Use of high-dose ganciclovir for a resistant cytomegalovirus infection due to UL97 mutation

Cytomegalovirus (CMV) infection is a major complication following solid organ transplantation resulting in significant morbidity and mortality. The guidelines published in 2004 have recommendations for therapy; however, the frequency of resistant CMV infection is increasing and therapy is not clearly defined. There are a few alternatives to ganciclovir such as foscarnet, cidofovir, and leflunomide; however, their use is limited by adverse effects. This report summarizes the successful use of high-dose ganciclovir for the treatment of a resistant CMV caused by UL97 mutation.

Warfarin and its interactions with foods, herbs and other dietary supplements

Despite its complex pharmacokinetic and pharmacodynamic profile, warfarin is still one of the most widely used oral anticoagulant agents. Attaining optimal anticoagulation with this agent is clinically challenging in view of its many food and drug interactions. Inappropriate anticoagulation control can expose patients to an increased risk of bleeding or thromboembolic complications, due to over and underanticoagulation, respectively. Fluctuations in dietary vitamin K intake can have a significant effect on the degree of anticoagulation in patients treated with warfarin. In addition, the explosion in use of various dietary supplements and herbal products can lead to undesired outcomes on anticoagulant levels. The aim of this review is to discuss the scope and the potential clinical impact of the most commonly reported food, dietary supplement and herbal interactions with warfarin therapy. Practical steps for patients and providers to minimise these interactions are highlighted.

Characterization of extended-spectrum β-lactamase (ESBL)-producing Kuwait and UK strains identified by the Vitek system, and subsequent comparison of the Vitek system with other commercial ESBL-testing systems using these strains

Two hundred and fifty-one unique patient isolates of Klebsiella pneumoniae (123), Escherichia coli (114), Klebsiella oxytoca (7), Enterobacter cloacae (5) and Citrobacter freundii (2), flagged as extended-spectrum β-lactamase (ESBL) positive by the Vitek system (GNS-526 card), were collected. These strains were isolated from a variety of clinical specimens submitted to the clinical bacteriology laboratories of the Royal Infirmary of Edinburgh (RIE), Edinburgh, UK (and associated GP practices), Hairmyers Hospital, Glasgow, UK, and the Amiri and Farwania Hospitals, Kuwait. Of the 101 RIE strains tested, 15 E. coli strains were found to be ESBL negative by Etest ESBL strips. On retesting the 15 E. coli strains with the Vitek GNS-532 card, 14 were found to be ESBL negative, despite being originally flagged as ESBL positive. The remaining 236 ESBL-producing strains were also subjected to the double disc-diffusion (DDD) technique for the detection of ESBLs. Of these, two were false negatives by Etest ESBL test strips (using both cefotaxime and ceftazidime strips), and 38 were false negatives by the DDD method. The Etest false-negative ESBL-producing strains of K. pneumoniae were positive by DDD. Technically, the Vitek method was the least demanding method to perform, as it was an integral part of the routine susceptibility test card. Etest strips were reliable, but were the most expensive of all the techniques used. The DDD test, while relatively inexpensive, was technically subjective, and in our hands, seven of the ESBL-positive strains that were confirmed by the other two techniques were not detected. Despite the false-positive ESBL-producing E. coli strains, the Vitek susceptibility card with its integral ESBL test offers the clinical laboratory a valuable and quick option to screen for ESBL-producing Klebsiella spp. and E. coli as part of the routine laboratory methodology.

Indirect impacts of invasive cane toads (Bufo marinus) on nest predation in pig-nosed turtles (Carettochelys insculpta)

The cane toad (Bufo marinus) was introduced into Australia in 1935. Because this toxic frog is novel to the Australian fauna, its introduction has impacted native fauna in a variety of ways. We anticipated a severe decline in the yellow-spotted monitor lizard (Varanus panoptes) associated with the arrival of cane toads along the Daly River, Northern Territory, and predicted a simultaneous impact on nest predation in the pig-nosed turtle (Carettochelys insculpta) because the lizard is the chief predator of C. insculpta eggs at the site. We surveyed for monitors and cane toads for five years at two sites before and after the arrival of cane toads, and surveyed for turtle nest predation for three years before, and one year after, the arrival of the toads. Collectively, our data and observations, combined with unpublished reports, indicate that: (1) cane toads arrived at our study sites during the wet seasons of 2003–04 and 2004–05; (2) the lizard V. panoptes readily succumbs to cane toad toxins; (3) . panoptes has experienced a marked decline in relative population numbers coincident with the arrival of the toads at the site; and (4) V. panoptes has been reduced to such low numbers that it is currently no longer a significant predator of pig-nosed turtle eggs.

