Case management and patient reactions: a study of STD care in a province in Zambia

Sexually transmitted disease (STD) case management was evaluated through observation and interviews at 2 urban and 4 rural health centres and 2 district hospital STD clinics in one urban and 2 rural districts in Central Province, Zambia. The analysis was limited to 59 patients (42 men and 17 women) who paid first visits for their disease and were managed by a clinical officer. The evaluation suffered from the lack of a standard for case management. Results showed that the patients engaged in risky sexual behaviour without being aware of the risks. At the health institutions, few patients were informed about condoms, the risk of HIV, and abstinence from sex during treatment and few were asked to notify their partners. Clinical officers with special STD training performed better than others but sill informed only one-fifth of the patients. Few clinical officers managed patients according to the syndromic approach recommended by the STD control programme.

Effect of varying atrial sensitivity, AV interval, and detection algorithm on automatic mode switching

Automatic mode switching (AMS) is absolutely dependent on atrial tachyarrhythmia detection. The effects of programming several features that could influence tachyarrhythmia detection were assessed in 18 patients (six women; mean age 64 years) with pacemakers having AMS capability. The atrial electrogram amplitude in sinus rhythm at implant (SR-EGM), last measured atrial sensing threshold prior to tachycardia (A-SENS), and atrial sensing threshold for effective AMS during atrial tachyarrhythmia (AMS-SENS) were obtained. Additionally, ten patients had AV intervals increased from 60 to 200 ms, while seven patients had detection algorithms made more stringent from 5 beats at 150 beats/min to 11 beats at 200 beats/min to assess their effects on AMS efficacy.

RESULTS

Sensitivities:Mean SR-EGM = 3.55 mV; mean A-SENS = 2.06 mV; and mean AMS-SENS = 1.46 mV. Fourteen patients developed atrial fibrillation and four atrial flutter. Thirteen of 14 patients who developed atrial fibrillation sensed adequately at > or = 1.0 mV in normal sinus rhythm (NSR), but only six patients had effective AMS at these settings in atrial fibrillation. Three of four patients who developed atrial flutter had effective AMS at > or = 2.0 mV. AV Interval:AMS was effective in eight of ten patients at AV intervals up to 200 ms. One patient lost AMS at an AV interval of 120 ms. Algorithm: In two of seven patients, AMS was not effective if the detection algorithm was more stringent than five beats at 150 beats/min.

CONCLUSIONS

(1) In atrial fibrillation, effective AMS requires more sensitive atrial settings than in NSR; (2) AV intervals as short as 120 ms can interfere with AMS function; and (3) More stringent detection algorithms may be inappropriate for effective AMS function.

STD care in Zambia: an evaluation of the guidelines for case management through a syndromic approach

Clinical diagnosis of STDs is unreliable and therefore constitutes a poor basis for choice of treatment. A syndromic approach has been suggested to increase effectiveness of treatment in resource poor settings. Algorithms for the treatment of STD syndromes were evaluated. A total of 436 patients were followed; cure rates were defined and estimated for genital ulcer disease (GUD), urethral and vaginal discharge. Cure rates for the discharge syndromes were high, 97-98%, for both sexes. The cure rate for GUD was 83% for female and 69% for male patients. A higher prevalence of syphilis in the female study population probably contributed to this. It is likely that a large proportion of the treatment failures were due to decreased susceptibility of Haemophilus ducreyi to trimethoprim-sulpha. The determination of cure rates met with a number of methodological problems. This makes it difficult to evaluate the algorithms as part of routine activities, as suggested earlier by WHO.

Outbreak of Escherichia coli O157 phage type 2 infection associated with eating precooked meats

Fourteen cases of Escherichia coli O157 infection were reported to the consultant in communicable disease control in Sunderland Health Authority in August 1995. E. coli O157 phage type 2, Vero cytotoxin 2 was isolated from the faeces of ten cases. Nine of the isolates were indistinguishable by Vero cytotoxin subtyping and analysis of chromosomal DNA. Two cases with haemolytic uraemic syndrome were confirmed serologically and two cases remained unconfirmed. A case control study showed infection with E. coli O157 to be associated with having eaten precooked meats from a single shop. Environmental investigations at the shop showed that cooked meats were stored close to raw beef, raw meats were left on preparation surfaces, and the same staff served both raw and cooked meats. This outbreak draws attention to standards of food preparation and handling in outbreaks of E. coli O157, the issue of cross contamination, and the need to improve local surveillance of haemolytic uraemic syndrome.

