Expression of canonical SOS genes is not under LexA repression in Bdellovibrio bacteriovorus

The here-reported identification of the LexA-binding sequence of Bdellovibrio bacteriovorus, a bacterial predator belonging to the delta-Proteobacteria, has made possible a detailed study of its LexA regulatory network. Surprisingly, only the lexA gene and a multiple gene cassette including dinP and dnaE homologues are regulated by the LexA protein in this bacterium. In vivo expression analyses have confirmed that this gene cassette indeed forms a polycistronic unit that, like the lexA gene, is DNA damage inducible in B. bacteriovorus. Conversely, genes such as recA, uvrA, ruvCAB, and ssb, which constitute the canonical core of the Proteobacteria SOS system, are not repressed by the LexA protein in this organism, hinting at a persistent selective pressure to maintain both the lexA gene and its regulation on the reported multiple gene cassette. In turn, in vitro experiments show that the B. bacteriovorus LexA-binding sequence is not recognized by other delta-Proteobacteria LexA proteins but binds to the cyanobacterial LexA repressor. This places B. bacteriovorus LexA at the base of the delta-Proteobacteria LexA family, revealing a high degree of conservation in the LexA regulatory sequence prior to the diversification and specialization seen in deeper groups of the Proteobacteria phylum.

Reconstruction of the evolutionary history of the LexA-binding sequence

In recent years, the recognition sequence of the SOS repressor LexA protein has been identified for several bacterial clades, such as the Gram-positive, green non-sulfur bacteria and Cyanobacteria phyla, or the ‘Alphaproteobacteria’, ‘Deltaproteobacteria’ and ‘Gammaproteobacteria’ classes. Nevertheless, the evolutionary relationship among these sequences and the proteins that recognize them has not been analysed.Fibrobacter succinogenesis an anaerobic Gram-negative bacterium that branched from a common bacterial ancestor immediately before the Proteobacteria phylum. Taking advantage of its intermediate position in the phylogenetic tree, and in an effort to reconstruct the evolutionary history of LexA-binding sequences, theF. succinogenes lexAgene has been isolated and its product purified to identify its DNA recognition motif through electrophoretic mobility assays and footprinting experiments. After comparing the available LexA DNA-binding sequences with theF. succinogenesone, reported here, directed mutagenesis of theF. succinogenesLexA-binding sequence and phylogenetic analyses of LexA proteins have revealed the existence of two independent evolutionary lanes for the LexA recognition motif that emerged from the Gram-positive box: one generating the Cyanobacteria and ‘Alphaproteobacteria’ LexA-binding sequences, and the other giving rise to theF. succinogenesandMyxococcus xanthusones, in a transitional step towards the current ‘Gammaproteobacteria’ LexA box. The contrast between the results reported here and the phylogenetic data available in the literature suggests that, some time after its emergence as a distinct bacterial class, the ‘Alphaproteobacteria’ lost its vertically receivedlexAgene, but received later through lateral gene transfer a newlexAgene belonging to either a cyanobacterium or a bacterial species closely related to this phylum. This constitutes the first report based on experimental evidence of lateral gene transfer in the evolution of a gene governing such a complex regulatory network as the bacterial SOS system.

Patterns of colonization by Pseudomonas aeruginosa in intubated patients: a 3-year prospective study of 1,607 isolates using pulsed-field gel electrophoresis with implications for prevention of ventilator-associated pneumonia

OBJECTIVE

To identify routes and patterns of colonization with Pseudomonas aeruginosa in intubated patients to design strategies of prevention for respiratory infection.

DESIGN AND SETTING

Prospective and observational study in the 16-bed intensive care unit of a teaching hospital.

PATIENTS AND PARTICIPANTS

Ninety-eight intubated patients were investigated over a 3-year period. Those ventilated less than 72 h were excluded.

MEASUREMENTS AND RESULTS

Samples from the tap water from each patient's room, stomach, oropharynx, subglottic secretions, trachea, and rectum were collected when the patient was intubated, and then three times per week. Pulsed-field gel electrophoresis was performed to type the strains. We identified 1,607 isolates pertaining to 35 different pulsotypes. Overall 54.2% of patients presented colonization, and tracheal colonization was present in 30.5%. Ten patients had colonization at intubation, and four of these developed ventilator-associated pneumonia (VAP) after a mean of 4+/-2 days. ICU-acquired colonization occurred in 31 patients, and 4 of these developed VAP after a median of 10+/-5 days. P. aeruginosa was isolated from the room's tap water in 62.4% of samples. More than 90% of tap water samples had pulsotypes 1 and 2, which were frequently isolated in the stomach (59%) but were only rarely associated with VAP.