Assessment of quality of life in the supportive care setting of the big lung trial in non-small-cell lung cancer

PURPOSE

The Big Lung Trial (BLT) was a large, pragmatic trial to evaluate the addition of chemotherapy to primary treatment (ie, surgery, radical radiotherapy, or supportive care) in non-small-cell lung cancer (NSCLC). In the supportive care group, there was a small but significant survival benefit in patients treated with chemotherapy compared with supportive care alone (no chemotherapy). A substudy was undertaken to evaluate the quality of life (QoL) implications of the treatment options. QoL was assessed using European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaires C30 (QLQ-C30) and LC17, and daily diary cards.

PATIENTS AND METHODS

EORTC QLQ-C30 and LC17 were collected at 0, 6 to 8, 12, 18, and 24 weeks. Diary cards were completed during the first 12 weeks of the study. The primary end point was global QoL at 12 weeks.

RESULTS

A total of 273 patients were randomly assigned: 138 to no chemotherapy and 135 to chemotherapy. There was no evidence of a large detrimental effect on QoL of chemotherapy. No statistically significant differences in global QoL or physical/emotional functioning, fatigue and dyspnea, and pain were detected at 12 weeks. Higher rates of palliative radiotherapy in the no chemotherapy arm may have lessened differences in QoL. Global QoL, role functioning, fatigue, appetite loss, and constipation were prognostic indicators of survival at 12 weeks.

CONCLUSION

There were no important adverse effects of chemotherapy on QoL.

Estimation of the additional costs of chemotherapy for patients with advanced non-small cell lung cancer

BACKGROUND

A large multicentre randomised trial, the Big Lung Trial, which in part compared supportive care with or without cisplatin-based chemotherapy in patients with advanced non-small cell lung cancer, provided an opportunity to evaluate the impact on the UK National Health Service of the costs incurred with the use of chemotherapy.

METHODS

This costing study was based on the retrospective collection of resource use data from hospital records. Case notes from 194 patients (98 chemotherapy + supportive care (C), 96 supportive care alone (NoC)) were inspected in eight centres recruiting the largest numbers of patients into the Big Lung Trial. Quantities were multiplied by fixed unit costs to calculate a total cost for each patient. The main outcome measure was the total cost incurred by the use of secondary care resources (including investigations, chemotherapy, radiotherapy, surgical procedures, inpatient days, outpatient attendances, and hospice inpatient care) in the two groups.

RESULTS

Patients randomised to receive cisplatin-based chemotherapy had an average of 3.4 more inpatient bed days than the mean of 11.9 days for patients randomised to supportive care alone, and more outpatient attendances. NoC patients were more likely to have received palliative radiotherapy. The mean total cost for C patients was 5355 sterling pound compared with 3595 sterling pound for the NoC group, difference 760 sterling pound (95% CI 781 sterling pound to 2742 sterling pound ). When split, the cost in the C group associated with the administration of chemotherapy was 1233 sterling pound and non-chemotherapy costs were 4122 sterling pound .

CONCLUSION

The additional cost of chemotherapy was not offset by a reduction in subsequent costs (as the non-chemotherapy costs were similar), so the survival benefit of about 10 weeks observed in the C group was achieved with the cost of chemotherapy administration.

Dietary habits and children's family lives

PURPOSE

To investigate associations between 'less healthy eating' and 'unhealthy snacking' at age 11, and family life (family structure, meals and maternal employment status) together with potential socio-economic confounders and gender.

METHODS

Children participated in a school-based survey, questionnaires also being completed by parents. Analyses were based on those with complete data, weighted to account for bias in return of parental questionnaires (N = 2146). Data from a dietary inventory, questions on food choice and snacks were used to classify 'less healthy eating' and 'unhealthy snacking'.

RESULTS

Less healthy eating' (57%) and 'unhealthy snacking' (32%) were associated with greater deprivation, fewer maternal qualifications and being male. Compared with children of full-time homemakers, the likelihood of 'less healthy eating' was reduced among those whose mothers worked part-time (this effect remaining after socio-economic adjustment), full-time (effect removed after adjustment), or were unemployed, sick or disabled (effect emerging after adjustment). 'Unhealthy snacking' was not related to maternal employment, and neither measure was associated with family structure or daily meals.

