detection of galactomannan) was not tested with the LA test as 34 of 81 specimens from controls gave false-positive results. The sensitivity (95%), specificity (90%) and negative predictive value (99%) of the LA test were similar to previously published results obtained with two EIAs. However, the positive predictive value was only 67% compared to > or = 95% obtained with the EIAs. In addition, the LA test was also of less value than the EIAs in predicting the onset of invasive pulmonary aspergillosis. It was the earliest indicator of infection in only 1 of 19 proven cases.

Growth hormone (GH) receptors are expressed on human fetal mesenchymal tissues--identification of messenger ribonucleic acid and GH-binding protein

The role of GH in the fetus remains unclear, in spite of high circulating levels. In order to determine potential sites of action of GH in the human fetus, we have used a combination of immunocytochemistry and northern blotting to examine human fetal tissues for GH receptor or binding protein and its messenger RNA. Human fetal abortus tissues of 15-20 weeks gestation were obtained for sternum and skin. Decalcified paraffin sections, were prepared for immunostaining with a monoclonal antibody to the GH receptor or control antibodies. Chondrocytes were digested from sternum and costal cartilage for primary culture in monolayers for up to 14 days. Skin fibroblasts were similarly cultured and studied at passages 5-10. Polyadenylated mRNA was prepared from cultured chondrocytes and fibroblasts for subsequent northern blotting with a complementary DNA probe to the hGH receptor. Positive immunostaining for GH receptor was seen in growth plate, including chondrocytes in the proliferative and hypertrophic zones, perichondrium, osteoblasts, and erythroid precursor cells. GH receptor immunostaining was also seen in skin sections throughout epidermis, including sebaceous and sweat glands, and vessels and fibroblasts in the dermis. Cultured chondrocytes showed patchy staining, with colonies of immunopositive cells proliferating in culture. Skin fibroblasts showed uniform GH receptor immunostaining. Control sections and cultured cells did not stain. Cultured chondrocytes showed specific binding of 125I-hGH(1-3%), with a typical displacement curve for GH receptor. As for immunostaining, binding increased with time in culture. Finally, northern blotting revealed a single 5.1 kilodalton band representing GH receptor mRNA in both chondrocytes and skin fibroblasts. This study has demonstrated the presence of GH receptor protein and mRNA on human fetal tissues including growth plate chondrocytes and osteoblasts, as well as skin epidermal structures and dermal fibroblasts. These receptors are capable of binding hGH, raising the possibility that, in contrast to current dogma, GH receptors play a functional role in the human fetus by 15 weeks gestation.

The 18-kilodalton antigen secreted by Aspergillus fumigatus

One of the major antigens secreted in vitro by Aspergillus fumigatus is an 18-kDa basic protein which has been purified by cation-exchange chromatography. It is recognized by sera from aspergilloma patients. It is also the major circulating antigen found in urine of patients with invasive aspergillosis. Our results indicated that this antigen has potential for the diagnosis of both aspergilloma and invasive aspergillosis.

Identification and localization of insulin-like growth factor receptors in human infant pituitary gland-similar distribution to somatotrophs

Abstract Insulin-like growth factors(IGF) are involved in feedback regulation of growth hormone(GH) secretion from the pituitary. Though receptors for IGF-I and IGF-II have been identified on particulate preparations of rat pituitary, their localization and relationship to GH-secreting acidophils has not been determined. We used quantitative in vitro autoradiography and immunocytochemistry to simultaneously determine the distribution of IGF receptors and GH-secreting cells in human infant pituitary gland. Frozen or fixed post-mortem human infant pituitary glands were sectioned for binding studies, or immunocytochemistry. Binding for IGF-I and IGF-II showed characteristic specificity for respectively Type I and Type II receptors. Binding sites were visualized throughout the pituitary gland, with similar density and distribution for IGF-I and IGF-II receptor sites. Receptor density was two-fold higher in anterior than posterior pituitary, with highest density in the lateral horns of the anterior pituitary. The distribution of GH-containing cells (acidophils) was similar to IGF receptor distribution. Increased density of IGF receptors in regions of GH-secreting cells may point to the mechanism whereby IGF uniquely inhibits synthesis of human GH in contrast to its promotion of synthetic processes in other cells.

The retained surgical sponge following intra-abdominal surgery. A continuing problem

The surgical sponge retained following intra-abdominal surgery is a continuing problem. Despite precautions, the incidence of this problem is grossly underestimated. During the past 10 years, we have treated four patients with this problem. The presentation of a retained surgical sponge is highly variable, as is the time before the onset of symptoms. The clinical presentation, predisposing factors, and management are presented as well as guidelines for prevention.