CONCLUSIONS

Although colonization/infection with P. aeruginosa in intubated patients tends to be endogenous, exogenous sources should not be ruled out. A combination of early identification (and eradication) of airways colonization by P. aeruginosa plus infection control measures targeted to reduce cross-contamination should be the basis to prevent pulmonary infection.

LexA-independent DNA damage-mediated induction of gene expression in Myxococcus xanthus

Myxococcus xanthus, a member of the Proteobacteria delta-class, has two independent recA genes, recA1 and recA2, but only recA2 is DNA damage-inducible. The lexA gene has been isolated from M. xanthus by PCR amplification with oligonucleotides designed after sequence identification by tblastn analysis of its genome at the Cereon Microbial Sequence Database. The M. xanthus purified LexA protein is shown to bind specifically to the consensus sequence CTRHAMRYBYGTTCAGS present upstream of lexA and recA2. A degenerate copy of this motif but with important differences can be identified in the region upstream of the recA1 gene. A knock-out lexA(Def) mutant that has been generated does not differ significantly from wild type in morphology, growth rate, light-induced carotenogenesis or development. Using transcriptional lacZ fusions and quantitative RT-PCR analysis, it has been demonstrated that expression of both lexA and recA2 genes is constitutive in the lexA(Def) mutant, whereas the transcription of the DNA damage non-inducible recA1 gene is not affected in this strain. recN and ssb, whose expression in Escherichia coli are LexA-regulated, are induced by DNA damage in the M. xanthus lexA(Def) mutant. These data reveal the existence of different regulatory mechanisms for DNA damage-inducible genes in bacteria belonging to different phyla.

[An outbreak of gram-negative bacteremia (GNB), especially enterobacter cloacae, in patients with long-term tunnelled haemodialysis catheters]

Vascular access through a venous catheter for haemodialysis is associated with increased risk of thrombosis, central venous stenosis, short access survival and inadequate dialysis. The most important catheter-related complications, which determine method survival, are infection and dysfunction. In particular, infectious episodes are in some studies the leading cause for untimely catheter removal and for catheter-related morbidity but also for morbidity in dialysis patients. Double-lumen central venous catheters used for haemodialysis, are common causes of septicaemia. Most cases are caused by staphylococci. Episodes of gram-negative bacteriemia have been traced to bacterial contamination of water and/or dialysate, errors in dialyzer reprocessing, and improper setup procedures. In this paper, we describe and outbreak of gram-negative bacteremia, firstly E. cloacae, in an outpatients haemodialysis unit, in the patients with long-term tunnelled haemodialysis catheters. We describe the epidemic investigation that we achieved to identify the source of contaminating bacteria and the route by which bacteria gained access to the bloodstream. We prove the contamination by gram-negative bacterium of the water-distribution lines and haemodialysis machines. Moreover, E. cloacae strains isolated from the lines and machines are genotypically identical to the isolated from the patients. Also, we prove that the hands of health care personnel are unintentional carriers. The outbreak was finished when decontamination of dialysis machines was enhanced and dialyzer-priming fluid was modified.

Presence of polyclonal Pseudomonas aeruginosa in an intensive care unit: a 27-month prospective study on molecular epidemiology

Pseudomonas aeruginosa was isolated in 22.2% of 305 intensive care unit environmental cultures. A high genetic heterogeneity (18 pulsotypes) was evident. Taps and related surfaces were a stable reservoir for certain pulsotypes. The 15.4% of the P. aeruginosa-positive cultures were polyclonal. Different colony morphotypes should be assayed in surveillance studies.

