A field trial to assess the effect of vaccination against feline herpesvirus, feline calicivirus and feline panleucopenia virus in 6-week-old kittens

A trivalent (feline panleucopenia, feline herpesvirus, feline calicivirus), modified live, commercially available cat vaccine was used at either 6, 9 and 12 weeks of age (early schedule) or 9 and 12 weeks of age (conventional schedule), and the serological response to vaccination was assessed. The level of maternally derived antibody present at 6 weeks of age was also established. The use of early vaccination at 6 weeks of age induced an antibody response to each virus by 9 weeks of age in a significant proportion of kittens compared with unvaccinated littermates. There was no difference between the conventionally and early-vaccinated groups in terms of antibody response to any antigen by 12 and 15 weeks of age.

Pivotal phase III trial of two dose levels of denileukin diftitox for the treatment of cutaneous T-cell lymphoma

PURPOSE

The objective of this phase III study was to determine the efficacy, safety, and pharmacokinetics of denileukin diftitox (DAB389IL-2, Ontak [Ligand Pharmaceuticals Inc, San Diego, CA]) in patients with stage Ib to IVa cutaneous T-cell lymphoma (CTCL) who have previously received other therapeutic interventions.

PATIENTS AND METHODS

Patients with biopsy-proven CTCL that expressed CD25 on > or = 20% of lymphocytes were assigned to one of two dose levels (9 or 18 microg/kg/d) of denileukin diftitox administered 5 consecutive days every 3 weeks for up to 8 cycles. Patients were monitored for toxicity and clinical efficacy, the latter assessed by changes in disease burden and quality of life measurements. Antibody levels of antidenileukin diftitox and anti-interleukin-2 and serum concentrations of denileukin diftitox were also measured.

RESULTS

Overall, 30% of the 71 patients with CTCL treated with denileukin diftitox had an objective response (20% partial response; 10% complete response). The response rate and duration of response based on the time of the first dose of study drug for all responders (median of 6.9 months with a range of 2.7 to more than 46.1 months) were not statistically different between the two doses. Adverse events consisted of flu-like symptoms (fever/chills, nausea/vomiting, and myalgias/arthralgias), acute infusion-related events (hypotension, dyspnea, chest pain, and back pain), and a vascular leak syndrome (hypotension, hypoalbuminemia, edema). In addition, 61% of the patients experienced transient elevations of hepatic transaminase levels with 17% grade 3 or 4. Hypoalbuminemia occurred in 79%, including 15% with grade 3 or 4 changes. Tolerability at 9 and 18 microg/kg/d was similar, and there was no evidence of cumulative toxicity.

CONCLUSION

Denileukin diftitox has been shown to be a useful and important agent in the treatment of patients whose CTCL is persistent or recurrent despite other therapeutic interventions.

Alternaria-associated asthma

In addition to house dust mites, there is increasing evidence that mold allergens, especially Alternaria, are implicated in contributing to allergic reaction, rhinitis, and asthma indoors. Situations leading to the exacerbation of asthma in an employee were investigated and subsequent medical evaluations were performed. An industrial hygiene study was conducted and bioaerosol testing revealed several mold allergens were present. However, based on the medical evaluation and testing results (skin prick test and radioallergosorbent test [RAST]), it was concluded that Alternaria was inducing the respiratory reaction. Alternaria was present in the drip pan of the air conditioner unit and remedial actions were taken to remove the mold. Post-remedial bioaerosol sampling results revealed Alternaria was no longer present in the air and the employee returned to the office without recurrence of symptoms. Practically, several factors should be considered prior to concluding an association between exposure and illness. First, the employee's symptoms and signs should be consistent with a medical diagnosis. Second, there should be either in vitro or in vivo evidence of exposure. Third, environmental assessment should reveal evidence of plausible biological exposure. Fourth, there should be substantial improvement or even resolution of the illness after appropriate remediation of the health hazard. This case study illustrates the importance of teamwork by industrial hygienists and occupational health physicians in treatment and prevention of occupational and environmental diseases.