Monoclonal antibodies against Haemophilus ducreyi lipooligosaccharide and their diagnostic usefulness

Monoclonal antibodies against the lipooligosaccharide of Haemophilus ducreyi were produced. Two of them, MAHD6 and MAHD7, were found to be relatively, although not absolutely, specific and reacted with nearly all strains of Haemophilus ducreyi tested: 59 of 60 and 60 of 60, respectively. The diagnostic usefulness of MAHD7 was assessed. Clinical specimens collected in Zambia from patients with genital ulcers were tested using indirect immunofluorescence (IF), enzyme immunoassay (EIA), the polymerase chain reaction (PCR) and bacterial culture. Compared with culture, IF had a sensitivity of 100%; compared with PCR, sensitivity was 89%. The corresponding figures for the EIA were 83% and 74%, respectively. The sensitivity of culture compared with PCR was 63%. The results suggest that IF on genital smears using MAHD7 might be an excellent tool for the diagnosis of chancroid in high-prevalence populations. However, further evaluation of the specificity of this test is needed.

Long term outcome of renal transplantation in the pre cyclosporin era: one centre's experience

The number of renal transplants has been increasing steadily over the last twenty years. This increase has been associated with a significant improvement in the one year graft and patient survival. However, as survival improves, long term complications are becoming more clinically important. We, therefore, retrospectively reviewed our experience of renal transplantation in 165 patients between January 1970 and December 1980, and describe in detail the complications experienced by those whose grafts functioned for 10 years or longer. The 10 year patient survival rate was 47% and graft survival rate was 30%. The graft survival rate for living related grafts was superior to that of cadaveric grafts. The major cause of mortality in the first year following renal transplantation was infection and in subsequent years, cardiovascular disease predominated. Patients whose grafts functioned for 10 years or more developed a variety of complications including infection, skin cancer and hepatic dysfunction. Clinicians involved in the long term care of the patients need to be aware of these problems and skilled in their management.

Cloning and structure-function analysis of the Leishmania donovani kinetoplastid membrane protein-11

This report describes the complete translated gene sequence, predicted secondary structure and lipid bilayer association of a novel kinetoplastid membrane protein (KMP-11) from Leishmania donovani promastigotes. KMP-11 was previously referred to as the lipophosphoglycan-associated protein (LPGAP). The isolation, species distribution and chemical characterization, including a partial protein sequence analysis and post-translational modifications, of this major membrane component have been described [Jardim, Funk, Caprioli and Olafson (1995) Biochem. J. 305, 307-313]. C.d. measurements of KMP-11 indicated a very high helical content estimated to be approximately 86% in trifluoroethanol. This was in agreement with computer-based secondary-structure analyses which predicted KMP-11 to be almost exclusively alpha-helical, with the protein adopting a helix-loop-helix motif. Arrangement of the residues located in the putative helical regions on an Edmundson helical wheel showed that this molecule could have a strongly amphipathic conformation and provided an explanation for how such a highly charged protein might be inserted into the plasma membrane. Evidence in support of KMP-11 association with lipid bilayers was provided by showing that KMP-11 could mediate carboxyfluorescein release from liposomes. These findings suggested that KMP-11 may function in part to increase bilayer pressure, stabilizing molecules such as lipophosphoglycan within the parasite pellicular membrane.

Advance patient directives: are they worth it?

The Patient Self-Determination Act became effective in December 1991. After two complete years of experience, data are emerging to indicate how implementation of the Act has affected the issues of patient autonomy and cost containment. In this third article of a series on advance directives, the authors conclude that the preliminary results of their study are consistent with other studies recently completed that demonstrate the favorable effect of the Act on enhancing patient autonomy and containing the costs of health care. The authors suggest a basic study design for replication and adaptation by others, encourage more uniformity by researchers in future studies to more precisely measure the effect of the Act, and briefly describe the expansion of their continuing study.

Advance patient directives: assessing the alternatives

Whereas the Patient Self-Determination Act is a significant step in the right direction, there are ethical, legal, and medical questions yet unresolved. In this second installment of a three-part series, the authors describe the options available to patients.

Advance patient directives: preserving consumer choice

In the first of three articles, the authors discuss the public policy issues addressed by advance patient directives, including the Cruzan case and decision-making standards for incompetent patients.