Thermal inactivation of the plasma membrane H+-ATPase from Kluyveromyces lactis. Protection by trehalose

The activity of the isolated plasma membrane H+-ATPase from Kluyveromyces lactis was measured during incubation at 35-45 degrees C and in the absence or in the presence of 0-0.6 M trehalose. As the temperature of incubation was raised from 35 to 45 degrees C, increasing enzyme inactivation rates were observed. Thermal inactivation kinetics of the H+-ATPase were biphasic exhibiting a first rapid phase and then a second slow phase. The transition from the native state occurred through a temperature-mediated increase in the inactivation rate constants of both phases. A model is proposed where the native H+-ATPase yields a partially active intermediary during the first phase of inactivation and then the intermediary is slowly converted into a totally inactive enzyme in the second phase. At each of these temperatures trehalose protected the enzymatic activity in a concentration dependent manner. Full protection was observed at 0.6 M trehalose in the range of 35-40 degrees C. Whereas, at 42 and 45 degrees C, the trehalose-mediated thermoprotection of the H+-ATPase was only partial. Trehalose stabilized the enzyme mainly by preventing the temperature dependent increase of the first and second inactivation rate constants.

[Excess of mineralocorticoids in essential hypertension: clinical-diagnostic approach]

BACKGROUND

Primary hyperaldosteronism is more frequent among subjects with essential hypertension than previously thought. The prevalence, according to local and international evidence could fluctuate between 9 and 10%.

AIM

To investigate if subjects with essential hypertension have different aldosterone and renin plasma levels than normotensive subjects.

PATIENTS AND METHODS

One hundred twenty five subjects with essential hypertension, not receiving medications for at least two weeks prior to the study and 168 age and sex matched normotensive controls were studied. Blood was drawn between 9 and 10 AM during a sodium free diet to determine plasma aldosterone, plasma renin activity and potassium.

RESULTS

Plasma aldosterone was higher in hypertensive subjects than controls (11.6 +/- 7.6 and 9.9 +/- 5.1 ng/dl respectively; p = 0.04). Plasma renin activity was lower in hypertensives than controls (1.42 +/- 1.28 and 1.88 +/- 1.39 ng/ml/b respectively; p < 0.001). Thus, plasma aldosterone/plasma renin activity ratio was higher in hypertensives (13.8 +/- 13.5 and 8.3 +/- 7.8; p < 0.001). A pathological ratio was defined as over 25, corresponding to the mean plus two standard deviations of the control group. Primary hyperaldosteronism was found in 5/125 hypertensives (4%) and 1/168 normotensive subject (0.6%). None had hypokalemia.

CONCLUSIONS

Subjects with essential hypertension have higher plasma aldosterone and lower plasma renin activity than normal controls. A plasma aldosterone/plasma renin activity over 25 was defined as abnormal.

Primary hyperaldosteronism in essential hypertensives: prevalence, biochemical profile, and molecular biology

There is evidence that primary aldosteronism (PA) may be common in patients with essential hypertension (EH) when determinations of serum aldosterone (SA), plasma renin activity (PRA), and the SA/PRA ratio are used as screening. An inherited form of primary hyperaldosteronism is the glucocorticoid-remediable aldosteronism (GRA) caused by an unequal crossing over between the CYP11B1 and CYP11B2 genes that results in a chimeric gene, which has aldosterone synthase activity regulated by ACTH. The aim of this study was to evaluate the prevalence of PA and the GRA in 305 EH patients and 205 normotensive controls. We measured SA (1-16 ng/dL) and PRA (1-2.5 ng/mL x h) and calculated the SA/PRA ratio in all patients. A SA/PRA ratio level greater than 25 was defined as being elevated. PA was diagnosed in the presence of high SA levels (>16 ng/dL), low PRA levels (<0.5 ng/mL x h), and very high SA/PRA ratio (>50). Probable PA was diagnosed when the SA/PRA ratio was more than 25 but the other criteria were not present. A Fludrocortisone test was done to confirm the diagnosis. GRA was differentiated from other forms of PA by: the aldosterone suppression test with dexamethasone, the high levels of 18-hydroxycortisol, and the genetic detection of the chimeric gene. In EH patients, 29 of 305 (9.5%) had PA, 13 of 29 met all the criteria for PA, and 16 of 29 were initially diagnosed as having a probable PA and confirmed by the fludrocortisone test. Plasma potassium was normal in all patients. The dexamethasone suppression test was positive for GRA in 10 of 29 and 18-hydroxycortisol levels were high in 2 of 29 patients who had also a chimeric gene. In normotensive subjects, 3 of 205 (1.46%) had PA, and 1 of 205 had a GRA. In summary, we found a high frequency of normokalemic PA in EH patients. A high proportion of PA suppressed SA with dexamethasone, but only a few had a chimeric gene or high levels of 18-hydroxycortisol. These results emphasize the need to further investigate EH patients.