Dysphonia associated with inhaled steroids

The use of inhaled steroids in the treatment of asthma is not without its complications. In some studies up to 50% of such patients complain of oropharyngeal and voice problems. We present the findings in 22 patients complaining of dysphonia who underwent videostrobolaryngoscopy (VSL) and computerized speech analysis. A number of abnormalities were identified. On VSL, these included mucosal changes (noted in 58%), apposition abnormalities (noted in 43%), and supraglottic hyperfunction (noted in 40%). On speech analysis, cycle-to-cycle irregularity was frequently noted (mean of 39%). Maximum phonation time was reduced in 73%. Our findings did not confirm the widely held views that steroid dysphonia is due primarily to a fungal infection or a steroid-induced adductor myasthenia of the larynx. A larger-scale prospective study is indicated.

Adoptive immunotherapy in patients with recurrent malignant glioma: preliminary results of using autologous whole-tumor vaccine plus granulocyte-macrophage colony–stimulating factor and adoptive transfer of anti-CD3–activated lymphocytes

Object

This trial was designed to determine the ability of autologous whole–tumor cell vaccines to induce cell-mediated immune responses in patients with recurrent malignant glioma, as well as to determine whether combining such vaccination with adoptive transfer of in vitro activated T lymphocytes prolongs patient survival.

Methods

Nineteen patients with recurrent malignant glioma, in whom previous external beam radiotherapy and at least one course of chemotherapy had failed were vaccinated twice with irradiated autologous whole tumor cells by using granulocyte-marcrophage colony–stimulating factor as an adjuvant. Patients then underwent leukapheresis followed by adoptive transfer of peripheral blood lymphocytes activated in vitro with anti-CD3 and interleukin-2. In vivo immune response, radiological response, clinical outcome, and survival were monitored.

Seventeen patients developed a delayed-type hypersensitivity (DTH) response to vaccination that appeared to be directed against the autologous tumor. In eight patients there was radiological evidence of a response and in five there was evidence of clinical improvement. Median survival was 12 months (range 6–28 months), and both the presence of a DTH response and the radiological response correlated with survival (p < 0.02 and p < 0.04, respectively).

Conclusions

These preliminary results suggest that autologous whole–tumor cell vaccines induce a cell-mediated immune response, which appears to be tumor specific in most patients. Furthermore, vaccination combined with adoptive immunotherapy with in vitro activated cells may induce a radiologically demonstrated tumor response and improved survival despite a condition of advanced disease and immunosuppression resulting from previous treatment or tumor burden. Further studies of immunotherapy are warranted.

Corpus cavernosum as an alternative means of intravenous access in the emergency setting

BACKGROUND

The present study was designed to investigate the feasibility of using the corpus cavernosum as an alternative means of intravenous access in the emergency setting.

METHODS

The feasibility of achieving the infusion flow rates was first ascertained using direct intracavernous infusion of normal saline. The effect of atropine and adrenaline when given via this route was then studied. Hypovolaemic shock was then induced in dogs who were then actively resuscitated via this route using normal saline, Haemaccel and whole blood.

RESULTS

Infusion flow rates were achieved for normal saline of 32.3, 50.3 and 67.3 mL per min at 100, 200 and 300 mmHg pressure, respectively. The peak effects of atropine and adrenaline via this route were seen at approximately 1 min after injection. Resuscitation using this method was uniformly successful in all dogs via the corpus cavernosum, with all reaching or exceeding their premorbid central venous pressure (CVP), and approaching or reaching their premorbid mean arterial pressure (MAP). In comparison the control dog's CVP and MAP did not rise during the period of observation after it was bled.

CONCLUSIONS

The corpus cavernosum is a practical alternative means of intravenous access in the emergency setting in the dog model.

