The presence and significance of the Pi class glutathione S-transferase isoenzyme in cerebrospinal fluid during the course of meningitis in children

A rise in the concentration of the Pi class isoenzyme of glutathione S-transferase (GST) in the cerebrospinal fluid (CSF) during meningitis may be an early indicator of inflammation and cell damage. Pi class GST concentrations were measured in 48 samples of CSF from 46 children with proven or suspected meningitis using a commercially available immunoassay. Forty-four fetal brain samples were assayed by isoelectric focusing to determine the nature and number of isoenzymes likely to be released. Twenty-four percent of children had measurable amounts of the isoenzyme in their CSF during the initial stages of the disease. One child, for whom CSF samples were taken pre-, mid-, and post-antibiotic treatment, had measurable Pi class GST in the CSF only in the mid-treatment sample, when bacterial lysis and inflammation are likely to be at their peak. Where follow-up data were available, two of three children with measurable Pi class GST in their CSF at the initial stages had recordable disabilities at 5 y of age compared with 4 of 11 of those in whom no Pi class GST was detected. Two proteins analogous to Pi class GST were detected in frozen brain tissue, but only one was active with a known substrate; only the active protein was seen in fresh tissue. We conclude that 1) initial high levels of CSF Pi class GST may be an indicator of the severity of inflammation and thus of prognostic significance and 2) only one Pi class GST occurs in brain tissue.

Pathophysiology of CML: do defects in integrin function contribute to the premature circulation and massive expansion of the BCR/ABL positive clone?

Hematopoiesis takes place in close contact with the marrow microenvironment. Normal progenitors adhere through a variety of receptors to stroma and extracellular matrix components, including fibronectin. Adhesion through beta1-integrin receptors to fibronectin not only anchor progenitors to the stroma but also result in direct adhesion-mediated signaling that inhibits progenitor proliferation. In contrast to normal hematopoiesis, chronic myelogenous leukemia (CML) is characterized not only by abnormal, premature circulation of primitive progenitors in the blood but also by continuous progenitor proliferation. Although CML progenitors express the same integrin receptors as normal progenitors, they fail to adhere to stroma and fibronectin, suggesting structural or functional abnormalities of these receptors. Furthermore, CML cells present in contact with stroma or fibronectin continue to proliferate, suggesting that failure to adhere through integrin receptors may also underlie the abnormal proliferation of CML progenitors. The observation that integrin-mediated adhesion and proliferation-inhibitory signaling can be restored through treatment with interferon-alpha or an activating anti-beta1-integrin antibody suggests a functional rather than structural defect that may be related to the presence of the BCR/ABL gene rearrangement in these cells. Insights into the role of integrins as adhesion molecules but also receptors that instruct hematopoietic progenitors to survive, proliferate, and possibly differentiate will not only further our understanding of the normal hematopoietic process but also provide insights into diseases characterized by deranged adhesion and proliferation that may lead to novel therapeutic approaches.

The role of managed care "products" in managed care "plans"

This paper presents information about the form and structure of managed care products offered by group/staff health maintenance organizations (HMOs), network/independent practice association (IPA) HMOs, and preferred provider organizations (PPOs). The information comes from a 1994 national survey of managed care plans and their arrangements with physicians. The findings confirm that multiple product offerings are now common in managed care plans. The two reasons plans most often cite for including these expanded offerings are to respond to customer interest and to ease the transition to more traditional managed care. Though plans commonly use a consistent provider network for different products, they also vary some arrangements with physicians across their products and pay them in different ways. We discuss the implications of our findings-the most comprehensive study of these issues to date-to aid in understanding the evolution of markets and of managed care, and as a basis for the design of future research and the databases it will require.

Anonymous questionnaire survey on the knowledge and practices of hospital staff in infection control

We carried out an anonymous questionnaire survey to assess the extent to which hospital medical and nursing staff were familiar with the written policies and procedures of infection control and their intended course of action in situations where no formal policies were available. All 25 full-time medical staff below the grade of consultant and 70 of 163 permanent nursing staff caring for inpatients at one day shift were sampled. Nineteen (76%) medical and 56 (80%) nursing staff returned their copies. Nurses were significantly more familiar with all written policies and procedures than medical staff. They were also more likely to seek advice in situations where there were no written guidelines. Many hospital staff were uncertain about the practical details of policies and procedures for infection control. Ways to educate and motivate staff to comply with infection control measures are urgently required; some degree of national standardization of policies and procedures in infection control is desirable.

Integrin-mediated regulation of hematopoiesis: do BCR/ABL-induced defects in integrin function underlie the abnormal circulation and proliferation of CML progenitors?