Motor performance, histologic damage, and calcium influx in rats treated with NBQX after focal ischemia

2,3-Dihydroxy-6-nitro-7-sulfamoylbenzo(F)-quinoxaline (NBQX), an alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) receptor antagonist, has been reported to provide neuronal protection after global ischemia. The objectives of this study were to evaluate the neuroprotective effects of NBQX initiated after focal cortical ischemia and to validate a method for measuring functional outcome in this model. Male spontaneously hypertensive rats (SHRs) were exposed to various durations of transient or permanent tandem middle cerebral artery (MCA) occlusion. Studies compared motor performance using balance beam and prehensile-traction tests, calcium-calmodulin (Ca-CaM) binding by immunohistochemistry, and infarct volume between NBQX-treated animals [intravenous (i.v.) 5 mg/kg/h x 6 h or intraperitoneal (i.p.) 30 mg/kg q 30 min x 3 begun postischemia] and controls. All ischemic groups performed less well than sham-operated controls on the motor performance tasks in proportion to the severity of ischemia. No significant improvement in motor performance was noted in the NBQX-treated versus the control animals after 1 h or permanent MCA/CCA occlusion. Treatment with NBQX (i.v. or i.p. dosing) did not reduce Ca-CaM binding after 1 h of occlusion with 1 h of reperfusion or after 2 h of occlusion. Similarly, there was no reduction in infarct size between NBQX-treated and control animals after 24 h of permanent MCA/CCA occlusion (74.6 +/- 7.1 vs. 80.1 +/- 6.0 ml; ns) or after 1 h of occlusion with 23 h of reperfusion (55.1 +/- 4.4 vs. 47.4 +/- 6.2 ml; ns).(ABSTRACT TRUNCATED AT 250 WORDS)

Unstable amplification of two extrachromosomal elements in alpha-difluoromethylornithine-resistant Leishmania donovani

We describe the first example of unstable gene amplification consisting of linear extrachromosomal DNAs in drug-resistant eukaryotic cells. alpha-Difluoromethylornithine (DFMO)-resistant Leishmania donovani with an amplified ornithine decarboxylase (ODC) gene copy number contained two new extrachromosomal DNAs, both present in 10 to 20 copies. One of these was a 140-kb linear DNA (ODC140-L) on which all of the amplified copies of the odc gene were located. The second was a 70-kb circular DNA (ODC70-C) containing an inverted repeat but lacking the odc gene. Both ODC140-L and ODC70-C were derived from a preexisting wild-type chromosome, probably by a conservative amplification mechanism. Both elements were unstable in the absence of DFMO, and their disappearance coincided with a decrease in ODC activity and an increase in DFMO growth sensitivity. These results suggest the possibility that ODC70-C may play a role in DFMO resistance. These data expand the diversity of known amplification mechanisms in eukaryotes to include the simultaneous unstable amplification of both linear and circular DNAs. Further characterization of these molecules will provide insights into the molecular mechanisms underlying gene amplification, including the ability of linear amplified DNAs to acquire telomeres and the determinants of chromosomal stability.

Cloning of the gene encoding Leishmania donovani S-adenosylhomocysteine hydrolase, a potential target for antiparasitic chemotherapy

A full-length gene encoding the S-adenosylhomocysteine hydrolase (AdoHcyase) enzyme has been isolated from a genomic library of Leishmania donovani DNA in lambda GEM-11 by cross-hybridization to the full-length human AdoHcyase cDNA. The nucleotide sequence of the SalI fragment contained a single open reading frame that encoded a polypeptide of 438 amino acids (47,712 Da). After maximum gap alignment, the predicted amino acid sequence of the leishmanial AdoHcyase was 70-73% identical to AdoHCyases from higher eukaryotes. In addition, a data base search revealed that the primary structure of all AdoHcyase proteins was highly homologous to that of a protein encoded by a mRNA from Drosophila melanogaster that maps near the r element function of the Abd-b homeotic gene. In Northern blots, the SalI fragment hybridized to a 3.0-kb transcript that presumably encodes the parasite enzyme. Southern blot analysis of genomic DNA revealed that the AdoHcyase gene did not exist as a tandemly repeated array within the L. donovani genome. Moreover, monoclonal antibodies generated against human AdoHcyase recognized a leishmanial protein on immunoblots. Finally, the growth of L. donovani promastigotes could be arrested by micromolar concentrations of 3-deazaaristeromycin (C3Ari) and 9-(trans-2',trans-3'-dihydroxycyclopentanyl)adenine, 2 known inhibitors of mammalian AdoHcyase. C3Ari also induced a substantial expansion of the intracellular pools of both AdoHcy and S-adenosylmethionine (AdoMet), as well as a significant diminution of the AdoMet/AdoHcy ratio. Thus, AdoHcyase may have therapeutic potential for the selective treatment of diseases of parasitic origin.

