Nasal leiomyoma

Leiomyoma is a benign tumor showing smooth muscle differentiation. Leiomyoma in the nasal cavity is a rare entity which can present with common nasal symptoms. We report a case of 19 years old male patient with nasal leiomyoma. The patient presented with recurrent episodes of nasal obstruction and epistaxis. On nasoendoscopy, there was a single grayish polypoidal mass in the right middle meatus which bled on touch. CT-scan of nose and paranasal sinus showed homogenous opacity indistinguishable from the right middle turbinate. The mass was excised endoscopically. There is no recurrence a year after the endoscopic excision of the nasal leiomyoma. Nasal leiomyoma carries a good prognosis after complete excision.

Selenium intoxication with selenite broth resulting in acute renal failure and severe gastritis

Selenium (Se) is an essential trace element in human and animal nutrition. It is also widely utilized in industrial processes. Reports of acute selenium toxicity in humans are rare. We report a case of a 23-year-old female who consumed about 100 mL of liquid selenite broth and presented with severe nausea, vomiting, abdominal pain, hematemesis and acute renal failure (ARF). The serum selenium level was significantly increased. Gastro-duodenoscopy revealed severe corrosive gastritis. Renal biopsy showed features of acute tubular necrosis (ATN), affecting primarily the proximal tubules. The patient was managed with gastric lavage, blood transfusions, infusion of fresh frozen plasma (FFP) and platelet concentrates and hemo-dialysis. The patient was discharged five weeks after admission and her renal functions recovered completely by eight weeks after admission. She continues to be on regular follow-up for any possible sequelae of mucosal corrosive damage. This case highlights a case of selenium intoxication from selenite broth resulting in ARF and corrosive gastritis. The recovery was complete.

Spectroscopic and lasing performance of Tm3+-doped bulk TZN and TZNG tellurite glasses operating around 1.9 microm

We report spectroscopic and bulk laser performance characteristics for Tm(3+)-doped tellurite glasses when used as gain media operating around 1.9 microm. Two glass hosts studied are TZN and TZNG and their performances have been compared. In each case, well-characterized cw laser performance was obtained and this has been related to detailed spectroscopic measurements of the important lasing parameters of the laser transitions around 1900 nm when pumped at 793 nm. The maximum output power achieved was 124 mW from the TZNG sample with an associated slope efficiency of 28 % with a tuning range of 135 nm. Efficiency and loss analyses yielded a calculated maximum attainable efficiency of 48 % in Tm(3+):TZN compared to 28 % for the TZNG host.

3,5-Bis(Phenylmethylene)-1-(N-arylmaleamoyl)-4-piperidones: A Novel Group of Cytotoxic Agents

A series of novel 3,5-bis(phenylmethylene)-1-(N-arylmaleamoyl)-4-piperidones 3 have been synthesized which displayed potent cytotoxicity towards human Molt 4/C8 and CEM T-lymphocytes as well as murine P388 and L1210 leukemic cells. In contrast, the related N-arylmaleamic acids 4 possessed little or no cytotoxicity in these four screens. Molecular modeling revealed certain interplanar and bond angles and interatomic distances which were perceived to contribute to the observed bioactivity as well as providing suggestions for future structural modifications of the piperidones 3. Evaluation of representative compounds in series 3 and 4 on the activity of human N-myristoyltransferase revealed that, at the maximum concentration utilized, namely 250 microM, only weak inhibiting properties were displayed by some of the compounds in series 4. Various members of series 3 and 4 were well tolerated in mice.

Active waveguides written by femtosecond laser irradiation in an erbium-doped phospho-tellurite glass

We report on fs-laser micromachining of active waveguides in a new erbium-doped phospho-tellurite glass by means of a compact cavity-dumped Yb-based writing system. The spectroscopic properties of the glass were investigated, and the fs-laser written waveguides were characterized in terms of passive as well as active performance. In particular, internal gain was demonstrated in the whole C+L band of optical communications (1530- 1610 nm).