CONCLUSIONS

There was no evidence that family structure or meals were associated with children's diets, although maternal employment had a positive association. Contrasting with the size of these effects, relationships between diet and socio-economic status were strong.

Chemotherapy versus supportive care in advanced non-small cell lung cancer: improved survival without detriment to quality of life

BACKGROUND

In 1995 a meta-analysis of randomised trials investigating the value of adding chemotherapy to primary treatment for non-small cell lung cancer (NSCLC) suggested a small survival benefit for cisplatin-based chemotherapy in each of the primary treatment settings. However, the meta-analysis included many small trials and trials with differing eligibility criteria and chemotherapy regimens.

METHODS

The aim of the Big Lung Trial was to confirm the survival benefits seen in the meta-analysis and to assess quality of life and cost in the supportive care setting. A total of 725 patients were randomised to receive supportive care alone (n = 361) or supportive care plus cisplatin-based chemotherapy (n = 364).

RESULTS

65% of patients allocated chemotherapy (C) received all three cycles of treatment and a further 27% received one or two cycles. 74% of patients allocated no chemotherapy (NoC) received thoracic radiotherapy compared with 47% of the C group. Patients allocated C had a significantly better survival than those allocated NoC: HR 0.77 (95% CI 0.66 to 0.89, p = 0.0006), median survival 8.0 months for the C group v 5.7 months for the NoC group, a difference of 9 weeks. There were 19 (5%) treatment related deaths in the C group. There was no evidence that any subgroup benefited more or less from chemotherapy. No significant differences were observed between the two groups in terms of the pre-defined primary and secondary quality of life end points, although large negative effects of chemotherapy were ruled out. The regimens used proved to be cost effective, the extra cost of chemotherapy being offset by longer survival.

CONCLUSIONS

The survival benefit seen in this trial was entirely consistent with the NSCLC meta-analysis and subsequent similarly designed large trials. The information on quality of life and cost should enable patients and their clinicians to make more informed treatment choices.

Pharyngitis clinical prediction rules: effect of interobserver agreement: a MetroNet study

OBJECTIVE

Pharyngitis clinical prediction rules improve Group A beta-hemolytic streptococcus (GABHS) diagnosis and decrease unnecessary antibiotic use, yet few studies have addressed clinician variability in assessment of sore throat signs and symptoms.

STUDY DESIGN AND SETTING

We conducted a cross-sectional study in which two clinicians examined each of 200 adult sore throat patients. Each patient had a rapid GABHS antigen test. Clinicians were blinded to each other's assessment and to the rapid antigen result. Interobserver agreement was estimated using a kappa coefficient. Effect of agreement on sensitivity, specificity, and hypothetic rapid antigen testing and antibiotic prescribing was determined for two clinical prediction rules.

RESULTS

We found moderate inter-rater reliability on sore throat history and physical assessments. Clinician agreement was associated with significantly fewer hypothetic rapid antigen tests performed.

CONCLUSION

Interobserver agreement enhances the utility of pharyngitis clinical prediction rules. Medical school and residency training should focus on correct assessment of history and physical examination components used in GABHS clinical prediction rules. Correct assessment will result in less GABHS testing and antibiotic prescriptions for sore throat patients.

Herbal product use and menopause symptom relief in primary care patients: a MetroNet study

OBJECTIVES

The four study objectives were to determine (1) the prevalence of use of four herbal product types promoted to reduce menopause symptoms (phytoestrogens, St. John's wort, Ginkgo biloba, and ginseng) among primary care patients approaching or in menopause, (2) the extent to which women who use these types of herbal products report menopause-related symptoms compared with herbal product nonusers, (3) the frequency of reported symptom reduction after use, and (4) if use was disclosed to their physicians.

METHODS

A cross-section of ethnically diverse women 40-55 years of age (35.5% African American, 60.2% Caucasian) who were recruited from eight primary care centers in Michigan to complete a self-report survey. The questionnaire included demographic items, health history, recent use of four herbal product types purported to relieve menopause symptoms and perception of symptom improvement, and interest in additional herbal product information.

RESULTS

Of 397 women, 24.9% reported taking, in the previous 6 months, at least one of the four study herbs. Herbal product use did not vary by patient demographics or health characteristics. Herbal product users reported more menopause symptoms than nonusers, and 68% of the users said that the herbs improved their symptoms; 56.4% said that their physician was aware of their herbal product use.