Isolation, genomic organization, and expression analysis of the mouse and rat homologs of MEFV, the gene for familial mediterranean fever

Familial Mediterranean fever (FMF) is a recessive disorder characterized by episodes of fever with serositis or synovitis. Recently the FMF gene (MEFV) was cloned; the protein product, pyrin/marenostrin, is thought to regulate inflammation in myeloid cells. In this manuscript we report the mouse and rat homologs of MEFV. The murine gene contains ten exons with a coding sequence of 2304 bp, while the rat homolog has nine exons with a coding sequence of 2253 bp. A considerable amino acid sequence homology was observed between the mouse and human (47.6% identity and 65.5% similarity) and between the mouse and rat genes (73.5% identity and 82.1% similarity). The predicted rodent proteins have several important domains and signals found in human pyrin, including a B-box zinc finger domain, Robbins-Dingwall nuclear localization signal, and coiled-coil domain. However, perhaps because of an ancient frame-shift mutation, neither the mouse nor the rat protein has an intact C-terminal B30.2 domain, in which most FMF-associated mutations have been found in human MEFV. Nevertheless, like the human gene, mouse Mefv is expressed in peripheral blood granulocytes but not lymphocytes. Consistent with its expression in granulocytes, Mefv was detected at high levels in the primary follicles and marginal zones of the splenic white pulp. Mefv is localized on mouse Chromosome (Chr) 16, region A3-B1, extending a region of synteny with human Chr 16p13.3. Development of knockout and knockin mouse models may provide further insights into the functional evolution of this gene.

The gene for familial Mediterranean fever, MEFV, is expressed in early leukocyte development and is regulated in response to inflammatory mediators

Familial Mediterranean fever (FMF) is a recessive disorder characterized by episodes of fever and neutrophil-mediated serosal inflammation. We recently identified the gene causing FMF, designated MEFV, and found it to be expressed in mature neutrophils, suggesting that it functions as an inflammatory regulator. To facilitate our understanding of the normal function of MEFV, we extended our previous studies. MEFV messenger RNA was detected by reverse transcriptase-polymerase chain reaction in bone marrow leukocytes, with differential expression observed among cells by in situ hybridization. CD34 hematopoietic stem-cell cultures induced toward the granulocytic lineage expressed MEFV at the myelocyte stage, concurrently with lineage commitment. The prepromyelocytic cell line HL60 expressed MEFV only at granulocytic and monocytic differentiation. MEFV was also expressed in the monocytic cell lines U937 and THP-1. Among peripheral blood leukocytes, MEFV expression was detected in neutrophils, eosinophils, and to varying degrees, monocytes. Consistent with the tissue specificity of expression, complete sequencing and analysis of upstream regulatory regions of MEFV revealed homology to myeloid-specific promoters and to more broadly expressed inflammatory promoter elements. In vitro stimulation of monocytes with the proinflammatory agents interferon (IFN) gamma, tumor necrosis factor, and lipopolysaccharide induced MEFV expression, whereas the antiinflammatory cytokines interleukin (IL) 4, IL-10, and transforming growth factor beta inhibited such expression. Induction by IFN-gamma occurred rapidly and was resistant to cycloheximide. IFN-alpha also induced MEFV expression. In granulocytes, MEFV was up-regulated by IFN-gamma and the combination of IFN-alpha and colchicine. These results refine understanding of MEFV by placing the gene in the myelomonocytic-specific proinflammatory pathway and identifying it as an IFN-gamma immediate early gene.

Acute stress persistently enhances estrogen levels in the female rat

Here we tested whether exposure to either tailshock or swim stress alters ovarian hormone levels, estrogen and progesterone, in females and whether the effects are persistent. Adrenal hormone levels were also measured in males and females. Estradiol levels were elevated in unstressed females during proestrus relative to females in other stages of estrous, and exposure to the stressors enhanced estradiol beyond basal levels. For females stressed during diestrus 2, estradiol levels were elevated immediately after stressor cessation and up to 24 hrs. Exposure to tailshock, but not swim-stress, transiently enhanced progesterone in females stressed during the stage of proestrus and estrus. Glucocorticoid levels were elevated in response to both stressors and were supraelevated in females under both basal and stress conditions relative to males, particularly in blood from females exposed to acute swim stress. These results indicate that exposure to a relatively acute stressful event immediately and persistently enhances serum estradiol and are discussed in the context of reports that exposure to the same stressors immediately and persistently impairs associative learning in the female rat.

The effect of acidified enteral feeds on gastric colonization in critically ill patients: results of a multicenter randomized trial. Canadian Critical Care Trials Group

OBJECTIVE

To evaluate the effect of acidified enteral feeds on gastric colonization in critically ill patients compared with a standard feeding formula.

