A rapid and sensitive method of identification of HTLV-II subtypes

There are 2 subtypes of human T-cell lymphoma/leukemia virus type II (HTLV-II), A and B. HTLV-II is increasingly associated with rare forms of lymphocytic neoplasia and a neurodegenerative disorder, characterized by hyperspasticity and ataxia. We have used PCR to amplify, clone and sequence 140 bp of the pol gene from many isolates of HTLV-IIA and HTLV-IIB from around the world. Analysis of these and other published sequence established that all HTLV-IIA sequences contained a unique Hinf I site and all HTLV-IIB sequences a unique Mse I site. A rapid and specific oligomer restriction (OR) assay was developed utilizing the primer pair SK110/SK111 and subsequent digestion with these enzymes. Concordance between sequenced and OR-based subtyping of DNA amplified by PCR was absolute among 22 HTLV-II isolates tested. Further OR or sequence analyses on an additional 30 other isolates indicated that the majority of North American non-indian HTLV-II isolates were subtype A, while all Paleo-Amerindian samples, including those from the Seminole of Florida; the Guaymi from Panama; and the Toba, Chorote, Wichi, and Chulupe of Argentina, belonged to subtype B. The SK110/SK111 PCR-OR format should facilitate molecular epidemiology studies of HTLV-II infection and allow for subtype stratification in assessing the sensitivity and specificity of HTLV detection formats and HTLV-II disease association.

[The nursing situation in the old and new parts of the Federal Republic of Germany: a comparison of requirements, obstacles and nursing autonomy]

Differences with regard to demands, obstacles and elbow room, affecting nursing activities in general hospitals are examined. An instruments measuring various facets was devised (TAA KH). The results reveal that in all three areas there are significant differences between activities of nursing staff in East and West German Hospitals. The differences are being discussed against the background of the situation in the new Bundesländer.

Developing a clinical information system: the role of the chief information officer

BACKGROUND

Chief information officers (CIOs) must play a pivotal role in the formation and implementation of a clinical information system, the subset of an organizational information system that deals specifically with support of clinical care activities.

MAJOR ELEMENTS OF A CLINICAL INFORMATION SYSTEM

Major elements include the applications software, technology and data architecture, databases, and analysis. The organizational structures and processes that manage the development of improvement activities, including the clinical information system itself, are just as vital to the design of an information system as the hardware and software.

THE ROLE OF THE CIO

To develop, sustain, and advance an information infrastructure, the CIO must help establish certain organizational precursors, such as medical staff involvement, experience with quality improvement, and ability to meet data needs. The CIO must then work with the senior administrative and medical leadership in developing a vision for the information system. The CIO must also create new roles and knowledge for information system and medical staff members. Interaction between information services and medical staff is vitally important to the success of a clinical information system. Organizational committees and structures that Brigham and Women's Hospital in Boston put in place to formalize the relationship between information systems and medical staff include the Clinical Initiative Development Program and the Center for Applied Medical Information Systems Research.

CONCLUSION

Improving the clinical management of care and the efficacy of care processes involves complex changes in organizational culture and processes, medical practice and information system applications, technologies, staff, and data.

Prospective study of the incidence of ultrasound-detected hepatic hematomas due to percutaneous Menghini needle liver biopsy and laparoscopy-guided Silverman needle biopsy

Recently, a high incidence of sonographically detected hepatic hematomas following percutaneous liver biopsy and laparoscopy-guided liver biopsy has been reported. For this reason a prospective study in 178 patients was performed. The patients were examined by ultrasound before and 24 hours after percutaneous liver biopsy using the 1.4 mm-Menghini needle (n = 107) and by laparoscopically-guided biopsy with the 2.5 mm-Silverman needle (n = 71). Four of the 107 patients (4%) who underwent percutaneous Menghini biopsy displayed hepatic hematoma on ultrasonography, and in 2 of these cases the hematoma was > 6 cm in diameter and persisted for more than seven months. In the group of patients who underwent laparoscopy-guided Silverman biopsy (n = 71) a liver hematoma occurred twice (3%). Both hematomas were small and disappeared within several days. There was no need for special therapeutic interventions due to complications. In contrast to recent data about Tru-cut and JAM-Shidi biopsy, the results of this study indicate that percutaneous Menghini biopsy and laparoscopy-guided Silverman biopsy are relatively safe diagnostic procedures.

