Multicenter randomized trial of fluconazole versus amphotericin B for treatment of candidemia in non-neutropenic patients. Canadian Candidemia Study Group

A randomized trial was conducted to compare the efficacy and safety of fluconazole versus that of amphotericin B in the treatment of candidemia in non-neutropenic adults. Enrollment was stratified by disease severity (APACHE II score). Patients were randomized (1:1) to receive amphotericin B 0.6 mg/kg/day (cumulative dose 8 mg/kg) or fluconazole 800 mg intravenous loading dose, then 400 mg daily for four weeks (intravenous for at least 10 days). Patients were monitored for six months. A total of 106 patients were enrolled. A protocol amendment implemented midway through the trial required patients to be removed from the study and treated with amphotericin B if species identification indicated candidemia due to Candida glabrata or Candida krusei. Baseline characteristics were similar for the two groups; 103 patients (fluconazole, 50; amphotericin B, 53) met the major enrollment criteria. The intention-to-treat analysis indicated successful therapy in 50% of fluconazole recipients compared to 58% of the amphotericin B group (p = 0.39; one-sided 95% CI, -8 to 24%). The efficacy analysis included 84 patients (fluconazole, 42; amphotericin B, 42); successful outcomes were observed in 57% and 62% of cases in the fluconazole and amphotericin B groups, respectively (p = 0.66: one-sided 95% CI, -12 to 22%). The mortality at day 14 for the fluconazole group was 26% and for the amphotericin B group 21% (p = 0.52; chi-square test) and remained similar throughout the course of follow-up, Drug-related adverse events were more frequent with amphotericin B than with fluconazole and prompted switching of therapy for two (4%) and zero cases, respectively. Fluconazole and amphotericin B were associated with similar clinical response rates and survival in the treatment of candidemia among non-neutropenic patients; however, drug-related adverse events were more frequent with amphotericin B.

Maintenance of employment on dialysis

This article describes the components of a multidisciplinary effort focused on promoting, among other goals, continued employment during end-stage renal disease (ESRD) treatment. The education and guidance of the patient begin during the pre-ESRD period, intensify through dialysis treatment, and continue even through posttransplantation follow-up. Such focused programs support patients in retaining their usual lifestyle, staying in their current jobs where possible, and maximizing self-esteem and quality of life.

Computer-assisted self-interviewing: a multimedia approach to dietary assessment

Currently available dietary assessment tools have limited ability to obtain valid data within the resource constraints of large-scale studies. Many obstacles to gathering data can be overcome with computer-assisted self-interviewing (CASI). Computers can conduct personalized, in-depth interviews without interviewers; provide standardized data collection with appropriate levels of probing; automate data entry; encourage subjects to review and correct inconsistent data; and ensure that responses are complete. Interactive multimedia tools can motivate subjects and improve participation. Visual and aural cues may stimulate recall and improve data quality. CASI is appropriate for use in populations in which literacy is low and in multiple ethnic groups. A prototype CASI diet-history program was developed for use in the United States. The diet-history approach was selected to improve cognitive support and capture information on usual diet. Scripts were based on recorded interviews with dietitians and interviewers from the National Health and Nutrition Examination Survey. At the end of the interview, participants are given information on how their reported nutrient intakes compare with current recommendations for their age and sex. The prototype was tested in focus groups of mixed age, sex, ethnicity, and education, with encouraging results. The development of multimedia-based dietary assessment tools seems a logical next step in improving dietary assessment methods.

Younger versus older gay men: risks, pleasures and dangers of anal sex

This study reports on the practice and the pleasure and danger perceptions of protected and unprotected anal sex of young adult gay men (< or = 30) and older gay men (30+). It is assumed that, if prevention efforts were successful, younger gay men-sexually socialized during the AIDS era-should have more favourable perceptions of anal sex with a condom. Data from a cohort of gay men in Flanders, Belgium (1993, n = 553) are used in this analysis. The results indicate that younger gay men do not differ from older gay men in the riskiness/safety of their actual sexual behaviour. However, younger men hold different valuations regarding anal sex. They report a higher appraisal for both insertive and receptive anal sex with a condom. The perceived safety of protected anal sex is also higher among the younger men. We also found that younger men with a steady partner report more gratification from insertive anal sex with a condom than do older partnered men. We interpret these findings as evidence of the effectiveness of HIV prevention efforts.

Recognising the smiles that cry for help

This article describes a small project set up by nurses and a speech and language therapist in a day unit for people with learning difficulties. The project looked at communication between clients and their visitors.