Hematopoiesis takes place in close contact with the marrow microenvironment. Normal progenitors adhere through a variety of receptors to stroma and extracellular matrix components, including fibronectin. Adhesion through integrins to fibronectin may not only serve to anchor progenitors to the microenvironment but also to directly alter the proliferative behavior of normal hematopoietic progenitors. Chronic myelogenous leukemia (CML) is a malignant disease of the hematopoietic stem cell. At the molecular level, CML is characterized by the BCR/ABL gene rearrangement which encodes for the oncoprotein, p210bcr-abl. Presence of the p210bcr-abl tyrosine kinase is necessary and sufficient for the malignant transformation of hematopoietic cells. Clinically, CML is characterized by an abnormal, premature release of primitive progenitors and precursors in the blood and by the continuous proliferation of the malignant progenitor population. In vitro, CML progenitors fail to adhere to or be regulated by marrow stroma. Since CML progenitors express similar numbers of integrin adhesion receptors as normal progenitors, functional rather than quantitative differences of these receptors on CML progenitors may be responsible for the abnormal circulation and proliferation of the malignant clone. In this manuscript we will review the role of integrin adhesion receptors present on normal hematopoietic progenitors in the regulation of their proliferation and discuss signal transduction mechanisms that may be responsible for these effects. We will also discuss the integrin defect in CML which may be caused by the presence of the oncoprotein, P210bcr-abl, and may explain the abnormal trafficking and proliferation observed in CML.

Chronic proliferative hepatitis in A/JCr mice associated with persistent Helicobacter hepaticus infection: a model of helicobacter-induced carcinogenesis

Helicobacter hepaticus causes hepatitis in selected strains of mice and in A/JCr mice is linked to liver cancer. To analyze whether H. hepaticus persists in specified ecological niches, to determine whether biomarkers of infection exist, and to analyze the influence of H. hepaticus on hepatocyte proliferation, a longitudinal study of H. hepaticus-infected A/JCr mice was undertaken. A/JCr mice were serially euthanatized from 3 through 18 months and surveyed by enzyme-linked immunosorbent assay; bacterial culture of liver, colon, and cecum; histology; electron microscopy; hepatocyte proliferation indices determined by using 5-bromo-2'-deoxyuridine; and measurement of the liver enzyme alanine aminotransferase. In infected animals throughout the 18-month study, H. hepaticus was consistently isolated from the lower bowel but only sporadically from the liver. By electron microscopy, H. hepaticus was noted infrequently and only in bile canaliculi. Infected mice, particularly males, showed chronic inflammation; oval cell, Kupffer cell, and Ito cell hyperplasia; hepatocytomegaly; and bile duct proliferation. The inflammatory and necrotizing lesion was progressive and involved the hepatic parenchyma, portal triads, and intralobular venules. Hepatic adenomas were noted only in male mice, whereas 5-bromo-2'-deoxyuridine proliferation indices were markedly increased in both sexes, but especially in males, compared to control A/J mice. Infected mice also developed sustained anti-H. hepaticus serum immunoglobulin G antibody responses and elevated alanine aminotransferase levels. H. hepaticus, which persists in the lower bowels and livers of A/JCr mice, is associated with a chronic proliferative hepatitis, and hepatomas in selected male mice indicate that this novel bacterium may cause an increased risk of hepatic cancer induction in susceptible strains of mice. This murine model should prove useful in dissecting the molecular events operable in the development of neoplasms induced by bacteria belonging to this expanding genera of pathogenic Helicobacter species.

A national survey of the arrangements managed-care plans make with physicians

BACKGROUND

Despite the growth of managed care in the United States, there is little information about the arrangements managed-care plans make with physicians.

METHODS

In 1994 we surveyed by telephone 138 managed-care plans that were selected from 20 metropolitan areas nationwide. Of the 108 plans that responded, 29 were group-model or staff-model health maintenance organizations (HMOs), 50 were network or independent-practice-association (IPA) HMOs, and 29 were preferred-provider organizations (PPOs).

RESULTS

Respondents from all three types of plan said they emphasized careful selection of physicians, although the group or staff HMOs tended to have more demanding requirements, such as board certification or eligibility. Sixty-one percent of the plans responded that physicians' previous patterns of costs or utilization of resources had little influence on their selection; 26 percent said these factors had a moderate influence; and 13 percent said they had a large influence. Some risk sharing with physicians was typical in the HMOs but rare in the PPOs. Fifty-six percent of the network or IPA HMOs used capitation as the predominant method of paying primary care physicians, as compared with 34 percent of the group or staff HMOs and 7 percent of the PPOs. More than half the HMOs reported adjusting payments according to utilization or cost patterns, patient complaints, and measures of the quality of care. Ninety-two percent of the network or IPA HMOs and 61 percent of the group or staff HMOs required their patients to select a primary care physician, who was responsible for most referrals to specialists. About three quarters of the HMOs and 31 percent of the PPOs reported using studies of the outcomes of medical care as part of their quality-improvement programs.

CONCLUSIONS

Managed-care plans, particularly HMOs, have complex systems for selecting, paying, and monitoring their physicians. Hybrid forms are common, and the differences between group or staff HMOs and network or IPA HMOs are less extensive than is commonly assumed.