Pulmonary fungal infections in immunocompromised patients: incidence and risk factors

In a prospective study, 178 patients with fever > 38.4 degrees C and newly diagnosed pulmonary infiltrates underwent bronchoscopy with bronchoalveolar lavage (BAL), aspiration of bronchial secretions (BS) and, in 71 cases, protected specimen brushing (PSB). In 42/143 immunocompromised patients (haematological malignancies, n = 92; AIDS, n = 22; immunosuppressant therapy, n = 29) and in 4/35 patients with no defined underlying disease fungal pneumonia was present (candidosis, n = 35; aspergillosis, n = 8 mixed fungal infection, n = 3). Candidosis was combined, in 17 cases, with Aspergillus (n = 3), bacterial (n = 15) or cytomegalovirus (n = 2) infection. Aspergillosis was combined in eight cases with infection with Candida (n = 3), Pneumocystis carinii (n = 1) or bacteria (n = 5). The sensitivity of BAL and PSB in Candida pneumonia was 48% and 50%, respectively; specificity was 75% and 74% respectively. Bronchial secretions were more sensitive in detecting Candida pneumonia, but specificity was only 55%. In aspergillosis, the specificity of BAL, BS and PSB in each case was 100%; the sensitivity of BAL, BS and PSB was 38%, 64% and 100%. Twenty-four fungal infections were fatal. Unfavourable prognostic factors were respiratory failure needing mechanical ventilation, diffuse bilateral pulmonary infiltrates, mixed fungal infections and start of i.v. antifungal treatment > 14 days after fever onset, which were associated with a mortality rate of 74%, 67%, 67% and 63% respectively.

[Prospective study of the incidence of ultrasound detectable liver hematomas after laparoscopically controlled liver puncture with the Silverman needle]

BACKGROUND

A high incidence of hepatic haematomas detected at sonography following percutaneous liver biopsy and laparoscopy-guided liver biopsy has recently been reported.

PATIENTS AND METHODS

Prompted by this report, we carried out a prospective study on 71 patients aged between 20 and 79 years (median age: 51 years). The patients were examined by ultrasound prior to and following laparoscopy-guided biopsy with the Silverman needle.

RESULTS

Only two of the 71 patients (3%) had a hepatic haematoma after biopsy. The haemangiomas had a maximum diameter of 2.6 cm, caused no pain, and disappeared again within ten days at the latest. No therapeutic measures were required.

CONCLUSION

The results of this study indicate that laparoscopy-guided liver biopsy with the Silverman needle is associated with relatively few complications.

Diagnosis of chronic pancreatitis by means of a sonographic secretin test

The pancreatic duct can be demonstrated today by sonography in about 90% of all persons examined. In 159 persons, aged 18-79 yr, we measured sonographically the pancreatic duct diameter before and after intravenous secretin injection. After secretin stimulation, 20 healthy controls and 90 patients without pancreatic disease showed a distinct pancreatic duct dilatation of 93 and 94% of basal duct diameter lasting only several minutes. No distinct secretin-induced duct enlargement was observed in 35 of 40 patients with chronic pancreatitis. Patients with chronic pancreatitis and circumscript duct stenosis even had a marked and longer-lasting duct dilatation of 156% of basal duct diameter after secretin stimulation. This study showed a high reliability of the sonographic secretin test in the diagnosis of chronic pancreatitis--even in an early stage--recording a sensitivity of 92.5%, a specificity of 93%, and a predictive value of 84%.

[Organization of socially acceptable working hours in nursing]

Three dimensions in the structure of the working hour system of nurses, rendering them socially acceptable, are becoming important: duration of the working day, the time of day which is being worked and the distribution of working hours. The latter two are of particular importance because flexible shift is becoming the dominant pattern in nursing. Six indicators are discussed as criteria for social acceptability: security of employment which includes access to the labour-market, level of income, health, opportunity for social relationships, social participation, and autonomy. Responses of 297 nurses in one General Hospital taking part in a study, were analysed to examine empirically the concept of 'socially acceptable structure of the working hours'. Ideal and factual patterns are considered first. Secondly aspects of autonomy are considered and the way this depends on time, thirdly the criteria used to define 'social acceptability' are examined for validity. Results show firstly the cross contrast between the hospital's expectation and the nurses' wishes with regard to working hours. Furthermore, inspite of the demand for flexibility, staff have very little choice and there is little sign of joint decision making. Thirdly results show that health, interpersonal and social aspects are of special importance and that, correspondingly, in the view of nurses, financial and practical problems are of lesser importance in their every day life.