DESIGN

Randomized, double-blind, multicenter trial.

SETTING

Eight mixed intensive care units at tertiary care hospitals.

PATIENTS

We recruited mechanically ventilated critically ill patients expected to remain ventilated for >48 hrs. We excluded patients with gastrointestinal bleeding, acidemia, and renal failure requiring dialysis. We enrolled 120 patients; 38% were female, age (mean +/- SD) was 57.6+/-19.3 yrs, and Acute Physiology and Chronic Health Evaluation II score (mean +/- SD) was 21.6+/-7.6.

INTERVENTIONS

Vital High Nitrogen (Abbott Laboratories, Ross Products Division, Columbus, OH) was used as the standard feeding formula for the control group (pH = 6.5). Hydrochloric acid was added to Vital High Nitrogen to achieve a pH of 3.5 in the experimental group.

MEASUREMENTS AND MAIN RESULTS

The main outcome measure was gastric colonization. Secondary outcomes included gastric pH, pneumonia, and mortality. The mean gastric pH in patients receiving acid feeds was lower (pH = 3.3) compared with controls (pH = 4.6; p<.05). One patient (2%) on acid feeds was colonized in the stomach with pathogenic bacteria, compared with 20 patients (43%) in the control group (p<.001). There was no difference in the incidence of pneumonia (6.1% in the acid feeds group vs. 15% in the control group; p = .19). Overall, there were 15 deaths in the acid feeds group and seven in the control group (p = .10); four patients in the acid feeds group and three in the control group died during the study period (p not significant).

CONCLUSIONS

Acidified enteral feeds preserve gastric acidity and substantially reduce gastric colonization in critically ill patients. Larger studies are needed to examine its effect on ventilator-associated pneumonia and mortality.

Underground coal miners' foot and boot problems

The New South Wales (NSW) Joint Coal Board Health and Safety Trust funded an investigation into foot problems reported by 400 randomly selected underground coal miners from 15 mines in NSW. Miners were interviewed and their responses were entered directly into laptop computers. Digital cameras were also used to take pictures of skin conditions and miners' posture. Observations of the skin results indicate that miners find gumboots to be hot, sweaty and uncomfortable. Skin breakdown and tinea, is frequent and disabling and responsible for absences from the workforce that are costly for both miner and employer. A more comfortable and better designed boot is needed, fabricated in waterproof leather together with socks that 'wick' the moisture away from the foot. Socks worn were of varying components and washed at irregular intervals, indicating a need for regular changes of socks and improved hygiene.

Germline mutations in the extracellular domains of the 55 kDa TNF receptor, TNFR1, define a family of dominantly inherited autoinflammatory syndromes

Autosomal dominant periodic fever syndromes are characterized by unexplained episodes of fever and severe localized inflammation. In seven affected families, we found six different missense mutations of the 55 kDa tumor necrosis factor receptor (TNFR1), five of which disrupt conserved extracellular disulfide bonds. Soluble plasma TNFR1 levels in patients were approximately half normal. Leukocytes bearing a C52F mutation showed increased membrane TNFR1 and reduced receptor cleavage following stimulation. We propose that the autoinflammatory phenotype results from impaired downregulation of membrane TNFR1 and diminished shedding of potentially antagonistic soluble receptor. TNFR1-associated periodic syndromes (TRAPS) establish an important class of mutations in TNF receptors. Detailed analysis of one such mutation suggests impaired cytokine receptor clearance as a novel mechanism of disease.

Effect of caffeine on the vocal folds: a pilot study

Caffeine is considered to be a dehydrating agent with detrimental effects on the quality of voice of persons ingesting it. This has led medical personnel dealing with voice disorders, especially in the case of professional voice users, to give advice against the use of caffeine. Yet this is an anecdotal truth as an extensive Medline literature search did not reveal any scientific evidence of caffeine being proven to have adverse effects on the vocal folds. We, therefore, initiated this pilot study to ascertain the connection between caffeine and voice quality on a laboratory basis. Two hundred and fifty mg of caffeine were provided to eight volunteers in tablet form, and blood levels along with laryngograph readings were recorded to document the changes produced. Analysing the irregularities of frequencies in a) free speech b) a reading passage and c) singing 'Happy Birthday', substantial changes were seen to authenticate the fact that caffeine does produce alterations in voice quality but these alterations have considerable intra-subject variability. A full study with wider parameters is to be performed on this subject as we consider it to be of importance in the management of voice disorders.