Pyrolysis mass spectrometry of cephalosporin-resistant Enterobacter cloacae

Thirteen clinical and four environmental isolates of third-generation cephalosporin-resistant Enterobacter cloacae (CREC) together with single isolates from the hands of a nurse and from a blood gas analyser were associated with two clusters of nosocomial infection. With an unrelated CREC isolate they had been typed by serotype, biotype, ribotype and phage-type and were examined by pyrolysis mass spectrometry (PYMS) as described here. PYMS data yielded two clusters, major and minor. All except one isolate in the major cluster corresponded to type group identity (serotype 07, biotype 62, ribotype D) which had caused neonatal sepsis and colonization. Multivariate analysis showed a homogeneous group consisting of this strain plus two outliers. The minor cluster included four different strains, one of which, serotype 03, biotype 62, ribotype C had caused excoriation of the buttocks and colonization.

Maternal serum human chorionic gonadotrophin during early pregnancy resulting in boys with hypospadias or cryptorchidism

OBJECTIVE

To compare maternal serum human chorionic gonadotrophin (hCG) samples before 18 weeks gestation in mothers of boys with cryptorchidism or hypospadias with that in mothers of normal boys. The effect of season on maternal hCG was also assessed.

SUBJECTS AND METHODS

Stored serum samples from mothers of singleton male fetuses born between January 1988 and December 1992 were assayed for total hCG, using a Delfia assay. There were 153 eligible samples from 96 mothers of normal boys, 31 of those with cryptorchidism, and 26 of those with hypospadias.

RESULTS

The data from mothers of normal boys were used to construct a time-specific reference range for hCG. Plotting the hCG levels of the other groups and superimposing the reference range showed no significant difference between them (P = 0.09). Maternal hCG was not significantly different between cryptorchid boys requiring orchidopexy and those experiencing early spontaneous descent. An analysis of covariance allowing for gestational age showed that maternal hCG is significantly higher during the peak summer than peak winter months (P = 0.046).

CONCLUSION

While a seasonal effect on maternal hCG was demonstrated our data does not suggest this to be the sole cause for cryptorchidism or hypospadias or to account for the observation that both have a seasonal frequency.

Behind the curve: a critical assessment of how little is known about arrangements between managed care plans and physicians

Extraordinary growth in managed care arrangements over the past decade has been both widely praised and criticized. Proponents and critics agree that the nature of medical practice is being profoundly altered by this growth, even if they cannot articulate the direction and consequences of this change. We explore the roots of this uncertainty by examining the available evidence on critical features of the arrangements managed care plans currently have with affiliated physicians. Our approach is to review and synthesize the literature in several key substantive areas from a broad range of sources. We found that existing knowledge is dated, derived form a limited subset of plans, inattentive to important structural differences between plans, and responsive to a very narrow set of issues poorly reflecting the range of medical practice and change introduced by managed care. We highlight key questions of interest and the knowledge gaps critical to address so that policy and management decisions can both reflect and be informed on these issues that define the arrangements managed care plans make with physicians and ultimately influence medical practice.

A reappraisal of chloramphenicol metabolism: detection and quantification of metabolites in the sera of children

Seventy-four samples of serum from 27 children (age range: 26 weeks preterm to 12 y) treated with chloramphenicol for serious infections, were analyzed by high performance liquid chromatography (HPLC) for the presence of chloramphenicol metabolites. Five, including a previously unreported human metabolite--chloramphenicol aldehyde, were detected and identified by comparative HPLC, enzymic degradation or gas chromatography followed by mass spectrometry. The presence of these metabolites in the serum suggests that the biotransformation of chloramphenicol takes place by oxidation, reduction and conjugation and not by conjugation alone, as has been previously supposed. Sera from 84% of the patients contained one or more metabolites, however the presence of particular compounds did not correlate with toxicity in the four patients in whom this was observed.

Metabolism of chloramphenicol by glutathione S-transferase in human fetal and neonatal liver

The glutathione S-transferases of human fetal and neonatal liver catalyse the conjugation of glutathione with chloramphenicol at a low but measurable rate. The highest rates were 1.30 nmol/min/mg protein in a preterm neonate of 26 weeks of gestation and 1.11 nmol/min/mg in a fetus of 22 weeks of gestation, while the lowest measurable was 0.1 nmol/min/mg in a fetus of 17 weeks of gestation. The activity did not correlate with gestational age, but appeared dependent on the concentration of glutathione in the reaction mixture. The rate rose by a factor of three, from 0.39 nmol/min/mg protein with no added glutathione to 1.24 nmol/min/mg with 2 mumol/ml added to the reaction mixture. Chloramphenicol-aldehyde was detectable in the reaction mixture when a liver extract was incubated with glutathione but the proposed intermediate, glutathione-chloramphenicol, could not be demonstrated. Differences in activity with chloramphenicol or a model substrate, under varying conditions, indicate that different isoenzymes are concerned with the conjugation of glutathione to the two substrates. These data support the hypothesis that when glucuronide conjugation is depressed by immaturity, chloramphenicol is metabolised via other pathways.

Measurement of fetal plasma levels of glutathione S-transferase B1 as an indicator of damage to the liver caused by hypoxia in utero

Glutathione S-transferase B1 (GST B1) concentration in blood and amniotic fluid from fetuses investigated for a variety of conditions including rhesus (Rh) allo-immunisation was assessed for its usefulness as a measure of liver damage caused by hypoxia in utero. The concentration in blood from the intrahepatic vein (IHV) was 10-fold higher than that from the placental cord insertion suggesting that parenchymal liver cells are damaged during blood sampling from the IHV. As a measure of hepatocellular impairment caused by intra-uterine hypoxia, levels were higher in frankly acidotic fetuses than in normally managed Rh fetuses. The degree of hypoxia required to trigger the release of GST B1 into the plasma remains unclear.