Diastolic function in children and adolescents on dialysis and after kidney transplantation: an echocardiographic assessment

Thirty-seven children and adolescents on renal replacement therapy (11 on haemodialysis, 14 on continuous ambulatory peritoneal dialysis and 12 after renal transplantation) were studied by echocardiography, echo-Doppler and phonocardiography. Right and left ventricular (R/L V) diastolic functions were measured by transmitral and transtricuspid flow velocities and by LV isovolumic relaxation time (LVIRT). Thirty-seven age- and sex-matched healthy subjects served as controls. R/L V diastolic dysfunction was only observed in the dialysis patients. In these patients LVIRT was prolonged. LV and RV peak inflow velocities were increased both in early (E) and late (A) diastole with a reduction in the E/A ratios. This pattern of diastolic dysfunction is compatible with the combined effects of a hypercirculatory state (volume overload, anaemia, arteriovenous fistula) and an abnormality of cardiac relaxation. The transplant patients showed no major cardiac abnormalities.

Effects of prenatal alcohol exposure on the developmental pattern of temperature preference in a thermocline

Prenatal alcohol exposure is associated with a variety of impairments in neonatal state regulatory systems. Since prenatal alcohol exposure causes thermoregulatory deficits in response to both heat and cold stress in rats, body temperature set-point might be altered in alcohol-exposed offspring. The effect of prenatal alcohol exposure on behavior in a thermocline was investigated in 10-, 15-, and 125-day-old male and female rats from three prenatal treatment conditions: alcohol liquid diet, pair-fed liquid diet control, or standard control. Subjects were placed in the thermocline in the cold, hot, or middle start positions and observed for 60 min. Subjects exposed to alcohol prenatally had a wider "preference zone" than control subjects at 10 and 15 days of age, but did not as adults. This widening of the temperature set-point in young subjects prenatally exposed to alcohol may represent a developmental lag in the development of body temperature set-point or a central compensatory process allowing the animal to adapt to alternating experiences of heat and cold stress.

[Prognostic value of long-term pH-metry in the B-II resected stomach]

In a prospective study we investigated the clinical value of ambulatory 24-hour pH monitoring in the stomach after Billroth-II-resection. Recorded data of 10 patients with and 11 patients without ulcer recurrence after gastric resection were compared. The pH medians of the record periods "total time", "supine", "upright", "fasting" and "postprandial" were evaluated. Further the cumulative recording time of pH levels pH < 1, pH < 2, etc. was determined and compared in both groups. A pH median less than 2.8 "supine" indicated a postoperative ulcer recurrence with a sensitivity of 90% and specificity of 81%. A pH median less than 2.6 "fasting" predicted an ulcer relapse with a sensitivity of 90% and specificity of 72% (p < 0.001). In patients with ulcer recurrence pH was < 4 in more than 30% of total recording rime, pH < 5 in more than 45% and pH < 6 in more than 75% (sensitivity 90%, specificity 100%). According to these findings 24-hour pH monitoring seems to be useful for the prognostic assessment of the further course of ulcer disease after B II-surgery of the stomach. Thus pH monitoring results may be helpful in defining patient groups which may be candidates for acid reducing therapy to prevent ulcer recurrence.

Effects of corticotropin-releasing factor on isolated rat heart activity

We investigated effects of bolus administration of corticotropin-releasing factor (CRF) on parameters of cardiac activity in isolated working rat hearts. Effects at a dose of 5 micrograms of CRF were compared in hearts perfused with Krebs-Henseleit solution, norepinephrine (NE, 10(-9) M), propranolol (3 x 10(-6) M), NG-nitro-L-arginine (L-NNA, 3 x 10(-5) M), or indomethacin (3 x 10(-5) M). CRF increased coronary flow for > 30 min (P < 0.01) with maximum increases of 31.7%, suggesting a prolonged vasodilatory action of the peptide. CRF, in addition, induced transient (lasting < 10 min) increases in maximum aortic pressure and oxygen consumption (P < 0.01), suggesting an inotropic action of the peptide. Perfusions of NE and propranolol did not change the cardiac response to CRF. L-NNA, inhibiting release of endothelium-derived relaxant factor (EDRF), and indomethacin diminished the vasodilatory response to CRF, as indicated by significantly shortened increases in coronary flow after CRF (P < 0.05). Indomethacin also enhanced peak increases in maximum aortic pressure after CRF (P < 0.01). The data confirm direct effects of CRF on cardiac activity. They also suggest that the mediation of coronary vasodilation by CRF involves the endothelial release of prostacyclin and EDRF.