Mutation and haplotype studies of familial Mediterranean fever reveal new ancestral relationships and evidence for a high carrier frequency with reduced penetrance in the Ashkenazi Jewish population

Familial Mediterranean fever (FMF) is a recessive disorder characterized by episodes of fever with serositis or synovitis. The FMF gene (MEFV) was cloned recently, and four missense mutations were identified. Here we present data from non-Ashkenazi Jewish and Arab patients in whom we had not originally found mutations and from a new, more ethnically diverse panel. Among 90 symptomatic mutation-positive individuals, 11 mutations accounted for 79% of carrier chromosomes. Of the two mutations that are novel, one alters the same residue (680) as a previously known mutation, and the other (P369S) is located in exon 3. Consistent with another recent report, the E148Q mutation was observed in patients of several ethnicities and on multiple microsatellite haplotypes, but haplotype data indicate an ancestral relationships between non-Jewish Italian and Ashkenazi Jewish patients with FMF and other affected populations. Among approximately 200 anonymous Ashkenazi Jewish DNA samples, the MEFV carrier frequency was 21%, with E148Q the most common mutation. Several lines of evidence indicate reduced penetrance among Ashkenazi Jews, especially for E148Q, P369S, and K695R. Nevertheless, E148Q helps account for recessive inheritance in an Ashkenazi family previously reported as an unusual case of dominantly inherited FMF. The presence of three frequent MEFV mutations in multiple Mediterranean populations strongly suggests a heterozygote advantage in this geographic region.

Pyogenic granuloma-like lesions in a patient using topical tretinoin

A 16-year-old male developed numerous pyogenic granuloma like-lesions across his neck, chest and back after 6 weeks isotretinoin therapy for cystic acne. The isotretinoin was ceased and he was commenced on oral steroids. After 6 weeks, the lesions were almost completely healed. However, due to worsening comedonal acne, the patient was commenced on topical tretinoin cream 0.05% twice daily to his chest. He was reviewed 2 weeks later and, surprisingly, 2 new pyogenic granuloma-like lesions had developed on his chest. These lesions persisted until the topical tretinoin was ceased 3 months later.

A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group

BACKGROUND

Critically ill patients who require mechanical ventilation are at increased risk for gastrointestinal bleeding from stress ulcers. There are conflicting data on the effect of histamine H2-receptor antagonists and the cytoprotective agent sucralfate on rates of gastrointestinal bleeding, ventilator-associated pneumonia, and mortality.

METHODS

In a multicenter, randomized, blinded, placebo-controlled trial, we compared sucralfate with the H2-receptor antagonist ranitidine for the prevention of upper gastrointestinal bleeding in 1200 patients who required mechanical ventilation. Patients received either nasogastric sucralfate suspension (1 g every six hours) and an intravenous placebo or intravenous ranitidine (50 mg every eight hours) and a nasogastric placebo.

RESULTS

The patients in the two groups had similar base-line characteristics. Clinically important gastrointestinal bleeding developed in 10 of 596 (1.7 percent) of the patients receiving ranitidine, as compared with 23 of 604 (3.8 percent) of those receiving sucralfate (relative risk, 0.44; 95 percent confidence interval, 0.21 to 0.92; P=0.02). In the ranitidine group, 114 of 596 patients (19.1 percent) had ventilator-associated pneumonia, as compared with 98 of 604 (16.2 percent) in the sucralfate group (relative risk, 1.18; 95 percent confidence interval, 0.92 to 1.51; P=0.19). There was no significant difference between the groups in mortality in the intensive care unit (ICU) (23.5 percent in the ranitidine group and 22.9 percent in the sucralfate group) or the duration of the stay in the ICU (median, nine days in both groups).

CONCLUSIONS

Among critically ill patients requiring mechanical ventilation, those receiving ranitidine had a significantly lower rate of clinically important gastrointestinal bleeding than those treated with sucralfate. There were no significant differences in the rates of ventilator-associated pneumonia, the duration of the stay in the ICU, or mortality.