Enterobacter cloacae in a neonatal intensive care unit: account of an outbreak and its relationship to use of third generation cephalosporins

After uneventful use of cefotaxime and ceftazidime as first line therapy for three years in our neonatal intensive care unit we isolated cephalosporin-resistant Enterobacter cloacae (CREC) strains which caused clusters of cases or colonization and/or serious neonatal infection. By using two or more typing methods, at least five different strains with similar patterns of antimicrobial sensitivities were identified. The results of a case-control study did not support the notion that the use of third generation cephalosporins was associated with colonization and infection by CREC. The outbreak was brought under control by interrupting the transmission of the epidemic strain D, by measures such as cohort nursing, diligent handwashing before and after procedures, and thorough environmental cleaning as well as by decontamination with glutaraldehyde after dismantling of the blood gas analyser believed to have acted as a persistent reservoir. Our experience highlights the danger of inadequate supervision and maintenance of equipment used for near-patient testing and the need to monitor such equipment not only in terms of its calibration and analytical performance but also microbiologically.

The placental transfer of cefuroxime at parturition

Maternal and fetal serum concentrations of cefuroxime were determined at birth in 39 women who were given a single intravenous dose of either 750 mg or 1500 mg of cefuroxime before delivery. Mean serum cefuroxime concentrations in maternal venous and umbilical venous blood were dose dependent, being significantly higher after 1500 mg of cefuroxime (55.0 mg/l, 95% CI 33.4-80.9 and 19.5 mg/l, 95% CI 9.5-26.3, respectively) than after 750 mg (14.7 mg/l, 95% CI 10.5-21.1 and 8.8 mg/l 95% CI 5.8-9.4, respectively). Antibiotic concentration in maternal blood correlated with sampling time but a similar relationship was not found in cord blood. Fetal concentrations did not correlate with mode of delivery or initial maternal blood pressure. No relationship could be demonstrated between cefuroxime concentration in maternal or cord blood and maternal weight, maternal weight gain, birthweight of baby or volume of fluid infused prior to epidural anaesthesia. It is concluded that maternal and fetal concentrations likely to be effective for prophylaxis before delivery require a maternal dose of 1500 mg of cefuroxime and are independent of these physiological variables.

Treponema denticola (ex Brumpt 1925) sp. nov., nom. rev., and identification of new spirochete isolates from periodontal pockets

Standard growth and isolation methods were used to obtain five new treponema strains in pure culture from deep periodontal pockets. The strains were identified to the species level by various methods, including agglutination, immunofluorescence, a dot blot immunoassay, electron microscopy, gas-liquid chromatography of metabolic volatile fatty acids, and DNA hybridization. Two isolates were strains of Treponema socranskii; the other three were strains of "Treponema denticola," a species described in 1925 by Brumpt. Because no type strain was designated for this species previously, the name was not included on the Approved Lists of Bacterial Names and has no current nomenclatural standing. We propose that Treponema denticola (ex Brumpt) sp. nov., nom. rev. is a valid and distinct species of the genus Treponema and designate strain ATCC 35405 as the type strain and strains ATCC 33520 and ATCC 35404 as reference strains. T. denticola appears to be the species that is most frequently isolated from periodontal pockets. Unless new isolation and cultivation techniques are introduced, it appears that present technology can yield only isolates belonging to the currently described oral anaerobic spirochete species and that there is little chance of isolating the larger treponemes.

Transplacental transfer of cefuroxime in uncomplicated pregnancies and those complicated by hydrops or changes in amniotic fluid volume

The transplacental transfer of cefuroxime was determined at antenatal fetal blood sampling in a cross sectional study of 78 patients between 15-35 weeks' gestation, 8-138 minutes after a maternal intravenous dose of 750 mg. Mean serum cefuroxime concentration, measured by high performance liquid chromatography, was 7.4 (95% confidence interval (CI) 6.8 to 8.1) mg/l in control fetuses; concentrations in hydropic fetuses were similar (6.2 mg/l, CI 4.7 to 7.7) but in fetuses with oligohydramnios they were significantly lower, (4.9 mg/l, CI 3.6 to 6.2). Antibiotic concentration did not correlate with gestational age and remained unchanged by transfusion of packed red cells. We conclude that (i) fetal serum concentrations of cefuroxime obtained after a maternal dose of 750 mg are only adequate for prophylaxis against organisms with a minimum inhibitory concentration of < 4 mg/l and (ii) transplacental passage of cefuroxime is significantly reduced in the presence of oligohydramnios.