Cytological diagnosis of bancroftian filariasis in lesions clinically anticipated as neoplastic

Filariasis is a common disabling parasitic disease in this region and cytological diagnosis is often not required. Cytology has important role in diagnosis of sub-clinical filariasis. Most cases of cytologically diagnosed filariasis are clinically unanticipated. Microfilaria, ova and fragments of adult worm of Wuchereria bancrofti, in exfoliative as well as aspiration cytology have been reported and are useful in cytological detection of bancroftian filariasis. Microfilaria is frequently detected in association with neoplasm, although the role in tumorogenesis is controversial. The objective of the study was to investigate importance of cytology in diagnosis of filariasis in lesions clinically anticipated to be of neoplastic and to review the cytomorphology of bancroftian filaria and its association with neoplasm. This is a retrospective study carried out in cytology department of Tribhuvan University Teaching Hospital. 14 cases of cytological specimen out of 4291 (0.3%) showed microfilaria; 12 cases were from FNAC from different sites and 2 cases were from pleural fluid. 2 cases showed ova in addition to microfilaria and one of them in addition showed fragment of adult worm. Microfilaria in 4 cases of FNAC and one case ofpleural fluid were associated with malignant cells.

Bone marrow examination in cases of pancytopenia

This study was carried to identify the causes of pancytopenia and to find out the bone marrow morphology in cases of pancytopenia. It was a cross sectional study conducted over a period of two years in the Department of Pathology, Tribhuvan University Teaching Hospital. Bone marrow aspiration smears of patients fulfilling the criteria of pancytopenia were examined. The data obtained were analyzed using measures of central tendency. One hundred and forty eight cases underwent bone marrow aspiration and it constituted 15.74% of total cases. Mean age was 30 years (range, 1-79 years). 42 cases were children (28.37%). Male: female ratio was 1.5:1. The commonest cause was hypoplastic bone marrow seen in 43 cases (29%) followed by megaloblastic anemia in 35 cases (23.64%), and hematological malignancy in 32 cases (21.62%). Erythroid hyperplasia was seen in 29 cases (19.6%) and normal bone marrow was seen in 5 cases (3.38%). There was one case each of Niemann-Pick disease and metastatic neuroblastoma in children and chronic pure red cell aplasia and leishmaniasis in adults. Acute leukemia was the commonest hematological malignancy. In children, commonest finding was hypoplastic bone marrow (38.1%) while in adults megaloblastic anemia (30.18%) was commonest finding followed by hypoplastic anemia (25.47%). In present study bone marrow examination was able to establish diagnosis in 77% of cases. Hypoplastic marrow was the commonest diagnosis, followed by megaloblastic anemia, and hematological malignancies.

Multiple rare earth emissions in a multicore tellurite fiber with a single pump wavelength

A three-core tellurite glass fiber having different combinations of rare earth oxide dopants in each core has been fabricated using shaped die-extrusion. Three cores, doped with Ho(3+)-Tm(3+)-Yb(3+), Er(3+)-Ce(3+), and Tm(3+)-Yb(3+) respectively, exhibited visible upconversion (blue, green and red) and infrared emissions at 1.4 microm, 1.5 microm, 1.9 microm and 2.05 microm when pumped at a wavelength of 980 nm. The prospects for multi-band amplifiers and lasers are discussed.

Herpes zoster in a five month old infant subsequent to intrauterine exposure to varicella infection

Herpes zoster is characterized by painful vesicular eruption in a dermatomal distribution of sensory nerves as a result of reactivation of latent herpes zoster virus in posterior root ganglia. The primary varicella infection is usually acquired in childhood and reactivation usually is seen in elderly. In rare instances herpes zoster can also occur in infancy as a result of reactivation of primary varicella infection acquired in utero or in early infancy. Here, we report a rare case of herpes zoster in a 5 month baby who acquired primary infection in utero from mother who had varicella infection at 6 months of gestation.

