Anaplasma phagocytophilum in central and western Wisconsin: a molecular survey

Anaplasma phagocytophilum is an obligate intracellular bacterium that is transmitted to humans through the bite of Ixodes spp. ticks, and causes a febrile disease known as human granulocytic anaplasmosis. The presence of A. phagocytophilum in Wisconsin white-tailed deer blood and in deer ticks was assessed using PCR and DNA sequencing. Sampling sites in the western part of the state (Buffalo County) and central region (Waushara, Waupaca, and Green Lake counties) were used. In Buffalo County, 5.6% of deer and 8.9% of ticks were infected. At Hartman Creek State Park (Waupaca County), 11.5% of ticks were infected, while the observed prevalence in deer from counties to the south of the park (Waushara and Green Lake) reached 19-26%. Based on 16S rRNA sequences, A. phagocytophilum strains associated and not associated with human infections were identified. Furthermore, two novel A. phagocytophilum variants were found in deer blood samples. Transmission of Lyme disease has been documented in both the Western and Central regions we sampled, and the presence of A. phagocytophilum in naturally occurring tick populations could present an additional risk of disease to humans that enter tick habitats.

Non-particulate (continuous bed or monolithic) acrylate-based capillary columns for reversed-phase liquid chromatography and electrochromatography

Three approaches are described to synthesize acrylic non-particulate beds (also called continuous beds or monoliths) in aqueous polymerization media for reversed-phase capillary liquid chromatography/electrochromatography. In the first, hexyl acrylate comonomer was dissolved together with water soluble polar comonomers using a non-ionic detergent. In the second, a new alkyl ammonium salt comonomer, (3-allylamino-2-hydroxypropyl)dodecyldimethylammonium chloride was used, which is water soluble and has detergent properties itself. The alkyl group of this comonomer provides hydrophobicity while the ionic groups generate electroosmosis in the non-particulate bed. In the third approach, the alkyl comonomer was used as a detergent to dissolve another hydrophobic comonomer in an aqueous polymerization medium. All three approaches were evaluated with respect to hydrophobicity, efficiency and electroosmotic properties of the beds. Hydrophobicity expressed as methylene group selectivity for the three types of the beds in 50% methanol mobile phase was 1.86, 1.16 and 1.78, electroosmotic mobility -5.14 x 10(-5), 6.89 x 10(-5) and 6.37 x 10(-5) cm2 V(-1) s(-1) and efficiency for the retained compound (methylparabene) 67,000, 93,000 and 110,000 plates m(-1) correspondingly. The columns were tested using pressure driven capillary chromatography and capillary electrochromatography. The influence of polymerization temperature on hydrodynamic permeability, separation impedance and inverse size exclusion porosimetry characteristics were used to evaluate the separation columns. The increase of the polymerization temperature resulted higher permeability of the bed, separation impedance and lower polymeric skeleton porosity. Further characterisation was provided by examining the separation efficiency observed for a series of benzoic acid esters and alkyl parabens.

Botulinum toxin A and chronic low back pain: A randomized, double-blind study

OBJECTIVES

To investigate the efficacy of botulinum toxin A in chronic low back pain and associated disabilities.

METHODS

Thirty-one consecutive patients with chronic low back pain who met the inclusion criteria were studied: 15 received 200 units of botulinum toxin type A, 40 units/site at five lumbar paravertebral levels on the side of maximum discomfort, and 16 received normal saline. Each patient's baseline level of pain and degree of disability was documented using the visual analogue scale (VAS) and the Oswestry Low Back Pain Questionnaire (OLBPQ). The authors reevaluated the patients at 3 and 8 weeks (visual analogue scale) and at 8 weeks (OLBPQ).

RESULTS

At 3 weeks, 11 of 15 patients who received botulinum toxin (73.3%) had >50% pain relief vs four of 16 (25%) in the saline group (p = 0.012). At 8 weeks, nine of 15 (60%) in the botulinum toxin group and two of 16 (12.5%) in the saline group had relief (p = 0.009). Repeat OLBPQ at 8 weeks showed improvement in 10 of 15 (66.7%) in the botulinum toxin group vs three of 16 (18.8%) in the saline group (p = 0.011). No patient experienced side effects.