Effect of antihypertensive agents on the arterial partial pressure of oxygen and venous admixture after cardiac surgery

OBJECTIVE

To determine whether stopping nitroglycerin and sodium nitroprusside (both vasodilators) infusions in hypertensive, postcardiac surgical patients requiring a high FIO2 improves PaO2 and venous admixture.

DESIGN

Prospective, clinical trial.

SETTING

Intensive care unit in a university-affiliated hospital.

PATIENTS

Thirty postcardiac surgical patients who, because of high FIO2 requirements, did not meet the criteria for weaning from mechanical ventilation and who were receiving infusions of nitroglycerin and/or sodium nitroprusside to control blood pressure.

INTERVENTIONS

PaO2, venous admixture, and oxygen transport data were determined at baseline using arterial and mixed venous blood gas samples and hemodynamic values from a pulmonary artery catheter. The nitroglycerin and sodium nitroprusside infusions were stopped, and intravenous boluses of labetalol were administered to maintain a target blood pressure. After the vasodilator infusions were stopped, the baseline measurements were repeated to redetermine PaO2, venous admixture, and oxygen transport values.

MEASUREMENTS AND MAIN RESULTS

Results included a mean increase in PaO2 from 79.3 +/- 15 torr (10.5 +/- 2.0 kPa) to 118.3 +/- 38 torr (15.7 +/- 5.1 kPa) and a mean decrease in venous admixture from 26.4 +/- 5.8% to 17.6 +/- 5.6% when the vasodilators were stopped. All 30 patients had an increase in PaO2 and a decrease in venous admixture. Because of the improvement in oxygenation, 28 of the 30 patients met the criteria for weaning from mechanical ventilation once nitroglycerin and sodium nitroprusside were stopped or decreased. Labetalol was well tolerated in this group of patients who had preserved ventricular function.

CONCLUSIONS

Substituting labetalol for nitroglycerin and sodium nitroprusside improves arterial oxygenation and venous admixture in hypertensive postcardiac surgical patients who require a high FIO2. This change in therapy may allow patients to be weaned from mechanical ventilation sooner.

Presence of paraoxonase in human interstitial fluid

Human serum paraoxonase (PON1) is postulated to have anti-atherosclerotic properties through its ability to prevent lipid peroxide generation on LDL. However, in order to perform this role it must be present in interstitial fluid, to prevent LDL oxidation which takes place in the sub-intimal space of the artery wall. The PON1 activity in interstitial fluid was 15.7 (2.3-183.0) (median (range)) nmol/min/ml compared to 105.3 (74.6-323.9) nmol/min/ml in serum. The PON1 concentration in interstitial fluid was found to be 20.2 (1.1-78.1) microg/ml (median (range)) compared to 109.6 (11.1-485.7) microg/ml in serum. Interstitial fluid PON1 concentration was dependent on the interstitial fluid apo AI concentration (r = 0.690, P < 0.005) indicating PON1 remained associated with HDL. However, the ratio of PON1 concentration to apo AI was lower in interstitial fluid (0.60 +/- 0.20) than in the serum (0.95 +/- 0.18) (P < 0.001) indicating sequestration of PON1 in the sub-intimal space. Therefore, PON1 is present and active in interstitial fluid where it can perform its anti-atherosclerotic function.

A high-resolution genetic map of the familial Mediterranean fever candidate region allows identification of haplotype-sharing among ethnic groups

Familial Mediterranean fever (FMF) is a recessive disorder of inflammation caused by mutations in a gene (designated MEFV) on chromosome 16p13.3. We have recently constructed a 1-Mb cosmid contig that includes the FMF critical region. Here we show genotype data for 12 markers from our physical map, including 5 newly identified microsatellites, in FMF families. Intrafamilial recombinations placed MEFV in the approximately 285 kb between D16S468/D16S3070 and D16S3376. We observed significant linkage disequilibrium in the North African Jewish population, and historical recombinants in the founder haplotype placed MEFV between D16S3082 and D16S3373 (approximately 200 kb). In smaller panels of Iraqi Jewish, Arab, and Armenian families, there were significant allelic associations only for D16S3370 and D16S2617 among the Armenians. A sizable minority of Iraqi Jewish and Armenian carrier chromosomes appeared to be derived from the North African Jewish ancestral haplotype. We observed a unique FMF haplotype common to Iraqi Jews, Arabs, and Armenians and two other haplotypes restricted to either the Iraqi Jewish or the Armenian population. These data support the view that a few major mutations account for a large percentage of the cases of FMF and suggest that some of these mutations arose before the affected Middle Eastern populations diverged from one another.