CONCLUSIONS

Primary care patients experiencing common menopausal symptoms are likely to use herbal products that are purported to provide menopause symptom relief, and many believe that these products improve their menopausal symptoms. Healthcare providers should be aware of patient's positive attitude, use patterns, and lack of disclosure of use of herbal medicines. Inquiry of herbal product use is another way for physicians to learn about patient self-medication of bothersome symptoms.

Real people. When hospital trustees speak, lawmakers listen to a community perspective

Because they have no economic stake in the hospitals they serve, trustees can be most effective in bringing the community's health care perspective to their legislators' attention.

Delta-conotoxin structure/function through a cladistic analysis

Delta-conotoxins are Conus peptides that inhibit inactivation of voltage-gated sodium channels. The suggestion that delta-conotoxins might be an essential component of the venoms of fish-hunting cone snails which rapidly immobilize their prey [Terlau, H., Shon, K., Grilley, M., Stocker, M., Stühmer, W., and Olivera, B. M. (1996) Nature 381, 148-151] has not been tested. On the basis of cDNA cloning, all of the fish-hunting Conus analyzed yielded at least one delta-conotoxin sequence. In addition, one delta-conotoxin isolated from the venom of Conus striatus had an amino acid sequence identical to that predicted from cDNA cloning. This new peptide exhibited properties of delta-conotoxins: it targeted sodium channels and potentiated action potentials by slowing channel inactivation. Homologous sequences of delta-conotoxins from two groups (clades) of related fish-hunting Conus species share consensus features but differ significantly from the two known delta-conotoxins from mollusc-hunting Conus venoms. Three large hydrophobic amino acids were conserved; analogues of the previously described delta-conotoxin PVIA with alanine substituted for the conserved amino acids F9 and I12 lost substantial biological activity. In contrast, both the T8A and K13A delta-conotoxin PVIA analogues, where substitutions were at nonconserved loci, proved to be biologically active. Taken together, our results indicate that a cladistic approach can identify amino acids critical for the activity of conotoxins and provide extensive information as to which amino acid substitutions can be made without significant functional consequences.

Poor but healthy? The youngest generation of Irish catholics in west Scotland

OBJECTIVE

Catholic adults in the West of Scotland, who are mainly of Irish origin, have been shown to suffer excess morbidity and mortality compared to the general population. A major contributing factor to this inequality is socio-economic disadvantage. This paper investigates the health and socio-economic position of Catholics in the youngest generation.

DESIGN

Secondary analysis of baseline data from the West of Scotland 11-16 STUDY: Teenage Health, which is a longitudinal school-based survey.

SETTING

One hundred and thirty five primary schools in Glasgow and surrounding districts.

SUBJECTS

Two thousand five hundred and eighty six final-year pupils (average age eleven years and three months), born in 1983/1984.

RESULTS

Comparing Catholics and non-Catholics on a range of indicators of general health, recent acute symptoms, chronic conditions, mental health and physical measures, we found no evidence of any systematic health inequality. A few indicators did show statistically significant differences at the five percent level, but these were not in any consistent direction. In terms of household socio-economic position, though, we found strong evidence of disadvantage for Catholics. Catholic children were more likely to have parents of manual social class, without any formal qualifications, who were less likely to own their home or a car, more likely to express difficulty 'making ends meet', and more likely to live in a deprived area.

CONCLUSIONS

We discuss the prospects for diminishing socio-economic inequality over time between Catholics and non-Catholics in this cohort, which will depend on Catholic social mobility. We consider the likelihood of enduring health equality for Catholics, which will depend on the effects of different influences on health over the life course.

Social class and smoking at age 15: the effect of different definitions of smoking

AIM

To explore whether the association between social class and smoking among teenagers varies according to the definition of smoking adopted. Design, setting and participants. A survey of 2196 15-year-olds in 43 secondary schools in the West of Scotland.

MEASURES

Current smoking status and number of cigarettes smoked, and social class based on the occupation of the head of the household.

FINDINGS

'Current smoker' was the only category not significantly differentiated by class; the ratio of smokers from unskilled compared with professional backgrounds rose with increasingly stringent definitions of smoking.

CONCLUSION

The extent to which teenage smoking is patterned by social class depends on the definition of smoking adopted.