Comparison of IS1245 restriction fragment length polymorphism and pulsed-field gel electrophoresis for typing clinical isolates of Mycobacterium avium subsp avium

SETTING

Little is still known about the epidemiology and pathogenesis of Mycobacterium avium subsp avium (MASA) infection.

OBJECTIVE

Examination of the reproducibility and the stability over time of pulsed-field gel electrophoresis (PFGE) and IS1245 restriction fragment length polymorphism (IS1245-RFLP) techniques. The ability of these typing systems for differentiating clinical isolates of MASA was also assessed.

DESIGN

Clinical isolates recovered from 63 patients (59 human immunodeficiency virus [HIV] positive and four HIV-negative) were studied by insertion sequence IS1245 and PFGE. For the study of in vivo and in vitro stability, strains collected over time from four patients and five strains chosen at random, respectively, were used.

RESULTS

The stability of PFGE and IS1245-RFLP in vitro was excellent. PFGE was also stable in vivo, but IS1245-RFLP patterns showed some variation. The discriminatory power of IS1245-RFLP and PFGE was 0.995 and 0.989, respectively. The cluster analysis did not reveal differences between strains recovered from HIV-negative and HIV-positive patients or between patients with colonisation, local infection or disseminated disease.

CONCLUSION

IS1245-RFLP and PFGE are useful tools for typing MASA strains. However, IS1245 variations in vivo may complicate the analysis of epidemiological relationships.

Interactions of arsenate, sulfate and phosphate with yeast mitochondria

In the presence of K(+), addition of ATP or ethanol to yeast mitochondria triggers the depletion of the transmembrane potential (DeltaPsi) and this is prevented by millimolar concentrations of phosphate (PO(4)). Different monovalent and polyvalent anions were tested for their protective effects on mitochondria from Saccharomyces cerevisiae. Only arsenate (AsO(4)) and sulfate (SO(4)) were as efficient as PO(4) to protect mitochondria against the K(+) mediated swelling, depletion of the DeltaPsi, and decrease in the ratio of uncoupled state to state 4 respiration rates. Protection by PO(4), SO(4) or AsO(4) was inhibited by mersalyl, suggesting that these anions interact with a site located in the matrix side. In addition, the effects of SO(4) and AsO(4) on the F(1)F(0)-ATPase were tested: both SO(4) and AsO(4) inhibited the synthesis of ATP following competitive kinetics against PO(4) and non-competitive kinetics against ADP. The mersalyl sensitive uptake of (32)PO(4) was not inhibited by SO(4) or AsO(4), suggesting that the synthesis of ATP was inhibited at the F(1)F(0)-ATPase. The hydrolysis of ATP was not inhibited, only a stimulation was observed when AsO(4) or sulfite (SO(3)) were added. It is suggested that the structure and charge similarities of PO(4), AsO(4) and SO(4) result in undiscriminated binding to at least two sites located in the mitochondrial matrix: at one site, occupation by any of these three anions results in protection against uncoupling by K(+); at the second site, in the F(1)F(0)-ATPase, AsO(4) and SO(4) compete for binding against PO(4) leading to inhibition of the synthesis of ATP.

[Echinococcosis/hydatidosis in the VII Region of Chile: diagnosis and educational intervention]

This study was designed to embrace three areas: a) serologic and radiologic diagnosis and surgical treatment of hydatidosis in an asymptomatic human population, b) animal diagnosis and the treatment of dogs, and c) evaluation of extent of knowledge and performance of educational interventions among rural families and health, livestock, and education professionals and technicians, in order to help control the disease transmission cycle. Indirect hemagglutination and ELISA tests were performed on 5,556 apparently healthy people. Of these, 42 (0.8%) had positive results on both tests, for a seroprevalence of 754.6 per 100,000. These 42 subjects were scheduled for liver ultrasonography and a chest x-ray; of the 26 who complied, 16 showed images compatible with a hydatid cyst. Those 16 cases were sent to the hospital for surgery. In 9 of the cases the diagnosis was confirmed surgically, for a prevalence of 161.7 per 100,000. Arecoline hydrobromide was administered as a laxative to 2,358 dogs to detect the strobilar form of Echinococcus granulosus, and positive results were found in 11% of the dogs. Official data for slaughterhouses indicated the presence of hydatid cysts in 13% of the cattle, 4.4% of the sleep, and 4.2% of the pigs slaughtered in the region. The educational program included an evaluation of the extent of knowledge by surveying heads of household; an educational intervention among families through an informal active participatory process using educational games, in which 1,082 families participated; and an educational intervention with professionals and technicians using distance and in-person approaches. To evaluate the program, the results of knowledge tests before and after educational interventions with 200 families (cases) were compared with those from 95 families who did not participate (controls). Of the 1,423 heads of household initially surveyed about their knowledge of echinococcosis/hydatidosis, 783 of them (55%) said they knew nothing about the infection. It was found that the participatory educational games were well adapted to the lifestyle of people from rural areas and made change possible. Training was provided to 276 health professionals, 201 technical assistants, and 453 rural teachers. The program reached 100% of the staff members of the area's rural primary health care services.