CONCLUSION

Paravertebral administration of botulinum toxin A in patients with chronic low back pain relieved pain and improved function at 3 and 8 weeks after treatment.

Bilateral painful hand-moving fingers: electrophysiological assessment of the central nervous system oscillator

We describe a 35-year-old woman who presented with the syndrome of painful hand-moving fingers on the right side. Eight months later, she developed similar finger movements and hand discomfort on the left side. She had a history of hand trauma and recurrent shoulder dislocation on the right side. Kinesiologic electromyography suggested a common central oscillator for finger movements in both hands. Electrophysiological assessment of spinal alpha motor neuron excitability, reciprocal inhibition, and Renshaw cell inhibition failed to show any abnormalities. Somatosensory evoked potential test showed marked attenuation of N20 potential recorded from the left somatosensory cortex; paired transcortical magnetic stimulation of the left motor cortex suggested failure of cortical facilitation. The data suggest that the central oscillator responsible for finger movements is located above the spinal cord level in this patient.

Ultraviolet spectrophotometric characterization and bactericidal properties of electrolyzed oxidizing water as influenced by amperage and pH

To identify the primary component responsible in electrolyzed oxidizing (EO) water for inactivation, this study determined the concentrations of hypochlorous acid (HOCl) and hypochlorite ions (OCl-) and related those concentrations to the microbicidal activity of the water. The ultraviolet absorption spectra were used to determine the concentrations of HOCl and OCl- in EO water and the chemical equilibrium of these species with change in pH and amperage. EO water generated at higher amperage contained a higher chlorine concentration. The maximum concentration of HOCl was observed around pH 4 where the maximum log reduction (2.3 log10 CFU/ml) of Bacillus cereus F4431/73 vegetative cells also occurred. The high correlation (r = 0.95) between HOCl concentrations and bactericidal effectiveness of EO water supports HOCl's role as the primary inactivation agent. Caution should be taken with standard titrimetric methods for measurement of chlorine as they cannot differentiate the levels of HOCl present in EO water of varying pHs.

Respiratory changes in vasovagal syncope

INTRODUCTION

Respiratory changes accompany the cardiovascular changes during head-up, tilt test-induced vasovagal syncope.

METHODS AND RESULTS

Using the 45-minute 60 degrees head-up Westminster protocol, 29 patients were studied (mean age 53.9+/-20.0 years; 19 females). Two groups resulted: tilt-induced vasovagal syncope positive and negative. The cardiorespiratory parameters blood pressure (BP), heart rate (HR), tidal volume, and minute volume were measured. Comparisons of the cardiorespiratory parameters were made within the positive group and negative group, and then between the two groups. There were 14 in the positive group and 15 in the negative group. Baseline measurements were normalized to 1.0. Comparing the late tilt periods between the positive and negative groups, there were differences in BP (P < 0.002), HR (P < 0.002), tidal volume (P < 0.05), and minute volume (P < 0.002). In the positive group comparing early with late intervals: BP 1.11+/-0.09 versus 0.49+/-0.17, P < 0.0001; HR 1.18+/-0.12 versus 0.85+/-0.35, P < 0.009; tidal volume 1.39+/-0.34 versus 2.17+/-1.00, P < 0.015; and minute volume 1.24+/-0.26 versus 3.3+/-2.03, P < 0.0025. There were no comparable cardiorespiratory changes in the negative group.

CONCLUSION

There were significant differences in the respiratory and cardiovascular parameters measured between those who were positive and those who were negative for tilt-induced vasovagal syncope. Within the positive group, in addition to the falls in HR and BP, there were significant increases in minute volume and tidal volume during late tilt. This suggests that there may be a role for respiratory sensors in vasovagal syncope that may permit earlier and hence possibly more effective therapy for selected patients.