A practical guide for the diagnosis and treatment of acute sinusitis

OBJECTIVE

To develop guidelines for the diagnosis and management of acute sinusitis.

OPTIONS

Diagnostic clinical criteria and imaging techniques, the role of antimicrobial therapy and duration of treatment, and the role of adjunct therapy, including decongestants, glucocorticosteroids and nasal irrigation.

OUTCOMES

Improved accuracy of clinical diagnosis, better utilization of imaging techniques and rational use of antimicrobial therapy.

EVIDENCE

A MEDLINE search for relevant articles published from 1980 to 1996 using the MeSH terms "sinusitis," "acute sinusitis," "respiratory infections," "upper respiratory infections," "sinusitis" and "diagnosis," "sinusitis" and "therapy," "sinusitis" and "etiology," and "antimicrobial resistance" and search for additional articles from the reference lists of retrieved articles. Papers referring to chronic sinusitis, sinusitis in compromised patients and documented nonbacterial sinusitis were excluded. The evidence was evaluated by participants at the Canadian Sinusitis Symposium, field in Toronto on April 26-27, 1996.

VALUES

A hierarchical evaluation of the strength of evidence modified from the methods of the Canadian Task Force on the Periodic Health Examination was used. Strategies were identified to deal with problems for which no adequate clinical data were available. Recommendations arrived at by consensus of the symposium participants were included.

BENEFITS, HARMS AND COSTS

Increased awareness of acute sinusitis, accurate diagnosis and prompt treatment should reduce costs related to unnecessary investigations, time lost from work and complications due to inappropriate treatment. As well, physicians will be better able to decide which patients will not require antimicrobial therapy, thus saving the patient the cost and potential side effects of treatment.

RECOMMENDATIONS

Clinical diagnosis can usually be made from the patient's history and findings on physical examination only. Five clinical findings comprising 3 symptoms (maxillary toothache, poor response to decongestants and a history of coloured nasal discharge) and 2 signs (purulent nasal secretion and abnormal transillumination result) are the best predictors of acute bacterial sinusitis (level I evidence). Transillumination is a useful technique in the hands of experienced personnel, but only negative findings are useful (level III evidence). Radiography is not warranted when the likelihood of acute sinusitis is high or low but is useful when the diagnosis is in doubt (level III evidence). First-line therapy should be a 10-day course of amoxicillin (trimethoprim-sulfamethoxazole should be given to patients allergic to penicillin) (level I evidence) and a decongestant (level III evidence). Patients allergic to amoxicillin and those not responding to first-line therapy should be switched to a second-line agent. As well, patients with recurrent episodes of acute sinusitis who have been assessed and found not to have anatomic anomalies may also benefit from second-line therapy (level III evidence).

VALIDATION

The recommendations are based on consensus of Canadian and American experts in infectious diseases, microbiology, otolaryngology and family medicine. The guidelines were reviewed independently for the advisory committee by 2 external experts. Previous guidelines did not exist in Canada.

Combined accelerated tissue-plasminogen activator and platelet glycoprotein IIb/IIIa integrin receptor blockade with Integrilin in acute myocardial infarction. Results of a randomized, placebo-controlled, dose-ranging trial. IMPACT-AMI Investigators

BACKGROUND

Platelet activation and aggregation may be key components of thrombolytic failure to restore and maintain perfusion in acute myocardial infarction. We performed a placebo-controlled, dose-ranging trial of Integrilin, a potent inhibitor of platelet aggregation, with heparin, aspirin, and accelerated alteplase.

METHODS AND RESULTS

We assigned 132 patients in a 2:1 ratio to receive a bolus and continuous infusion of one of six Integrilin doses or placebo. Another 48 patients were randomized in a 3:1, double-blind fashion to receive the highest Integrilin dose from the first phase or placebo. All patients received accelerated alteplase, aspirin, and intravenous heparin infusion; all but two groups also received an intravenous heparin bolus. The highest Integrilin dose group from the nonrandomized phase and the randomized patients were pooled for analysis and compared with placebo-treated patients. The primary end point was Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow at 90-minute angiography. Secondary end points were time to ST-segment recovery, an in-hospital composite (death, reinfarction, stroke, revascularization procedures, new heart failure, or pulmonary edema), and bleeding variables. The highest Integrilin dose groups had more complete reperfusion (TIMI grade 3 flow, 66% versus 39% for placebo-treated patients; P = .006) and a shorter median time to ST-segment recovery (65 versus 116 minutes for placebo; P = .05). The groups had similar rates of the composite end point (43% versus 42% for placebo-treated patients) and severe bleeding (4% versus 5%, respectively).