Intestinal uptake and lymphatic absorption of beta-carotene in ferrets: a model for human beta-carotene metabolism

To determine the appropriateness of the ferret as a model for human beta-carotene (beta-C) metabolism, we have perfused both 15,15'-beta-[14C]C and unlabeled beta-C through the upper 30-cm portion of the small intestine of ferrets in vivo. The effluents of a mesenteric lymph duct cannulation and a common bile duct cannulation, as well as portal vein blood periodically sampled via an indwelling catheter, were collected. Ten percent (9.5 +/- 0.06%) of the total administered beta-C was taken up by the intestine after a 4-h perfusion. Of the radioactivity taken up, 68.6 +/- 6.5% remained in the intestinal mucosa, 3.2 +/- 0.2% was recovered in the lymph, and 28.2 +/- 6.5% (calculated) was absorbed via the portal system. The total uptake/absorption of beta-C was 12.9 +/- 6.8 nmol.h-1.30 cm intestine-1. Large amounts of unchanged beta-C and relatively small amounts of both beta-apo-12'-carotenal and beta-apo-10'-carotenal were isolated in the intestinal mucosa after a 4-h perfusion with beta-C. Considerable amounts of metabolites more polar than retinol were formed and comprised 35% of the total radioactivity recovered in the intestinal mucosa. Polar metabolites were absorbed mostly into the portal venous system, whereas retinol and retinyl esters were absorbed mainly into the mesenteric lymph. Of the total absorbed radioactivity in lymph, 10 +/- 1.0% appeared as unchanged beta-C, with peak absorption occurring at 3 h after beginning the perfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Relapse of acute leukemia presenting as acute cholecystitis following bone marrow transplantation

Though included in the differential diagnosis of jaundice and abdominal pain, acute acalculous cholecystitis is an uncommon hepatobiliary complication of bone marrow transplantation. Leukemic infiltration of the gallbladder presenting as acute cholecystitis is rare. We describe two cases of acute cholecystitis following marrow transplantation that represented an unexpected relapse with leukemic infiltration of the gallbladder wall.

Isolation of Listeria species from precooked chilled foods

Cook-chill food prepared commercially was introduced to serve our patients and staff in 1989. The presence of Listeria monocytogenes in samples taken before regeneration was examined over two periods. For period A (April-November 1989), c. 0.2 g of food was examined; 2.7% of 992 meat samples and 0.6% of 1084 samples of other types of food were found to contain the organism. As a result, cold sliced meat was withdrawn from the patients' menu. For period B (February-July 1990), following the introduction of new guidelines, 25 g of food was examined after enrichment. Of the 854 meat samples examined 9% were positive for L. monocytogenes, and of the 1465 samples of other types of food examined 2.29% were positive. The significant increase between the two time periods occurred in the number of samples containing less than 10 colony forming units (cfu) g-1 of L. monocytogenes. The proportion of positive samples that contained 10-10(3) cfu g-1 remained the same for both periods (0.7%). Isolation of the organism was significantly associated with samples which had total viable counts of greater than 10(4) cfu g-1. There was no specific pattern of distribution of different serotypes in our isolates of L. monocytogenes. In the absence of evidence that small inocula of less than 10 cfu g-1 in cook-chill food before regeneration could be harmful to patients, we question whether the extra cost involved in following the Department of Health guidelines and examining 25 g of food for the presence of L. monocytogenes is justified.

Treatment of acute systemic toxicity after the rapid intravenous injection of ropivacaine and bupivacaine in the conscious dog

Two groups of six beagle dogs received rapid intravenous (IV) injections of ropivacaine or bupivacaine on two occasions in a blinded random fashion. Initially, a dose sufficient to cause convulsions (CD) was given followed by twice the CD (2 x CD), which was administered 48 h later. The CD of bupivacaine (4.3 mg/kg) and ropivacaine (4.9 mg/kg) caused significant (P less than 0.05) increases in heart rate and mean arterial blood pressure. There was no difference between drug groups. Seizures were abolished by 10 mg/kg of intravenous thiamylal. Endotracheal intubation and controlled respiration with O2-enriched air with no other treatment resulted in rapid and complete recovery in all dogs. All dogs receiving 2 x CD of bupivacaine (8.6 mg/kg) or ropivacaine (9.8 mg/kg) were initially treated with thiamylal and mechanical ventilation. Two dogs in the bupivacaine group developed hypotension, respiratory arrest, ventricular tachycardia, and ventricular fibrillation, which were resistant to closed chest cardiac massage, treatment with epinephrine, bretylium, and atropine, and direct current cardioversion. The four remaining dogs in the infusion group were successfully resuscitated. All of the animals in the ropivacaine-treated group survived the administration of the 2 x CD dose. Mild hypotension developed in one dog and was treated with intravenous epinephrine (0.75 mg). This resulted in nodal tachycardia, which was abolished after treatment with bretylium. Another dog had two 1-s bursts of premature ventricular contractions requiring no treatment. The rapid treatment of convulsions and cardiovascular toxicity resulted in a decreased number of deaths in both groups when compared with dogs from a previously published study in which no therapy was instituted. Thus, early aggressive treatment of central nervous system and cardiovascular system toxicity is capable of reducing the incidence of mortality associated with the rapid intravenous administration of excessive doses of local anesthetics.