Amplification and molecular cloning of the ornithine decarboxylase gene of Leishmania donovani

A strain of Leishmania donovani has been described that is resistant to DL-alpha-difluoromethylornithine (DFMO), an inhibitor of ornithine decarboxylase (OD-Case) activity, and contains 15-fold greater amounts of ODCase activity and protein than the wild type strain from which it was derived (Coons, T., Hanson, S., Bitonti, A.J., McCann, P.P., and Ullman, B. (1990) Mol. Biochem. Pharmacol. 39, 77-90). From this mutant strain, another ODCase overproducing L. donovani strain, DFMO16, was generated by virtue of its ability to proliferate under even higher concentrations of DFMO. To investigate the mechanism by which DFMO-resistant cells overexpress ODCase, the leishmanial ODCase gene was isolated by hybridization to a fragment of the L. donovani ODCase gene that was generated by the polymerase chain reaction. The nucleotide sequence of a 4.5-kilobase DNA fragment encompassed an open reading frame encoding 707 amino acids (Mr = 77,350). The leishmanial protein contained an extra approximately 200 amino acid NH2-terminal extension and lacked the COOH terminus of the mammalian ODCase. Northern blot analysis revealed two leishmanial OD-Case transcripts of 4.8 and 6.5 kilobases, both of which were amplified 10-20-fold in the DFMO16 cells. Genomic Southern blot analysis established that the augmented amount of ODCase activity and ODCase mRNA in the DFMO16 strain could be attributed to a approximately 10-20-fold amplification of the ODCase gene copy number. DFMO16 cells exhibited an unstable phenotype in that the amplification of the ODCase gene, the increased amount of ODCase transcript, the overproduction of ODCase activity, and the DFMO-resistance growth phenotype all reverted synchronously in the absence of selective pressure.

Nucleotide sequence of the Leishmania donovani medRNA gene

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Fatty acids modulate calcium-induced calcium release from skeletal muscle heavy sarcoplasmic reticulum fractions: implications for malignant hyperthermia

Based on studies in swine, the malignant hyperthermia syndrome has been postulated to result from an enhanced sensitivity (low threshold) of the Ca2(+)-induced Ca2(+)-release process. However, fatty acid production is elevated in homogenates of skeletal muscle from pigs and humans susceptible to malignant hyperthermia. In the present study, we demonstrate that the threshold of Ca2(+)-induced Ca2+ release is normal in susceptible humans and in susceptible swine depleted of triglycerides. Exogenously added unsaturated fatty acids decreased the threshold of Ca2(+)-induced Ca2+ release to a much greater extent in porcine and equine muscle than in human muscle. When triglyceride and free fatty acid values were reduced to about 40 and 60%, respectively, of control values, malignant hyperthermia-susceptible swine did not exhibit muscle rigidity when challenged in vivo with halothane and succinylcholine and the threshold of the Ca2(+)-induced Ca2(+)-release process in heavy sarcoplasmic reticulum fractions was normal. Despite the reduced triglyceride and fatty acid levels, these swine had a positive in vitro contracture test for malignant hyperthermia. A low Ca2(+)-induced Ca2(+)-release threshold is not essential for malignant hyperthermia susceptibility, but appears to be the result of excessive free fatty acids produced during organelle isolation.

Adenylate deaminase deficiency in a mutant murine T cell lymphoma cell line

From a population of wild type S49 cells, a clone, DTB6, was isolated in a single step from selective medium containing thymidine and dibutyryl cyclic AMP that exhibited a 60% deficiency in AMP deaminase (AMP-D) activity. The AMP-D deficiency conferred to the DTB6 cells a striking susceptibility to killing by low concentrations of either adenine or adenosine, the latter in the presence of an inhibitor of adenosine deaminase activity. This growth supersensitivity of DTB6 cells toward adenine could be ameliorated by the addition of hypoxanthine to the culture medium. Immunoprecipitation of AMP-D from wild type and mutant cells revealed that the DTB6 cell line contained markedly diminished amounts of the AMP-D isozyme which reacts with antisera to the predominant isoform expressed in adult kidney. The quantities of the AMP-D isozyme immunoprecipitated by antisera raised to the predominant isoform prepared from adult heart were equivalent in the two cell lines. Although Northern blot analyses revealed no alterations in mRNA sizes or levels encoded by either of the AMP-D genes, Southern blots of genomic DNA hybridized to a cDNA specific for the ampd2 gene revealed the presence of a new BamHI restriction fragment in the DNA of DTB6 cells. These data suggested that a point mutation has occurred in the ampd2 gene of DTB6 cells which encodes the AMP-D isozyme recognized by the kidney antisera. The DTB6 cells also possessed a virtual complete deficiency in thymidine kinase activity. The two enzyme deficiencies were distinguishable. The ability to isolate single step mutants with two seemingly independent biochemical abnormalities raises the speculation that there may be some link between cellular functions responsible for purine nucleotide and thymidine metabolism.