CONCLUSIONS

The incidence and speed of reperfusion can be enhanced when a potent inhibitor of the glycoprotein IIb/IIIa integrin receptor, such as Integrilin, is combined with accelerated alteplase, aspirin, and intravenous heparin.

Mutations within the yeast U4/U6 snRNP protein Prp4 affect a late stage of spliceosome assembly

We showed previously that the yeast Prp4 protein is a spliceosomal factor that is tightly associated with the U4, U5, and U6 small nuclear RNAs. Moreover, Prp4 appears to associate very transiently with the spliceosome before the U4 snRNA dissociates from the spliceosome. Prp4 belongs to the Gbeta-like protein family, which suggests that the Prp4 Gbeta motifs could mediate interactions with other components of the spliceosome. To investigate the function of the Gbeta motifs, we introduced mutations within the second WD-repeat of Prp4. Among the 35 new alleles found, 24 were pseudo wild-type mutants, 8 failed to grow at any temperature, and 3 were conditional sensitive mutants. The biochemical defects of the three thermosensitive prp4 mutants have been examined by immunoprecipitation, native gel electrophoresis, and glycerol gradient centrifugation. First, we show that snRNP formation is not impaired in these mutants and that Prp4 is present in the U4/U6 and U4/U6-U5 snRNP particles. We also demonstrate that spliceosome assembly is largely unaffected despite the fact that the first step of splicing does not occur. However, both Prp4 and U4 snRNA remain tightly associated with the spliceosome and this blocks the transition toward an active form of the spliceosome. Our results suggest a possible role of Prp4 in mediating important conformational rearrangements of proteins within the spliceosome that involve the region containing the Gbeta-repeats.

Predictors and profiles of rural versus urban family practice

BACKGROUND AND OBJECTIVES

Much of rural Colorado has been designated a shortage area for primary care health personnel. The state's only medical school and its family practice residency programs are expected to address this long-standing problem. This study identified predictors of rural practice location and contrasted the service profiles of rural versus urban family physicians and general practitioners.

METHODS

The Colorado Board of Medical Examiners mailed a questionnaire to all licensed Colorado physicians. Logistic regression analyses were conducted using variables determined to be significantly related to practice location (rural versus urban) by univariate statistical tests. Information from the 986 family physician and general practitioner respondents identified personal and educational variables strongly associated with choice of rural practice location and differentiated between practice tendencies of rural versus urban physicians.

RESULTS

Having been raised in rural Colorado was the most powerful predictor of rural practice location in the state. Family physicians and general practitioners serving rural populations spent much more time weekly providing direct patient care and more often cared for Medicaid patients.

CONCLUSIONS

Personal characteristics and background may be useful considerations in selecting among applicants for medical schools and family practice residency programs committed to reducing the severe shortage of health care service in rural areas.

Analysis of the structure of chemically synthesized HIV-1 protease complexed with a hexapeptide inhibitor. Part I: Crystallographic refinement of 2 A data

The structure of a complex between a hexapeptide-based inhibitor, MVT-101, and the chemically synthesized (Aba 67,95,167,195; Aba: L-alpha-amino-n-butyric acid) protease from the human immunodeficiency virus (HIV-1), reported previously at 2.3 A has now been refined to a crystallographic R factor of 15.4% at 2.0 A resolution. Root mean square deviations from ideality are 0.18 A for bond lengths and 2.4 degrees for the angles. The inhibitor can be fitted to the difference electron density map in two alternative orientations. Drastic differences are observed for positions and interactions at P3/S3 and P3'/S3' subsites of the two orientations due to different crystallographic environments.

Analysis of the structure of HIV-1 protease complexed with a hexapeptide inhibitor. Part II: Molecular dynamic studies of the active site region

Six models of the catalytic site of HIV-1 protease complexed with a reduced peptide inhibitor, MVT-101, were investigated. These studies focused on the details of protonation of the active site, its total net charge and hydrogen bonding pattern, which was consistent with both the observed coplanar configuration of the acidic groups of the catalytic aspartates (Asp-25 and Asp-125) and the observed binding mode of the inhibitor. Molecular dynamic simulations using AMBER 4.0 indicated that the active site should be neutral. The planarity of the aspartate dyad may be due to the formation of two hydrogen bonds: one between the inner O delta 1 oxygen atoms of the two catalytic aspartates and another between the O delta 2 atom of Asp-125 and the nitrogen atom of the reduced peptide bond of the bound inhibitor. This would require two additional protonations, either of both aspartates, or of one Asp and the amido nitrogen atom of Nle-204. Our results favor the Asp-inhibitor protonation but the other one is not excluded. Implications of these findings for the mechanism of enzymatic catalysis are discussed. Dynamic properties of the hydrogen bond network in the active site and an analysis of the interaction energy between the inhibitor and the protease are presented.