Sensitive method for detection of human herpesviruses 6 and 7 in saliva collected in field studies

To facilitate studies of the epidemiology and natural history of human herpesviruses 6 and 7 in infants, a practical method for collecting and quantifying the DNA of these viruses was developed. Saliva was collected using small strips of filter paper, and virus was detected using a real-time quantitative fluorescent-probe PCR assay. The sensitivity and specificity of this method even after prolonged drying of the specimens compared favorably to those of our traditional method of collecting and assaying saliva.

Contribution of head-up tilt testing and ATP testing in assessing the mechanisms of vasovagal syndrome: preliminary results and potential therapeutic implications

BACKGROUND

In patients with vasovagal syndrome, head-up tilt testing may reproduce symptoms generally associated with vasodepression. Recent research suggests ATP testing identifies patients with abnormal vagal cardiac inhibition. This preliminary study examined the joint contribution of both tests in identifying underlying mechanisms in the general population with vasovagal syndrome.

METHODS AND RESULTS

Both tests were performed in random order during 1 session and outside of predominant sympathetic periods in 72 patients hospitalized for syncope (n=56) or presyncope (n=16) for whom no cardiac or extracardiac cause was found. For passive and isoproterenol-provocative tilt testing by standard protocol, reproduction of symptoms defined a positive test. The ATP test consisted of injecting ATP 20 mg IV at bedside, continuously monitoring ECG and blood pressure; a vagal cardiac pause >10 seconds defined a positive test. For most patients (64%), >/=1 test was positive. Of the 41 patients (57%) with a positive tilt test (either passive or provoked by isoproterenol), 32% had cardiac disease; none had significant bradycardia (<50 bpm). Of the 8 patients (11%) with a positive ATP test, 62% had cardiac disease; the probability of a positive result increased with age (P=0.015). Both tests were positive in 3 patients and negative in 26 patients; the tilt and ATP test results were uncorrelated (P=0.28).

CONCLUSIONS

Results suggest tilt and ATP tests individually and jointly determine the mechanism of vasovagal symptoms in most patients and that vagal cardiac inhibition increases with age.

Reproducibility of the adenosine-5'-triphosphate test in vasovagal syndrome

INTRODUCTION

Adenosine-5'-triphosphate (ATP) provokes negative chronotropic and dromotropic vagal effects. In vasovagal syndrome, ATP test (20-mg i.v. bolus infusion) represents a promising technique for identifying patients at risk of severe cardioinhibitory response of vagal origin. The electrocardiographic and related symptom reproducibility of this descriptive test must be assessed.

METHODS AND RESULTS

In order to achieve this objective, ATP tests were performed twice in 80 patients (44 men, 36 women; mean age 72.3+/-12.2 years) by using the recently published test procedure and criteria of positivity. The second test was repeated shortly after the initial test (mean: 7 days) in 43 patients and long-term (mean: 3.7 years) in 37 patients. The initial ATP test provoked a cardiac pause > 10 seconds in 31 patients (39%) and a short cardiac pause (< or =10 sec) or no pause in 49 patients (61%). The electrocardiographic outcome was reproduced during the second ATP test in 36 patients (84%) of the short-term group and in 29 patients (78%) of the long-term group. Similarly, symptoms were reproduced in 38 patients (88%) of the short-term group and 29 patients (78%) of the long-term group, reflecting the severity of the electrocardiographic outcome.

CONCLUSION

The negative chronotropic and dromotropic vagal effect of ATP can be reproduced short term and long term in 84% and 78% of patients, respectively. Associated symptoms were related to the severity of the electrocardiographic outcome.

Thoracoscopic anterior spinal procedures in children

METHODS

From February 1996 through July 1997, 20 patients were determined to be appropriate for a thoracoscopic approach for the anterior portion of their spinal surgery. Ages ranged from 8 to 17 years of age and weight from 20 to 70 kg. The diagnosis included severe idiopathic and neurogenic scoliosis or kyphosis (n = 20) and congenital hemivertebra (n = 4). The procedures performed included diskectomy and anterior release from two to nine vertebral levels, hemivertebrectomy, and epiphysiodesis. Four patients also had an open lumbar exposure and all had a posterior fusion.