Diagnosis of subcutaneous cysticercosis in fine needle aspirates: a study of 10 cases

The objective of this study is to document the value of Fine Needle Aspiration Cytology (FNAC) in the diagnosis of subcutaneous cysticercosis. Aspirates smears of 10 cases of subcutaneous swellings were studied over a period of 1 year between January 2004 and January 2005. The subcutaneous swellings were presented at different sites like cheek, neck, forearm, arm, chest wall and abdominal wall. In none of these cases was cysticercosis considered as diagnostic possibility. The characteristic cytomorphological features of parasitic tegument, parenchymatous portion, presence of epithelioid cells, giant cells and inflammatory cells in cytological smears help diagnose the cases of subcutaneous cysticercosis. Biopsy confirmation was possible in 5 cases, of which, two cases showed parenchymatous portion of the parasite. FNAC provides safe and rapid tool for diagnosis of subcutaneous cysticercosis. In endemic areas, cysticercosis should be considered one of the differential diagnosis of the subcutaneous swellings.

Retinal injury as an early manifestation of posttransplant thrombotic microangiopathy: recovery with plasma exchanges and conversion to sirolimus--case report and review of the literature

Thrombotic microangiopathy (TMA) remains a serious event. We report a case of occurrence of TMA in the immediate postoperative period after a living-related renal transplantation. A distinguished feature of the case was major, early involvement of the retina with marked by decreased visual acuity along with thrombocytopenia and renal functional impairment. The syndrome was reversible with plasma exchange and conversion from tacrolimus to sirolimus. The patient's renal function is excellent at 11 months after transplantation. Decreased visual acuity and cotton wool exudates may be the first manifestation of posttransplant TMA.

Donor Gender Balance in a Living-Related Kidney Transplantation Program in Oman

It has been observed in several Eastern and Western countries that there is a gender imbalance among kidney donors. In the international experience, approximately 65% of live kidney donors have been women. We retrospectively studied the distribution of female and male donors or recipients among living kidney transplantations performed from 1980 to 2005, namely 198 Omani recipients of living-related kidney transplantations. To examine cultural influences, transplantations performed or expatriates were excluded from the study. For the whole period, 98 out of 198 donors (49.5%) were women. The number of female recipients 75 of 198 (38%) versus males were 123 (62%) recipients. We then subdivided the period into three intervals: 1980 to 1990, 1991 to 2000, and 2001 to 2005. The numbers of female donors for these three periods were 29 of 64 (45%), 42 of 89 (47%), and 27 of 45 (60%), respectively. There was a persistent preponderance of male recipients ranging from 58% to 66% during these periods. We concluded that there was no gender imbalance for kidney donors. Nevertheless, there was a male preponderance in the recipient group.

Dietary microbial levan enhances cellular non-specific immunity and survival of common carp (Cyprinus carpio) juveniles

A preliminary study with a 75days feeding trial was conducted to study the immunomodulatory effect of microbial levan on Cyprinus carpio juveniles. Five purified isonitrogenous and isocaloric diets with graded levels of levan, namely (T(1)) 0.1% levan, (T(2)) 0.2% levan, (T(3)) 0.5% levan, (T(4)) 1.0% levan, and a control group without levan were fed to five groups of fishes in triplicate. The total erythrocyte count and haemoglobin content was significantly (p<0.05) enhanced in the T(3) group, though the total leucocyte counts, total protein and A/G ratio did not show any significant difference (p>0.05) when compared with the control group. The respiratory burst activity (NBT) of blood phagocytes and lysozyme activity was also highest in T(3) group. The relative survival percentage after challenge with Aeromonas hydrophila was highest (100%) in the T(3) group followed by 83.33% and 66.67% in the T(2) and T(4) groups, respectively. This suggests that microbial levan at 0.5% can be used as a dietary immunostimulant for C. carpio juveniles. This is the first report on microbial levan having an immunomodulatory effect on C. carpio.