Infantile meningitis in England and Wales: a two year study

A two year prospective study identified 1922 cases of meningitis in children under 1 year of age. A further 201 cases were identified from other sources. The annual incidence of meningitis during the first year of life was 1.6/1000; during the first 28 days of life it was 0.32/1000, and among postneonatal infants it was 1.22/1000. The male:female ratio was 1.4:1. The overall case fatality rate was 19.8% for neonates and 5.4% for postneonatal infants. Two thirds of deaths identified in the study, 50% of all deaths, were not attributed to meningitis by the Office of Population Censuses and Surveys. Group B beta haemolytic streptococci (28%), Escherichia coli (18%), and Listeria monocytogenes (5%) were most frequently isolated from neonates and Neisseria meningitidis (31%), Haemophilus influenzae (30%), and Streptococcus pneumoniae (10%) from postneonatal infants. At 2-6 months of age N meningitidis meningitis was most common, and at 7-12 months H influenzae predominated. Meningitis caused by group B beta haemolytic streptococci occurred up to 6 months of age and had a consistent mortality of 25%. Neonatal meningitis due to Gram negative enteric rods had a mortality of 32%. Low birth weight was a significant predisposing factor for both neonates and postneonatal infants. In both groups mortality was significantly higher among children admitted in coma. There was no seasonal variation in incidence in either group. Neonates were treated with either group. Neonates were treated with either chloramphenicol (50%) or gentamicin (48%) usually in combination with a penicillin; 40% received a third generation cephalosporin. Of the 1472 postneonatal infants treated 84% received chloramphenicol with a penicillin and 10% received a third generation cephalosporin. Relapse occurred in 49 patients and three died. Eighteen babies coned as a result of raised intracranial pressure, including four neonates, and four died. Mortality among the 133 (7%) children who received steroids was significantly higher than in the rest of the study group.

Adjuvant post-operative radiotherapy in rectal cancer: results from the ANZ Bowel Cancer Trial (Protocol 8202)

In July 1982 the Gastrointestinal Section of The Clinical Oncological Society of Australia began a multicentre randomized trial to assess the value of post-operative pelvic radiotherapy in the local control of stage B and C carcinoma of the rectum. Patients who had undergone a potentially curative resection were randomized either to no further treatment (NO RT) or to pelvic radiotherapy (RT), 45 Gy in 25 fractions (plus a perineal boost of 5 Gy in 2 fractions after abdomino-perineal resection). The trial was prematurely terminated in December 1985 owing to slow accrual after 70 patients had been randomized: 36 patients to RT and 34 patients to NO RT. Two patients in each group were found to be ineligible after randomization and, for a variety of reasons, thirteen patients who were randomized to RT did not receive that treatment. The incidence of post-operative complications were comparable in both groups, indicating that radiotherapy produced no additional problems. Radiotherapy-related morbidity comprised mainly diarrhoea (grade 1 = 2/21; grade 2 = 5/21; grade 3 = 0/21; grade 4 = 1/21). There were no deaths due to radiotherapy and only one patient, with grade 4 diarrhoea, failed to complete the prescribed course of radiotherapy. After an average follow-up period of 52 months there were 15 local recurrences, 8 in the RT group and 7 in the NO RT group, giving an actuarial 2 year local recurrence rate of 16%. There was no difference in the time to local recurrence, either by randomization group (p = 0.50) or by actual treatment received (p = 0.91).(ABSTRACT TRUNCATED AT 250 WORDS)

A high performance liquid chromatography system for the simultaneous assay of some antibiotics commonly found in combination in clinical samples

Using a single reversed-phase HPLC column with a mobile phase of methanol and 100 mM phosphate buffer, concentrations of seven antibiotics (chloramphenicol, metronidazole, cefuroxime, cephalexin, ceftazidime, ampicillin and benzylpenicillin) which are commonly used clinically in combinations of two or more, can be assayed and results reported within one hour. No endogenous interference was detected in serum, urine or cerebrospinal fluid. The method was highly specific even in the presence of other drugs and metabolites commonly found in clinical samples and provides a rapid, simple technique suitable for use in routine microbiological practice.

Elderly dental care. Needs and costs in three different resident settings

Although the real dental treatment needs of the elderly has been established, the costs for these needs has not been determined. This report compares dental services and costs required for older adults living in three different resident settings. Dental needs and costs have been evaluated from a sample of 305 aged persons living in nursing homes (N = 156), low-cost housing facilities (N = 79) or dependent on home care services (N = 70). This study indicates that the homebound or institutionalized elderly population presents with poor dental and periodontal conditions, a high rate of edentulousness, and inadequate dentures. Dental needs are essentially characterized by the repair or replacement of prosthesis, the screening and treatment of mucosal lesions of prosthetic origin, and scaling/curettage of remaining teeth. The average rehabilitative dental costs was Can. $720 and there was no difference between the three types of residence. Important differences in cost, however, were observed between the dentate and edentulous population. The F-test (P less than .05) and chi-square were used to analyze differences in dental treatment needs and costs between different residences. Maintenance care corresponds to Can. $80/year/person.

Competition and survival of health service organizations: a population ecology approach

The survival of health care organizations is viewed, in this article, from a population ecology perspective. This perspective provides insight into how organizational forms are differentiated on the basis of resource availability under different environmental conditions. Selected hypotheses and a rationale are presented to illustrate the applicability of the perspective to health services.