RESULTS

All procedures were completed successfully endoscopically. Surgical times for the thoracoscopic portion of the procedure averaged 106 minutes and total procedure times were comparable with the standard open technique. Three patients were extubated at the end of the procedure with the majority extubated on postoperative day 1. Average intensive care unit stay was 1.8 days, and chest tubes were removed between postoperative day 1 and 5 (average, 2.2 days). In follow-up, surgical correction was deemed to be acceptable and equivalent to open techniques in all cases.

CONCLUSION

This technique has proven to be safe and effective in children and appears to be associated with less pain and morbidity as evidenced by earlier extubation and chest tube removal and shorter ICU stay.

Right ventricular pressure, dP/dt, and preejection interval during tilt induced vasovagal syncope

This study examined the potential utility of monitoring right ventricular dP/dt as a means of detecting imminent vasovagal syncope. To assess this possibility, continuous right ventricular pressure measurements were recorded in nine patients during induction of syncope by head-up tilt testing. Findings indicated that arterial pressure tended to fall prior to drop in heart rate. RV pressure exhibited a significant, but very small, fall during tilt. DP/dt max increased by 15-20% during tilt, then fell by a median of 30% from maximum value beginning about 2 minutes prior to syncope. Thus, further investigation of dP/dt as a potential marker of impending vasovagal syncope is warranted.

Identification of a new by-product detected in metoprolol tartrate

A new impurity has been found in some batches of metoprolol tartrate. As the amount exceeded 0.1% it was of interest to deduce the structure. Techniques involved in solving the problem were LC, LC-MS and GC-MS. The LC systems showed that the impurity and metoprolol behaved differently to modifications of the mobile phase, indicating that there were differences in the functional groups. LC-MS was used to determine the molecular weight, which was 74 mass units higher than metoprolol. A hydrogen-deuterium shift technique using micro column LC-MS gave the information that three hydrogen atoms were bound to heteroatoms, i.e. one more than in metoprolol. This led to the conclusion that the impurity had three extra carbon and two extra oxygen atoms. It was supposedly a by-product in the synthesis. Knowledge of the synthesis steps for beta-receptor blocking drugs suggested three possible structures. Two were independently synthesized and one of these was found to be identical to the impurity.

Utility of an implantable right ventricular oxygen saturation-sensing pacemaker for ambulatory cardiopulmonary monitoring

Mixed venous oxygen saturation (SvO2) is a physiologic parameter reflecting cardiac output (CO) and tissue oxygen utilization. An implantable oxygen sensor incorporated in a right ventricular pacing lead has been developed to assess the feasibility of ambulatory monitoring of SvO2 to predict cardiorespiratory parameters. Eight patients with a mean age of 62 +/- 2 years and sinoatrial disease received an SvO2-driven dual-chamber rate-adaptive pacemaker capable of continuous SvO2 measurement. During graded maximal exercise with measurement of oxygen consumption (Vo2), arterial oxygen saturation (SaO2), and telemetered derived SvO2 data, CO was assessed using the Fick principle. The accuracy of the derived CO was compared with CO measured directly by continuous-wave Doppler assessment of the ascending aortic flow. The maximum changes in SvO2 and SaO2 during exercise were 25 +/- 5 and 3 +/- 1%, respectively. SvO2 was significantly correlated with Vo2 (r = 0.9 +/- 0.1, p < 0.001), work done (r = 0.8 +/- 0.1, p < 0.05), and minute ventilation (r = 0.9 +/- 0.1, p < 0.05). Doppler-derived CO was significantly correlated with CO estimated from SvO2 measured (r = 0.8 +/- 0.1, p < 0.05) and is expressed as 46x derived CO +300. Although continuous SvO2 sensing was originally developed to increase pacing rate during exercise, its use can be extended for monitoring cardiopulmonary performance on an ambulatory basis. This may be useful as a direct assessment of cardiopulmonary status in diseased states and also as an objective means to evaluate cardiac response to medical therapy in patients with heart failure.