Complete Regression of Cutaneous B-Cell Lymphoma in a Renal Transplant Patient After Conversion From Cyclosporin to Sirolimus

Posttransplant lymphoproliferative disease remains a serious morbidity. Herein we have reported a case of complete regression of a biopsy-proven B-cell lymphoma that occurred in the posttransplant period. A 48-year-old man received a living donor renal transplant for end-stage renal disease due to undetermined etiology. His initial immunosuppression consisted of corticosteroid, mycophenolate mofetil, and cyclosporin. The patient developed severe pneumonia within the first 2 months after transplantation due to Acineotobacter, fungus, and cytomegalovirus infections. He experienced a complete recovery and was discharged for regional follow-up. Four months after discharge, he was referred again because of presence of two nodules on his trunk. A biopsy of the nodules revealed B-cell lymphoma. Cyclosporin was stopped and he was converted to sirolimus. The lesions regressed progressively and completely within 7 weeks. The patient remains well without clinical relapses at 19 months after conversion. Renal functions remained stable. We postulated that the antincoplastic properties of sirolimus may have played an active part in the positive outcome.

A rare case of juvenile fibrosarcoma of eyelid

Juvenile fibrosarcoma is not an uncommon tumor in children; however, eyelid involvement is extremely rare. Very few cases have been reported in the literature. This is the first case of JFS of the eyelid in Tribhuvan University Teaching Hospital and the first diagnosed case in Nepal. Histologically, it is similar to adult fibrosarcoma but it has an excellent prognosis. Surgical excision is the mainstay of treatment; however chemotherapy has been proved effective. Here we present a case of juvenile fibrosarcoma of the eyelid in a four year female child presenting with a rapidly enlarging, painless, left upper eyelid mass. An incisional biopsy, from the eyelid mass, showed typical histopathological features of juvenile fibrosarcoma.

Femtosecond laser inscription of optical waveguides in Bismuth ion doped glass

We report on the fabrication of high quality embedded channel waveguides inside Bi-doped silicate glass using femtosecond waveguide inscription. Waveguides are fabricated using both single and multi-scan fabrication techniques. Refractive index modifications of up to Deltan = 4.3 x 10(-3) are observed, allowing the fabrication of waveguides nearly mode-matched to telecom fibers. When optically pumped at 980 and 810 nm broadband fluorescence emission centered at 1.3 microm with a FWHM of up to 500 nm is detected.

Histopathological analysis of hysterectomy specimens

This was a retrospective study carried out on all hysterectomy specimens sent to Department of Pathology of Tribhuvan University Teaching Hospital, Kathmandu, Nepal from 1st September 2005 to 28th February 2006, to study the histopathological findings of these specimens. All informations used in the study were obtained from the records of Department of Pathology of the hospital. Out of 221 hysterectomy specimens received during the study period, 139 (62.9%) were total abdominal and 82 (37.1%) were vaginal hysterectomy specimens. Mean age of the patient was 53.4 years for vaginal hysterectomy group where as it was 37.6 years for total abdominal hysterectomy with unilateral salpingo-oophorectomy and 46.3 years for total abdominal hysterectomy with bilateral salpingo-oophorectomy group. Uterine prolapse was commonest indication of hysterectomy overall (37.1%) and accounted for 98.8% of vaginal hysterectomies. Other common indications of hysterectomy were uterine fibroid (24.9%), ovarian tumor (14.9%) and dysfunctional uterine bleeding (7.7%). Leimyoma was the most common pathology found in uterine corpus (27.1%). Chronic cervicitis in cervix, functional cysts in ovaries and paratubal cysts in fallopian tubes were most common histological findings. Ovarian neoplasms accounted for 18.3% of ovarian pathology. 38% specimens were unremarkable histopathologically. In Tribhuvan University Teaching Hospital, abdominal hysterectomies are more common than vaginal hysterectomies. Most vaginal hysterectomies are done for uterine prolapse and patients are older than those undergoing abdominal hysterectomies. Most abdominal hysterectomies are performed for uterine leiomyomas. Hysterectomy specimens may be unremarkable histopathologically, most of which are vaginal hysterectomies done for uterine prolapse.