Watery diarrhea-hypokalemia-achlorhydria syndrome and carcinoma of the esophagus

The watery diarrhea-hypokalemia-achlorhydria syndrome associated with ectopic secretion of vasoactive intestinal peptide has only been conclusively documented with tumors originating in the pancreas or sympathetic chain. We report here the case of a 50-yr-old woman who developed this syndrome 3 wk after an apparently effective course of radiotherapy for an obstructing, mixed-cell carcinoma of the esophagus. High concentrations of vasoactive intestinal peptide were found in plasma (100-200 pmol/L; normal less than 20 pmol/L) and in the metastatic skin nodules (750 pmol/g) that later developed and that contained one of the two cell types from the original tumor. Stool volumes reached a plateau of 15-20 L/day, and potassium requirements were greater than 1000 mmol/day. Symptoms failed to respond to any of the regimens previously described as effective in this syndrome. After 14 wk of massive fecal fluid and electrolyte losses, symptoms resolved dramatically with the first dose of 5-fluorouracil. Plasma vasoactive intestinal peptide concentration returned to normal, where it remained despite subsequent evidence of renewed tumor spread. This case illustrates the unpredictability of the response of this syndrome to medical treatment, and suggests that vasoactive intestinal peptide secretion may occur in a wider range of tumors than has so far been described.

The psychiatric intensive care unit

The first three and a half years' operation of a psychiatric intensive care unit, based on the general hospital model, is described. This eight-bedded ward focusses on the treatment of the most acutely psychiatrically ill patients, and not on the forensic or custodial aspects of such units previously described. It has gained general acceptance within the setting of a state psychiatric hospital, and has received 1132 admissions since its inception. Demographic, clinical, and treatment data are presented and the advantages and disadvantages of the unit are discussed.

The pharmacokinetics of chloramphenicol in the neonate and young infant

The peak and trough serum concentrations and total body clearance of chloramphenicol were determined by microbiological assay in a multicentre investigation of 90 babies. Chloramphenicol was administered by the intravenous, intramuscular or oral route and dosage ranged between 12 and 210 mg/kg/day. A wide variation in both serum levels and clearance amongst babies receiving the same dose was observed. Neonates (64) had significantly higher serum concentrations (P less than 0.001) and slower clearance (P less than 0.0001) than infants (26). Oral administration in neonates resulted in lower steady state serum levels (P less than 0.02) than those following intravenous administration. Term neonates cleared chloramphenicol more rapidly than their preterm contemporaries (P less than 0.005). Forty-one per cent of subjects had potentially toxic serum levels; subtherapeutic peak serum levels (less than 15 mg/l) were recorded in 39/90 babies. Concomitant penicillin therapy resulted in higher serum concentrations (P less than 0.05); phenobarbitone was not associated with increased clearance or lower steady state serum levels of chloramphenicol. Postnatal age and gestational age accounted for some of the variability in pharmacokinetic response to chloramphenicol. Although many babies receiving the recommended dose had serum levels within the accepted range (15-25 mg/l), others did not. Routine monitoring of chloramphenicol in every baby receiving this antibiotic is essential: the regimens of 18% babies in the present study were altered after assay.

Chloramphenicol toxicity in neonates: its incidence and prevention

The incidence of dose related chloramphenicol toxicity was determined in 64 neonates from 12 hospitals. Ten of the 64 exhibited symptoms attributed clinically to chloramphenicol toxicity. Nine received the dose prescribed and one an overdose. Symptoms of the grey baby syndrome were observed in five of the 10 babies; four babies suffered reversible haematological reactions; and one baby was described as very grey. Peak serum chloramphenicol concentrations in these 10 babies ranged from 28 to 180 mg/l and trough concentrations from 19 to 47 mg/l. Serum chloramphenicol concentrations above the therapeutic range (15-25 mg/l) were observed in a further 27 neonates (two had received a 10-fold overdose), none of whom showed signs of toxicity. Serious toxicity was associated with either prescription of dosages greater than that recommended or overdosage of chloramphenicol. High concentrations in young neonates may be avoided by prescribing and giving the recommended dose and then careful monitoring; concentrations should be maintained between 15 and 25 mg/l. No babies with concentrations within this range showed clinical signs of toxicity.

Incidence of potentially toxic concentrations of gentamicin in the neonate

The incidence of putatively toxic serum concentrations and the factors influencing their occurrence were investigated in a study of 91 neonates receiving parenteral gentamicin twice daily at a dose of mean (SD) 5.5 (0.1) mg/kg/day. Most neonates were preterm and of low birthweight. Serum concentrations, area under the curve (AUC), and clearance were calculated. Potentially toxic trough concentrations (greater than 2 mg/l) were recorded in 57 of 91 (63%) neonates; 24 of these had trough concentrations greater than 3 mg/l. These babies were of a significantly lower gestational age and were younger than the remainder of the population. Toxic trough concentrations were not accompanied by raised peak serum values. A wide variation in all pharmacokinetic variables was observed. Peak serum concentration was most highly correlated with dose, while trough concentration, AUC, and clearance were more dependent on postnatal age. Clearance of gentamicin decreased significantly with increasing serum urea and creatinine concentrations. Preterm neonates in the first week of life are likely to develop potentially toxic serum concentrations when receiving the currently recommended dose of gentamicin (5-6 mg/kg/day). To prevent accumulation the dosage interval may need to be increased to 18 hours in these babies.