Clinical improvement with bottom-line impact: custom care planning for patients with acute and chronic illnesses in a managed care setting

A fully capitated, integrated healthcare delivery system endeavored to improve the care of its sickest members. A computer algorithm severity index that encompassed a 1-year history of hospitalization and adjusted for inclusion of a variety of chronic conditions was calculated on the basis of clinical and administrative claims databases for the entire membership of the healthcare system. Monthly updated lists were produced to find patients with acute and chronic illnesses. These patients accounted for one-fourth of hospital admissions and almost half of inpatient days, but they numbered less than 1% of system membership. Each listed person, regardless of age or diagnosis, had a custom care plan formulated by nurses in consultation with the primary care physician and involved specialists. Plan development featured in-home assessments in most instances and incorporated a variety of ancillary services, telephone and home-care follow-up, and strategies to increase continuity and access to care. Patient-reported functional status was obtained at establishment of the care plan and periodically thereafter in expectation of raising the cross-sectional mean values of the population. Three months after initiation of the program, the expected winter hospitalization peak did not occur, and utilization tended to be lower in subsequent months. Inpatient admissions among members with acute and chronic illnesses decreased 20%, and inpatient days decreased 28% from baseline levels. Among the subset of seniors in the population, inpatient days decreased 37%. Net financial impact was a medical expenditure decrease of more than 5% from 1995 levels. On a population basis, functional status was raised, and the acuity of patients' conditions and need for inpatient hospital care were reduced.

Emergence of further serotypes of multiple drug-resistant Streptococcus pneumoniae in Queensland

We describe 27 cases of multiple drug-resistant pneumococcal infection in Queensland children (7 cases) and adults (20 cases), between February 1995 and October 1996. Seven patients had invasive disease. Serotypes were those commonly associated with paediatric infections and included types 19F (15 strains), 14 (6), 23F (4), 6A (1) and 19A (1). No rifampicin or vancomycin resistance was encountered. However, pneumococci fully resistant to cotrimoxazole, erythromycin and tetracycline were isolated from 25 of 27 cases (93%). Strains with high level resistance to penicillin and chloramphenicol were also recovered from 16 (59%) and 19 (70%) patients respectively. Twelve of 16 penicillin-resistant isolates showed intermediate resistance to ceftriaxone and two strains were fully resistant to this antibiotic. Clones of types 19F and 14 pneumococci, each with two distinctive resistance patterns, appear to be established in south-east Queensland.

Construction of a 1-Mb restriction-mapped cosmid contig containing the candidate region for the familial Mediterranean fever locus (MEFV) on chromosome 16p 13.3

In this paper we describe the assembly and restriction map of a 1.05-Mb cosmid contig spanning the candidate region for familial Mediterranean fever (FMF), a recessively inherited disorder of inflammation localized to 16p13.3. Using a combination of cosmid walking and screening for P1, PAC, BAC, and YAC clones, we have generated a contig of genomic clones spanning approximately 1050 kb that contains the FMF critical region. The map consists of 179 cosmid, 15 P1, 10 PAC, 3 BAC, and 17 YAC clones, anchored by 27 STS markers. Eight additional STSs have been developed from the approximately 700 kb immediately centromeric to this genomic region. Five of the 35 STSs are microsatellites that have not been previously reported. NotI and EcoRI mapping of the overlapping cosmids, hybridization of restriction fragments from cosmids to one another, and STS analyses have been used to validate the assembly of the contig. Our contig totally subsumes the 250-kb interval recently reported, by founder haplotype analysis, to contain the FMF gene. Thus, our high-resolution clone map provides an ideal resource for transcriptional mapping toward the eventual identification of this disease gene.