Insulin-like growth factors promote DNA synthesis and support cell viability in fetal hemopoietic tissue by paracrine mechanisms

There is significant evidence that the insulin-like growth factors (IGF) play a role in both murine and human hemopoiesis. In order to better define the nature and mechanisms of these effects, we have used a serum-free system to examine DNA synthesis and cell replication in murine hemopoietic cells. Cell preparations from 13-day fetal mice livers were incubated in serum-free DMEM alone or with erythropoietin (Epo) 0.5 U/ml, recombinant human IGF-I, purified IGF-II, or recombinant human growth hormone (GH) in various doses, and [3H]thymidine added for the last 3 hr of 21-hr incubation. Cell distribution was over 80% erythroid or erythroblasts. IGF-I and IGF-II promoted thymidine incorporation into cells at a half-maximal dose of 3 and 1 nM respectively, IGF-II with a maximum potency 65% of IGF-I; insulin stimulated at a half-maximum dose of 100 nM, with similar maximum effect to IGF-I, and their effects were not additive. GH was stimulatory at 1 microM. Epo was 2-9 times as effective as IGF-I and their effects were not additive. A monoclonal antibody to IGF-I reduced the effect of IGF-I by 50-80%, had no effect on Epo, and abolished the GH effect. Separation of erythroid cells and precursors from accessory and other liver cells did not alter the response to IGF-I. Cell counts increased in response to IGF-I or Epo, and cell viability was maintained by IGF-I compared to control medium.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlates of first trimester care in a public health prenatal clinic

Early access to prenatal care is a major issue in the prevention of low birth weight. Therefore, the authors studied 107 indigent women seen consecutively for their initial visits at a public health department's prenatal clinic to ascertain factors associated with first trimester care. The questionnaire included items on individual health behaviors, attitudes toward medical care, perceived social support, depression, and demographics. Data were collected over 12 weeks by a clinic nurse, and all patients agreed to participate. Using logit estimated odds ratios (OR), none of the independent variables examined were associated with first trimester care for married women. For unmarried women first trimester care was related to finding the clinic by word of mouth (OR = 5.5, 95% CI, 1.2-22.9) and maternal depression (OR = 4.0, 95% CI, 1.1-15.3). Finding the prenatal clinic by word of mouth and maternal depression were still associated with first trimester care after controlling for maternal education and health attitudes. These data suggest that subsequent explanatory research should explore the association between informal social support of unmarried women and first trimester prenatal care.

Neurodevelopment of monitored versus nonmonitored very low birth weight infants: the importance of family influences

Very low birth weight (VLBW) infants are at increased risk for neurodevelopmental delays. Follow-up programs have been instituted as one form of secondary prevention, to identify delays early and refer affected children to intervention. To examine the relationship between follow-up care and later development, 82 neonates who weighed 1500 g or less at birth were followed to 36 months of age. Effectiveness of care was assessed by neurodevelopmental status of 45 patients who participated and 37 patients who failed to participate in annual post-neonatal intensive care unit (NICU) monitoring service. At the outset, the groups had similar medical and socioeconomic status characteristics. However, by the third year of life, the monitored patients had a 14-point General Cognitive Index (GCI) advantage over the nonmonitored group. Examination of family process variables, family organization styles, and mother-child behaviors revealed significant differences between the groups, and suggested that monitored patients were raised in more normal, supportive home environments. Correlation and stepwise regression analyses indicated that mother-child behaviors and quality of the home environment were most predictive of 3-year intellectual development, with neonatal and biological measures adding to the predictive classification of neurosensory delays. It is suggested that an infant's medical record, mother-child behaviors, and overall quality of home environment be measured prior to hospital discharge, followed by home-based intervention where indicated.

Factors affecting breastfeeding among women of Mexican origin or descent in Los Angeles

Data on breastfeeding intentions and behavior were collected in prenatal and postpartum interviews as part of a study on first birth among 518 women of Mexican origin or descent in two Los Angeles hospitals. The prenatal intentions of 82 per cent of the women to breastfeed were maintained postpartum in one hospital but dropped sharply in the other. A greater number of hours a day with the baby in the hospital and earlier initiation of breastfeeding were associated with the hospital where prenatal breastfeeding intentions were more likely to be carried out. The intention to work postpartum was associated both with the decision not to breastfeed at all and with shorter intended duration of breastfeeding.