Selective hyperexpression of c-jun oncoprotein by glass fiber- and silica-transformed BALB/c-3T3 cells

Mining and mineral processing are important industries in the United States. A large number of workers are potentially exposed to silica during mining and to glass fibers during manufacturing. There is a concern regarding lung cancer risk among workers exposed to silica and glass fibers. Our previous studies showed that both glass fibers and silica induced transformation of BALB/c-3T3 cells. In order to explore the relationship between silica and glass fiber-induced cell transformation and oncoprotein expression, the protein products of seven proto-oncogenes (c-K-ras, c-H-ras, c-sis, c-myc, c-myb, c-erb B1 and c-jun) and one tumor suppressor gene (p53) were examined in BALB/c-3T3 cells transformed by glass fibers or silica using immunoblotting with specific monoclonal or polyclonal antibodies. The results showed that all transformants, including eight induced by glass fibers and eight by silica (Min-U-Sil 5), were positive for c-jun protein expression; the level of c-jun protein was elevated 8-21-fold in these transformants. Other protooncogene proteins in transformed cells were either not detectable or not different from non-transformed cells. These results suggest that the overexpression of c-jun is common in BALB/c-3T3 transformed cells induced by glass fibers or silica. It seems, therefore, that the expression of c-jun may play an important role in the transformation process.

Benzo[a]pyrene coated ferric oxide and aluminum oxide particles: uptake, metabolism and DNA binding in hamster pulmonary alveolar macrophages and tracheal epithelial cells in vitro

Ferric oxide (Fe2O3) and aluminum oxide (Al2O3) particles are widely encountered in occupational settings. Benzo[a]pyrene (B[a]P), a well-characterized environmental carcinogen, is frequently adsorbed onto particles. It has been shown that B[a]P-coated Fe2O3 particles (B[a]P-Fe2O3) significantly increased lung tumors in the hamster in contrast to B[a]P-coated Al2O3 (B[a]P-Al2O3) or B[a]P alone. In order to determine the genotoxic effects of these particles on the metabolism of B[a]P, pulmonary alveolar macrophages (AM) from male Syrian golden hamsters were incubated with 5 microg (19.8 nmol) B[a]P-coated respirable size (99% < 5 microm) Fe2O3 and Al2O3 particles with loads from 0.5 to 2.0 mg. Intracellular uptake of B[a]P by AM at 24 h was higher with B[a]P-Fe2O3 than that of B[a]P alone (P < 0.05) or B[a]P-Al2O3 (P < 0.05). Total B[a]P metabolism was significantly greater in AM exposed to B[a]P-coated Fe2O3 at 1.0 and 1.5 mg than in the AM exposed to B[a]p-al2O3 (0.5, 1.0 and 1.5 mg) (P < 0.05) or B[a]P alone (P < 0.05). Similar significant differences for Fe2O3 relative to Al2O3 and B[a]P alone were also apparent for total dihydrodiols, quinones and phenolic metabolites. Co-administration of 5 microg alpha-naphthoflavone (alpha-NF, an inhibitor of cytochrome P-4501A1 and P-4501A2) and 10(-3) M cyclohexene oxide (CO, an inhibitor of epoxide hydrolase) significantly reduced B[a]P metabolism in B[a]P-Fe2O3 (P < 0.05) and B[a]P-Al2O3 (P < 0.05) treated groups relative to B[a]P alone. AM were co-cultured with hamster tracheal epithelial cells (HTE) and treated as described above for metabolism studies to assess the DNA binding of B[a]P metabolites in the target cells, using 32P-postlabeling techniques. Two adducts were observed that had chromatographic behavior similar to 7R,8S,9S-trihydroxy-10R-(N2-deoxyguanosyl-3'-phosphate)-7,8,9,10-t etrahydrobenzo[a]pyrene [(+)-anti-BPDE-dG, adduct 1, major adduct representing 70-80% of total adducts] and 7S,8R,9R-trihydroxy-10S-(N2-deoxyguanosyl-3'-phosphate)-7,8,9,10-t etrahydrobenzo[a]pyrene [(-)-anti-BPDE-dG, adduct 2, representing 20-30% of total adducts]. B[a]P-Fe2O3 treatment enhanced the levels of the two B[a]P-DNA adducts in the HTE compared with B[a]P-Al2O3 (P < 0.05) or B[a]P alone. The inhibitors alphaNF and CO significantly reduced total adduct levels in the HTE (P < 0.05) in the B[a]P and B[a]P-Fe2O3 treatments as well as adduct 1 and adduct 2 levels. Our data suggest that the cocarcinogenic effect of B[a]P-Fe2O3 relative to B[a]P-coated Al2O3 can be due to: (i) the enhancement of B[a]P metabolism in AM by Fe2O3 associated with the increased uptake of B[a]P; and (ii) augmentation of DNA adduct formation in epithelial cells.