A(-6)G variant of angiotensinogen gene and aldosterone levels in hypertensives

Recently, a novel mutation in the promoter region of the angiotensinogen gene that involves the presence of an adenine instead of a guanine 6 bp upstream from the transcription initiation site (A(-6)G) has been shown to induce an increase in gene transcription. The aim of this study was to determine the prevalence of the A(-6)G mutation in essential hypertensive patients and to correlate it with aldosterone and renin activity levels. We studied 191 hypertensives. We measured levels of aldosterone (plasma and urinary) and plasma renin activity. We determined the variants A and G using a mutagenically separated polymerase chain reaction technique. In 191 hypertensives, the A variant was detected in 266 of 382 (69.6%) and the G variant in 116 of 382 alleles (30.4%). Plasma aldosterone was significantly higher in patients homozygous for AA than in those homozygous for GG (369+/-208 versus 246+/-142 pmol/L). Urinary aldosterone was significantly higher in homozygous AA than in AG or GG patients (62.4+/-39.4 versus 50.8+/-25.2 and 37.4+/-22.3 nmol/d, respectively). When the patients were grouped according to the presence or absence of the A allele, the aldosterone levels and the plasma aldosterone/plasma renin activity ratio were significantly higher in patients with the A allele. The presence of the A variant was associated with higher levels of aldosterone. These results suggest that the presence of the A variant could determine the appearance of arterial hypertension through higher transcription activity of the angiotensinogen gene and concomitant aldosterone production.

Long-term follow-up of patients with biliary atresia successfully treated with hepatic portoenterostomy. The importance of sequential treatment

The outcome of 18 biliary atresia (BA) patients (5 male, 13 female; age range 10.7-22.5 years; mean 15.4+/-0.7 years) treated with hepatic portoenterostomy (HPE) and jaundice-free for more than 10 years without liver transplantation (LT) is analyzed retrospectively. Eight of these patients subsequently required LT (age at LT 12. 8+/-0.5 years, range 10.5-15.2 years); 3 children (aged 11.6, 13.2 and 14.1 years, respectively) had episodes of gastrointestinal variceal bleeding associated with other signs of severe disease and are now candidates for LT; and among the 7 asymptomatic patients (age range 11.2-22.5 years; mean 15.9+/-2.1 years), 5 had sonographic and biochemical signs of moderate portal hypertension (PH). In order to analyze whether the age at transplantation influences the survival of children transplanted for BA, we also reviewed the outcome of 71 BA patients transplanted at our hospital between 1986 and 1996. All the children older than 10 years at the time of LT were alive; only patients younger than 10 years died following LT (n = 15). We conclude that the natural outcome of extrahepatic BA is toward PH, fibrosis, and cirrhosis, even in those cases successfully treated with HPE. In our experience, the results of sequential treatment with HPE and LT were excellent.

Treatment of chronic Chagas' disease with itraconazole and allopurinol

Four hundred four patients with chronic Chagas' disease were treated with itraconazole (6 mg/kg of body weight/day for 120 days), allopurinol (8.5 mg/kg of body weight/day for 60 days), or with a placebo of pure starch. Patients were monitored over a period of four years by clinical examination, serology, xenodiagnosis, hemoculture, and electrocardiogram. Drug tolerance was good, with only four treatments discontinued due to side effects that subsided after suspension of treatment. Parasitologic cure was evident in 44% of the those treated with allopurinol and 53% of those treated with itraconazole, and the electrocardiographic evaluation showed normalization in 36.5% and 48.2%, respectively, of patients with chronic or recent cardiopathy.