Alpha-difluoromethylornithine resistance in Leishmania donovani is associated with increased ornithine decarboxylase activity

The promastigote form of Leishmania donovani is sensitive to growth inhibition by DL-alpha-difluoromethylornithine (DFMO), an inhibitor of ornithine decarboxylase (ODC), the first enzyme of the polyamine biosynthetic pathway, with an EC50 value of approximately 30 microM. Exposure of a wild type (DI700) cell population to gradually increasing concentrations of DFMO resulted in the selection of a strain of Leishmania, DFMO-10, which was capable of proliferating in 10 mM DFMO. DFMO-10 cells possessed an EC50 value for DFMO greater than 4 mM, and were cross-resistant to alpha-methylornithine, alpha-monofluoromethyl-3,4-dehydroornithine methyl ester, and delta-methyl-acetylenic putrescine, three other inhibitors of ODC activity. DI700 and DFMO-10 cells accumulated and/or transported [3H]DFMO and a spectrum of basic, neutral, and acidic amino acids at comparative rates. However, the DFMO-resistant Leishmania, if suspended in culture medium in the absence of DFMO for several days, expressed up to 15-fold greater levels of ODC activity than did wild-type cells. The overexpressed ODC in mutant cells appeared kinetically normal, since the ODC activities from DI700 and DFMO-10 cells possessed similar apparent Km values for ornithine and were equally sensitive to inactivation by DFMO. Incubation of extracts of DFMO-10 cells, but not of wild-type parental cells, with [3H]DFMO for 1 h resulted in the labeling of a polypeptide, presumably ODC, which migrated with a molecular weight of 76,000 +/- 4000 on SDS-gel electrophoretograms. As a consequence of the elevated ODC activities, the levels of putrescine in mutant cells released from DFMO exposure were also elevated by about 15-fold over those of wild-type cells, although spermidine levels in DI700 and DFMO-10 cells were similar. In the absence of prolonged selective pressure, the resistance to DFMO, the ODC activity, and the putrescine levels of DFMO-10 cells all returned to those of wild type cells, indicating that the mutant phenotype of DFMO-selected L. donovani was unstable.

Importance of heart rate response during exercise in patients using atrioventricular synchronous and ventricular pacemakers

Atrioventricular synchronous pacing offers advantages over fixed-rate ventricular (VVI) pacing both at rest and during exercise. This study compared the hemodynamic effects at rest and exercise of ventricular pacing at a rate of 70 beats/min, ventricular pacing where the rate was increased during exercise and dual chamber pacing. Ten patients, age 63 +/- 8 years, with multiprogrammable DDD pacemakers were studied using supine bicycle radionuclide ventriculography. Radionuclide data during dual chamber pacing was acquired at rest and during a submaximal workload of 200-400 kpm/min. The pacemakers were then programmed to VVI pacing at a rate of 70 beats/min, and 1 week later, studies were repeated in the VVI mode at rest, during exercise at a rate of 70 beats/min, and during exercise with the VVI pacemaker programmed to a rate adapted to the DDD pacing exercise rate. At rest, the cardiac output was lower in the VVI compared with the AV sequential mode (4.1 +/- 1.1 vs 5.7 +/- 1.1 1/min, P less than 0.01). During exercise, the cardiac output increased from resting values in the DDD and VVI pacing modes, however cardiac output in the rate-adapted VVI mode was higher than in the VVI mode with the rate maintained at 70 beats/min (8.1 +/- 1.5 vs 6.3 +/- 1.1 1/min, P = 0.02). Three patients completed lower workloads with VVI pacing at 70 beats/min compared with AV synchronous pacing. At rest, AV sequential pacing was superior to VVI pacing, suggesting the importance of the atrial contribution to ventricular filling. With VVI pacing during exercise, cardiac output was improved with an increased pacemaker rate, suggesting that the heart rate response during exercise was the major determinant of the higher cardiac output.