1-N-(Arylmaleamoyl)-3,5-bis(phenylmethylene)4-piperidones: a novel class of antimycobacterial agents

Various acyl groups possessing markedly divergent topography were placed on the nitrogen atom of the antimycobacterial agent 3,5-bis(phenylmethylene)-4-piperidone (1). Some of the N-maleamoyl analogues of 1 displayed antitubercular properties thereby affording an insight into the structural requirements for interactions at a putative auxiliary binding site in the bacterium.

Cytotoxic 4'-aminochalcones and related compounds

A series of 4'-aminochalcones 1 and related maleamic acids 2 and Schiff bases 3 were designed and synthesized as candidate cytotoxic agents. The atomic charges on different atoms of representative compounds were calculated. Evaluation of the enones 1-3 against human Molt 4/C8 and CEM T-lymphocytes as well as murine P388 and L1210 leukemic cells revealed that approximately 40% of the IC50 values generated were less than 10 microM. In some cases cytotoxicity was correlated with the Hammett sigma values of the aryl substituents and less frequently with the aryl Hansch pi values. Evidence was obtained that in general these compounds displayed selective toxicity for certain malignant cells and were well tolerated in mice. This study has revealed various directions whereby the project may be amplified in the future with a view to finding compounds with increased cytotoxicity to tumour cells.

Hereditary punctate palmoplantar keratoderma--a clinical study

28 patients of hereditary punctate palmoplantar keratoderma (HPPK) were selected from DermatoVenereology out patients of Rajindra Hospital, Patiala. Cases were divided into group A with PPK as major feature and group 6 with PPK as minor feature. 11/28 belonged to group A and 17/28 to group B. Group A patients revealed scattered pundate PPK in 6 and scattered pundate plus focal plaques in 5, while in group B patterns seen were KPPC (6), KPPC with focal (6), focal plus scattered punctate (3) and diffuse with superimposed KPPC (2).

Pyoderma gangrenosum and urinary tract infection

A case of pyoderma gangrenosum is reported in a 52-year-old man who had skin lesions without any association. On investigation urinary tract infection was detected. Treatment of UTI led to spontaneous healing of the lesions in short period thus avoiding the need of oral corticosteroids.

To tell or not to tell-comparison of older patients' reaction to their diagnosis of dementia and depression

OBJECTIVE

Investigation of the reaction of elderly patients to the disclosure of their diagnosis of dementia compared with depression.

DESIGN

Elderly patients suffering from dementia and depression were asked to complete a questionnaire about the diagnosis and other aspects of their clinical summary sent to them by post. Demographic data included age, gender, marital status and occupation; degree of dementia or depression was established by administering the mini-mental state examination and the geriatric depression scale, respectively.

SETTING

Patients were consecutive attendees of outpatient clinics (old age psychiatry) located in two suburban areas near London.

MEASURES

Demographic data included age, gender, marital status and occupation; degree of dementia or depression was established by administering the mini-mental state examination and the geriatric depression scale, respectively.

RESULTS

One hundred cases were recruited, 53 with dementia and 47 with depression. Most depressed and dementia patients ( > 75%) liked the idea of reading their diagnosis but 25% of dementia cases felt upset. Within the dementia group, the majority of patients with mild or severe dementia welcomed the idea of knowing their diagnosis; and 13 (100%) of the patients with vascular dementia wished to know (compared with 68% cases with Alzheimer's disease). None felt upset, and only 39% of them felt pessimistic after reading their own clinical summary. However, among dementia patients who also happened to be depressed, a higher proportion (60%) expressed an unfavourable view towards knowing their diagnosis, but only a minority (40%) of them were actually upset. Most older married females, especially those with depression and Alzheimer's disease, felt pessimistic afterwards.

CONCLUSIONS

There was no significant difference between patients with dementia or depression in their wish to know their diagnosis. Patients with severe dementia, even if they felt upset, preferred to be told their diagnosis. Patients with vascular dementia tended to express a more favourable view.