Syndrome of Alagille: radiological and sonographic findings. A review of 37 cases

The objective of this study was to evaluate the association of intrahepatic cholestasis, pulmonary stenosis, and hyperlipemia with osseous and renal abnormalities in Alagille's syndrome. A total of 37 patients (25 males and 12 females) with ages ranging between 8 months and 27 years were included. Clinical records as well as radiological and ultrasonographic studies were reviewed. Chronic cholestasis was observed in all patients. Thirteen had favorable clinical outcome and normal hepatic sonograms. Clinical and sonographic evidence of portal hypertension was found in 13 patients and of cirrhosis in 8 patients. The remaining 3 patients required hepatic transplantation due to severe cholestasis. Hyperlipemia correlated with hepatic malfunction. Pulmonary stenosis and renal hypoplasia were the most frequently associated abnormalities. All patients showed a peculiar facies. Abnormal "butterfly" vertebrae were present in 18 patients and ulnar or phalangeal shortening in 11 patients. Ultrasonography allowed hepatobiliary disease assessment and helped to establish indications for hepatic transplantation. Renal and osseous abnormalities were not specific but in the appropriate clinical setting reinforced the diagnosis.

Detection and characterization by immunoblot analysis of potentially diagnostic Leishmania infantum polypeptides in human visceral leishmaniasis

Humoral immune responses were studied in 53 sera from 18 patients with visceral leishmaniasis by immunoblot analysis. Sera from visceral leishmaniasis patients recognized antigens with molecular weights ranging from < 14 kDa to more than 100 kDa. Bands ranging between 49 and < 14 kDa were the most specific. The 40, 33 and 17 kDa antigens were recognized by 90%, 79% and 79% of the patients sera, respectively. Sera from one patient with Chagas' disease identified 8 of 11 antigens of the specific region. Treatment with periodate eliminated the cross-reaction in three of these antigens (40, 29, 26 kDa). The study of serial sera collected from the different patients showed a decrease in intensity or dissappearance in some of the diagnostic bands, particularly the 17 kDa band. The band of 17 kDa seems to be useful to study the clinical evolution, for post-treatment control and also for epidemiologic purposes. (It has been identified in 7% of control sera from endemic areas.) Immunoblot could be a valuable tool in the diagnosis of visceral leishmaniasis, being more sensitive and specific than other serologic tests.

[Treatment of chronic human Chagas disease with itraconazole and allopurinol. Preliminary report]

The aim of this work was to assess the efficacy of itraconazole and allopurinol in chronic Chagas disease. Two hundred two subjects (137 infected, 59 with Chagas cardiopathy and 6 with non chagasic cardiopathy) were randomly assigned to be treated with itraconazole (87 subjects receiving 6 mg/kg/day for 120 days), allopurinol (68 subjects receiving 8.5 mg/kg/day for 60 days) or placebo (47 subjects during 60 days). Medications were well tolerated. Indirect hemagglutination test was modified in 5 subjects (3.2%) after treatment. Initially positive xenodiagnosis became negative in 34 of 36 subjects (94.4%) treated with itraconazole and 8 of 10 subjects (80%) treated with allopurinol. Initially normal EKG was not modified in 100% of patients receiving placebo, 84.9% receiving itraconazole and 86.7% receiving allopurinol. Initially abnormal EKG became normal in 10 of 31 subjects (32%) receiving itraconazole, 8 of 20 (40%) receiving allopurinol and none of 8 receiving placebo. It is concluded that xenodiagnosis and EKG improvements indicate that itraconazole and allopurinol have a role in the treatment of chronic Chagas disease. A 36 months follow up of these patients will help to confirm this conclusion.

[Request for a hemogram as a marker of the quality of health care]

The evaluation of markers of the health care activity, such as the reason for requesting a peripheral blood count in everyday practice and its inclusion in the clinical record, constitutes an estimate of the quality of care. To this end, we have reviewed the requests of 160 peripheral blood counts in our center during one month. It was found that the request itself and/or its cause had not been mentioned in the clinical record in 32.5% of instances. In the cases where the indication could be ascertained, it was not justified in 58.4%. Overall 72.5% of peripheral blood counts were normal. It was concluded that peripheral blood count is an over-utilized test, while its request is insufficiently recorded. This makes diagnostic decisions and the evaluation of the quality of care difficult.