Rate adaptive cardiac pacing using right ventricular venous oxygen saturation: quantification of chronotropic behavior during daily activities and maximal exercise

Central venous oxygen saturation (SvO2) closely reflects cardiac output and tissue oxygen consumption. In the absence of an adequate chronotropic response during exercise, SvO2 will decrease and the extent of desaturation may be used as a parameter for rate adaptive cardiac pacing. Eight patients with sinoatrial disease received a DDDR pacemaker capable of DDDR pacing by sensing either SvO2 or piezoelectric detected body movement. Both sensors were programmed to attain a rate of about 100 beats/min during walking, and with the lower and upper rates set at 50% and 90% of age predicted maximum, respectively. Chronotropic behavior of the two sensors were compared in the DDD mode with measurement of sensor responses, during everyday activities (walking, stair climbing, postural changes, and physiological stresses) and at each quartile of workload during a continuous treadmill exercise test. During walking at 2.5 mph, both sensors showed no significant difference in delay time (both react within 15 secs) or half-time (SvO2 = 36 +/- 12 sec and activity 24 +/- 3 sec; P = NS), although SvO2 driven pacing achieved 90% target rate response slower than activity sensing (124 +/- 16 sec vs 77 +/- 10 sec; P < 0.02). SvO2 pacing was associated with a more physiological rate response during walking upslope (68 +/- 12 beats/min vs 57 +/- 10 beats/min; P < 0.05), ascending stairs (59 +/- 10 beats/min vs 31 +/- 6 beats/min; P < 0.05), and standing (34 +/- 7 beats/min vs 9 +/- 2 beats/min; P < 0.05). The SvO2 sensor significantly overpaced in the first quartile of exercise (51.8 +/- 25.6% in excess of heart rate expected from workload), but the rate was within 20% of expected for the remainder of exercise. "Underpacing" was observed with the activity sensor at the higher workload. In conclusion, the SvO2 sensor demonstrated a more physiological response to activities of daily living compared with the activity sensor. Using a quantitative method, the speed of onset of rate response of the SvO2 sensor was comparable to activity sensing, and was more proportional in rate response. Significant overpacing occurs at the beginning of exercise during SvO2 driven pacing, which may be improved with the use of a curvilinear algorithm.

Hemodynamic response to the upright posture

The authors' objective was to review previous studies of immediate (first 30 seconds) and stabilized (30 seconds to 20 minutes) hemodynamic responses of healthy adults to the head-up posture, with particular reference to alteration of such responses in the elderly and the usefulness of such data in the diagnosis of orthostatic hypotension. The immediate response in healthy young adults is characterized by a prompt rise in heart rate, which peaks at about 8 to 15 seconds and then tapers; the arterial pressure and total vascular resistance decrease sharply at 5 to 10 seconds, followed by a rapid rebound and overshoot. Over the first 30 seconds there is a steady parallel decline of thoracic blood volume and stroke volume; there is also an initial surge of cardiac output followed by a steady decrease. During the stabilized response (30 seconds to 20 minutes), the hemodynamic variables are relatively steady, showing average increases in heart rate of about 15 to 30%, in diastolic pressure of 10 to 15%, and in total vascular resistance of 30 to 40%; during the 5th to 20th minutes there are also decreases in thoracic blood volume averaging about 25 to 30%, in cardiac output 15 to 30%, and in pulse pressure about 5 to 10%. It is evident that in normal human subjects, assumption of the upright posture results in profound hemodynamic changes, most of them occurring during the first 30 seconds. In elderly subjects (aged 60-69 years), there are, in the upright posture, lesser increments of heart rate and diastolic pressure, but no significant differences from younger age groups in the response of thoracic blood volume, cardiac output or total vascular resistance. However, beginning at about age 75, there is an increasing incidence of orthostatic hypotension, which averages about 14 to 20% at age 75 and older. The tendency toward orthostatic hypotension in the elderly is due (1) to the structural and functional changes in the circulation itself, (2) to a decline in autonomic function, and (3) to a probable functional deficiency of the skeletal muscle pump. The authors believe that closer hemodynamic monitoring of orthostatic hypotension patients would considerably increase our understanding and aid in the diagnosis of this condition.