Tm(3+)-Doped Tellurite Glass for a Broadband Amplifier at 1.47 num

Tm(3+)-doped tellurite glass is investigated as a host for a broadband amplifier at 1.47 mum. The Tm(3+) fluorescence spectrum, lifetime, and cross section in tellurite glass are compared with those in fluorozirconate glasses. The advantages of a Tm(3+)-tellurite amplifier, especially when it is employed in combination with an Er(3+)-tellurite 1.55-mum amplifier, are discussed.

Microstructural analysis of Al alloys dispersed with TiB2 particulate for MMC applications

A dispersion of TiB2 particulates in an Al alloy matrix was formed via the in-situ reaction between mixtures of K2TiF6 (K2ZrF6), KBF4 and molten aluminium. The dispersion of the ceramic phase in the aluminium matrix was also achieved in some experiments by adding exogenous TiB2 particles to the fluoride melt in contact with molten aluminium. In this work, we have examined the microstructure of the as-cast metal matrix composites using analytical electron microscopy and X-ray diffraction techniques. The phases formed as a result of the reaction between the molten fluoride flux and liquid aluminium have been identified. These were (Ti, Zr, Al)B2, Al3Ti and possibly AlB12 in the Al-matrix, and KAlF4 and KMgF3 in the solidified flux. The mechanism of formation of TiB2 and Al3Ti is explained. The role of alloying elements is also explained in the context of interfacial chemistry and dispersion.

Improving response to critical laboratory results with automation: results of a randomized controlled trial

OBJECTIVE

To evaluate the effect of an automatic alerting system on the time until treatment is ordered for patients with critical laboratory results.

DESIGN

Prospective randomized controlled trial.

INTERVENTION

A computer system to detect critical conditions and automatically notify the responsible physician via the hospital's paging system.

PATIENTS

Medical and surgical inpatients at a large academic medical center. One two-month study period for each service.

MAIN OUTCOMES

Interval from when a critical result was available for review until an appropriate treatment was ordered. Secondary outcomes were the time until the critical condition resolved and the frequency of adverse events.

METHODS

The alerting system looked for 12 conditions involving laboratory results and medications. For intervention patients, the covering physician was automatically notified about the presence of the results. For control patients, no automatic notification was made. Chart review was performed to determine the outcomes.

RESULTS

After exclusions, 192 alerting situations (94 interventions, 98 controls) were analyzed. The intervention group had a 38 percent shorter median time interval (1.0 hours vs. 1.6 hours, P = 0.003; mean, 4.1 vs. 4.6 hours, P = 0.003) until an appropriate treatment was ordered. The time until the alerting condition resolved was less in the intervention group (median, 8.4 hours vs. 8.9 hours, P = 0.11; mean, 14.4 hours vs. 20.2 hours, P = 0.11), although these results did not achieve statistical significance. The impact of the intervention was more pronounced for alerts that did not meet the laboratory's critical reporting criteria. There was no significant difference between the two groups in the number of adverse events.

CONCLUSION

An automatic alerting system reduced the time until an appropriate treatment was ordered for patients who had critical laboratory results. Information technologies that facilitate the transmission of important patient data can potentially improve the quality of care.

Do Medicare patients with disabilities receive preventive services? A population-based study

OBJECTIVE

To compare health maintenance procedure rates of Medicare patients with different levels of disability.

STUDY DESIGN

Observational study analyzing data from the 1995 Medicare Current Beneficiary Survey (MCBS, n = 15,590). Self-reported Pap smears, mammograms, and influenza and pneumococcal vaccinations were compared between groups with different levels of health-related difficulties in six activities of daily living (ADL).

RESULTS

Compared to those without disabilities, the most severely disabled women (limitations in 5 or 6 ADL) reported fewer Pap smears (age < or =70, 23% vs 41%, p < .001) and mammograms (age > or = 50, 13% vs 44%, p < .001). In a controlled analysis, individuals with this high level of disability were 57% (95% confidence interval [CI], 33% to 72%) and 56% (95% CI, 43% to 76%) less likely to report receiving Pap smears and mammograms, respectively, compared with able-bodied women, regardless of their age, whether they were in an HMO, or whether they lived in a long-term care facility. Functional limitations were not a deterrent to receiving vaccinations. In general, patients in HMOs reported more procedures than those in fee-for-service, while those in long-term care facilities reported fewer procedures than those living in the community.