Preattentive and attentive eye movements during visual scanning of a cocaine cue: correlation with intensity of cocaine cravings

The visual scanning of 19 recently abstinent crack cocaine-dependent men was assessed while they viewed a picture of a cocaine cue and a picture of a neutral cue. Cocaine craving scores were inversely correlated with the number of preattentive fixations and saccades and were positively correlated with the number of attentive fixations.

Posttransplant lymphoproliferative disease after cardiac transplantation. Two unusual variants with predominantly plasmacytoid features

Two patients who developed posttransplant lymphoproliferative disorder with plasmacytoid changes in the lymphocytes after heart transplant are described. The first case is one of multiple myeloma, and the second is a case of lymphoma with plasmacytoid features. The clinical course and the etiologic role of the immunosuppressive therapies that the patients received for heart transplantation are described. A review of posttransplant multiple myeloma and discussion of the etiology and prognosis of this entity are presented.

Modulation of membrane currents and mechanical activity by niflumic acid in rat vascular smooth muscle

The effects of niflumic acid on whole-cell membrane currents and mechanical activity were examined in the rat portal vein. In freshly dispersed portal vein cells clamped at -60 mV in caesium (Cs+)-containing solutions, niflumic acid (1-100 microM) inhibited calcium (Ca2+)-activated chloride currents (IC1(Ca)) induced by caffeine (10 mM) and by noradrenaline (10 microM). In a potassium (K+)-containing solution and at a holding potential of - 10 mV, niflumic acid (10-100 microM) induced an outward K+ current (IK(ATP)) which was sensitive to glibenclamide (10-30 microM). At concentrations < 30 microM and at a holding potential of -2 mV, niflumic acid had no effect on the magnitude of the caffeine- or noradrenaline-stimulated current (IBK(Ca)) carried by the large conductance, Ca(2+)-sensitive K+ channel (BKCa). However, at a concentration of 100 microM, niflumic acid significantly inhibited IBK(Ca)) evoked by caffeine (10 mM) but not by NS1619 (1-(2'-hydroxy-5'-trifluoromethylphenyl)-5-trifluoromethyl-2(3 H) benzimidazolone; 20 microM). In Cs(+)-containing solutions, niflumic acid (10-100 microM) did not inhibit voltage-sensitive Ca2+ currents. In intact portal veins, niflumic acid (1-300 microM) inhibited spontaneous mechanical activity, an action which was partially antagonised by glibenclamide (1-10 microM), and contractions produced by noradrenaline (10 microM), an effect which was glibenclamide-insensitive. It is concluded that inhibition of ICl(Ca) and stimulation of IK(ATP) both contribute to the mechano-inhibitory actions of niflumic acid in the rat portal vein.

The oligomerization domain of p53: crystal structure of the trigonal form

The structure of the oligomerization domain of the p53 tumor suppressor protein was determined in the trigonal crystal form, using a refined NMR structure as a model. A synthetic peptide comprising residues 319-360 of human p53 crystallized in the space group P3(1)21. There is one biologically relevant tetrameric domain in the crystallographic asymmetric unit. The structure was refined jointly with NMR data, only the third such case (the previous examples being IL-1beta (Shaanan, B., Gronenborn, A.M., Cohen, G.H., Gilliland, G.L., Veerapandian, B., Davies, D.R. and Clore, G.M. (1992) Science 257, 961-964 [1]) and BPTI (Schiffer, C., Huber, R., Wuthrich, K. and Van Gunsteren, W.F. (1994) J. Mol. Biol. 241, 588-599 [21)), to 2.5 A resolution with an R factor of 0.207. The distribution of tumor-derived mutations in the oligomerization region together with structural and biological data suggest a strategy for the design of antitumor therapeutics.