Cytomegalovirus infection in pregnancy: preliminary findings from a prospective study

8278 (56%) of 14 789 pregnant women who were screened for cytomegalovirus (CMV) antibodies at their first antenatal visit were seropositive. 42 (3 per 1000) infants screened were congenitally infected. 3 (7%) have serious handicaps, 14 (33%) have minor or transient problems, and 25 (60%) have so far had no problems. In 26 of the 42 mothers with infected infants CMV antibodies were present in the first antenatal blood sample. 28 (67%) of the infected infants were born to mothers who had experienced a primary infection in pregnancy and 7 (17%) to mothers who had experienced recurrent infection. In the remaining 7 (17%) it was not possible to determine the type of maternal infection. One handicapped infant was born after a probable recurrent CMV infection during pregnancy. These preliminary findings suggest that routine screening of pregnant women to detect evidence of primary CMV infection is not helpful.

Efficacy of chloramphenicol in the treatment of neonatal and infantile meningitis: a study of 70 cases

The efficacy of chloramphenicol in the treatment of 21 neonates and 9 infants with proven meningitis and 37 neonates and 3 infants with suspected meningitis was evaluated from mortality and morbidity data, and by assay of the drug in serum and cerebrospinal fluid. Minimum inhibitory concentrations (MICs) were established for ten isolates. 25% of neonates and 50% of infants had subtherapeutic concentrations of chloramphenicol in serum or cerebrospinal fluid. Dosage was less than that currently recommended in over half of these subjects. Mild toxicity (reversible thrombocytopenia) was observed in only 1 of 20 babies being treated at the recommended dose. Toxic reactions, including the grey-baby syndrome, occurred in 10 babies receiving higher doses. In 4 cases, doses up to ten times that prescribed had been given, and death of 1 baby was attributable in part to chloramphenicol toxicity. 5 of 21 neonates and 1 of 9 infants with bacteriologically proven meningitis died, an overall mortality of 20%. Those infected with gram-negative bacteria had a higher mortality than those infected with gram-positive bacteria (p less than 0 . 05). 21% of the survivors had neurological sequelae. Therapeutic concentrations of chloramphenicol will be achieved in serum and cerebrospinal fluid with daily doses of 25 mg/kg in preterm and term infants during the first week of life and 37 . 5-50 mg/kg for older term babies. The drug should be assayed at 48-hour intervals, to maintain concentrations in the therapeutic, non-toxic range. Dosage should be increased when the peak serum concentration falls below 20 mg/l and decreased when the trough serum concentration exceeds 15 mg/l or the peak concentration exceeds 30 mg/l.

Evaluation of a course on medical microbiology for non-medical graduate scientists from medical microbiological laboratories

An assessment of the educational value of a series of courses intended to improve the clinical awareness of non-medical graduate microbiologists has been made. Objective and subjective data were collected by means of questionnaires, pre- and post-course multiple choice tests and informal discussion. The format of the courses are described. The increase in cognitive knowledge acquired during three of the courses is comparable with results from another study in clinical students. The anomalous results from one of the four courses may be explained in terms of the composition of that course. The data presented contribute to the information required for the evaluation and assessment of educational courses.

Cefuroxime in the treatment of neonates

The new broad spectrum cephalosporin, cefuroxime, was used to treat 28 neonates with suspected or proved infection. All of them had had complications at birth or in early neonatal life which were known to predispose to infection. The treatment regimen consisted of intramuscular or intravenous cefuroxime (50 mg/kg twice a day) for 5 days. Previously, such infants would have received gentamicin with penicillin or ampicillin. Pathogenic or potentially pathogenic bacteria were isolated from 7 (25%) of them. All of these organisms were sensitive to cefuroxime. None of the babies had meningitis, but blood cultures from 2 gave positive results. There was significant clinical improvement in 27 of them after 5 days of treatment and each was well on discharge from hospital. Serum urea, total protein, albumin, and alanine transaminase levels were estimated before, during, and after cefuroxime treatment. There were no changes attributable to cefuroxime nor were any changes in haemoglobin, packed cell volume, or total differential white cell counts observed. There were no adverse clinical side effects. One hundred and ninety-four samples of serum were assayed for cefuroxime. The mean peak level after intramuscular injection (42.7 mg/l) was reached in 0.8 hours, and the mean trough level was 10.5 mg/l. The mean half-life of cefuroxime in infants aged less than 4 days was 5.8 hours. In 4 infants older than 8 days, it ranged from 1.6-3.8 hours. Half-life was not associated with birthweight. Cefuroxime is a safe, well-tolerated, and rapidly absorbed drug for the treatment of neonates with suspected or proved infections; it is a useful alternative to gentamicin, if the use of an aminoglycoside is not clearly indicated.