CONCLUSIONS

Disability among Medicare patients is a significant, independent risk factor for not receiving mammograms and Pap smears. Efforts should be made to identify the most severely disabled because they are at particular risk.

Constituents of the yew trees

Yew trees, taxonomically classified under the genus Taxus, are sources of a number of physiologically active compounds of different classes. Taxane derivatives with various carbon skeletons, lignans, flavonoids, steroids and sugar derivatives have been isolated from different Taxus species. Compounds isolated from the genus Taxus between 1908 and December 1997 have been comprehensively reviewed.

How promptly are inpatients treated for critical laboratory results?

OBJECTIVE

The purpose of the study is to determine how frequently critical laboratory results (CLRs) occur and how rapidly they are acted upon. A CLR was defined as a result that met either the critical reporting criteria used by the laboratory at Brigham and Women's Hospital or other, more complex criteria.

DESIGN

This is a retrospective cohort study in a large academic tertiary-care hospital.

MEASUREMENTS

The proportion of chemistry and hematology results obtained in a 13-day period that met the hospital laboratory's critical reporting criteria were calculated. The charts of a stratified random sample of patients with CLRs due to sodium, potassium, and glucose were reviewed to determine the time interval until an appropriate treatment was ordered and the time interval until the critical condition was resolved.

RESULTS

In 13 days, 1938 of 201,037 laboratory results (0.96%, or 0.44 per patient-day) met the hospital's critical reporting criteria. In the chart review, 222 CLRs were included in the stratified random sample, and 99 of these met the inclusion criteria. Among these 99 CLRs, the median time interval until an appropriate treatment was ordered was 2.5 hours. This interval was 1.8 hours when the CLR met the laboratory's criteria and a phone call was made, and 2.8 hours when the CLR met more complex criteria not requiring a phone call (p = 0.07). For 27 (27%) of the CLRs, an appropriate treatment was ordered only after five or more hours. The median time until the condition resolved was 14.3 hours: 12.0 hours for CLRs that met the hospital's criteria and 20.9 hours for the CLRs that met the more complex criteria (p = 0.006).

CONCLUSION

Although CLRs meeting the hospital's criteria were reported promptly by the laboratory, treatment delays were still common. Results that did not meet the hospital's critical criteria but still represented serious clinical situations were more often associated with treatment delays. Difficulty communicating critical results directly to the responsible caregiver is the likely cause of some delays in treatment. New communications methods, including computer-based technologies, should be explored and tested for their potential to reduce treatment delays and improve clinical care.

Predicting bacteremia in patients with sepsis syndrome. Academic Medical Center Consortium Sepsis Project Working Group

The goal of this study was to develop and validate clinical prediction rules for bacteremia and subtypes of bacteremia in patients with sepsis syndrome. Thus, a prospective cohort study, including a stratified random sample of 1342 episodes of sepsis syndrome, was done in eight academic tertiary care hospitals. The derivation set included 881 episodes, and the validation set included 461. Main outcome measures were bacteremia caused by any organism, gram-negative rods, gram-positive cocci, and fungal bloodstream infection. The spread in probability between low- and high-risk groups in the derivation sets was from 14.5% to 60.6% for bacteremia of any type, from 9.8% to 32.8% for gram-positive bacteremia, from 5.3% to 41.9% for gram-negative bacteremia, and from 0.6% to 26.1% for fungemia. Because the model for gram-positive bacteremia performed poorly, a model predicting Staphylococcus aureus bacteremia was developed; it performed better, with a low- to high-risk spread of from 2.6% to 21.0%. The prediction models allow stratification of patients according to risk of bloodstream infections; their clinical utility remains to be demonstrated.