First prenatal diagnosis of X-linked lymphoproliferative disease

A family study was performed in order to diagnose X-linked lymphoproliferative (XLP) disease in a fetus. The molecular genetic analysis indicated that the fetus, as well as its healthy 7-year-old brother, inherited XLP. Analysis of immunoglobulin subclasses from the 7-year-old brother supported the DNA-based diagnosis. This is the first XLP family of African descent.

Rat brain hypothalamic and hippocampal monoamine and hippocampal beta-adrenergic receptor changes during pregnancy

The concentration of noradrenaline (NA), dopamine (DA), serotonin (5-HT), and their metabolites was measured in hypothalamic and hippocampal brain tissue obtained from non-pregnant, 15- or 20-day pregnant and 4-day postpartum rats. At 20 days of pregnancy, hypothalamic NA and DA concentrations were significantly decreased and their turnover increased relative to postpartum and estrous values, respectively. Hippocampal 3-methoxy-4-hydroxy-phenylglycol (MHPG) levels were significantly decreased at 15 days of pregnancy and 4 days postpartum compared to estrous and 20-day pregnant levels and the MHPG/NA ratio was significantly reduced at 4 days postpartum relative to the estrous value. Hippocampal 5-HT and 5-hydroxyindole-3-acetic acid (5-HIAA) levels were significantly decreased at 15 days of pregnancy while 5-HIAA levels and the 5-HIAA/5-HT ratio were significantly decreased at 20 days of pregnancy. Hippocampal beta-adrenergic receptor density was significantly lower at 4 days postpartum than at 15 days of pregnancy. A positive correlation was observed between plasma progesterone and hippocampal beta-adrenoceptor Kd values, suggesting a possible causal relationship between these two variables. The monoamine and beta-adrenoceptor changes which occur during pregnancy may be an important contributing factor in determining the mood changes which occur during pregnancy and postpartum.

Extended fetal echocardiographic examination for detecting cardiac malformations in low risk pregnancies

OBJECTIVE

To improve the rate of prenatal detection of cardiac malformations in a low risk population.

DESIGN

Comparison of extended fetal echocardiography with the standard four chamber view in detecting abnormalities. Extended echocardiography comprised the four chamber view and visualisation of the left ventricular outflow tract, the right ventricular outflow tract, and the main pulmonary artery and its branches. In cases with abnormal results complete echocardiographic studies were performed by a paediatric cardiologist using M mode, Doppler, and colour flow mapping techniques.

SETTING

Obstetric ultrasonographic unit at Shaare-Zedek Medical Centre, Jerusalem.

SUBJECTS

5400 fetuses in low risk pregnancies between 18 and 24 weeks' gestation (mean 21 weeks); 53 were lost to follow up.

MAIN OUTCOME MEASURES

Detection of abnormality before and after birth.

RESULTS

During the study 23 infants (0.4%) were born with cardiac abnormalities, 21 of whom had major structural and functional heart disease. 18 fetuses had heart disease diagnosed prenatally, 11 by the four chamber view alone (sensitivity 48%) and a further seven by extended echocardiography (sensitivity 78%). Five fetal cardiac defects were missed prenatally (false negative rate 22%). These included coarctation of aorta, persistent truncus arteriosus, tetralogy of Fallot, ventricular septal defect, and pulmonic stenosis. Only one false positive diagnosis (coarctation of aorta) was made (specificity 99.9%, false positive rate 0.1%). The abnormality was correctly identified in 17 out of 18 cases.

CONCLUSIONS

The extended fetal heart examination detected 86% (18/21) of major abnormalities in a low risk population. The examination should be incorporated into routine prenatal ultrasonographic investigations.

Prenatal sonographic diagnosis and perinatal management of ectopia cordis

Ectopia cordis is a rare malformation presenting as an isolated lesion or as part of the Cantrell's pentology syndrome. Prenatal ultrasonographic diagnosis of ectopia cordis must be followed by a careful search for associated anomalies, since the prognosis may vary accordingly. A case of prenatal diagnosis of ectopia cordis in the early second trimester is presented. Routine sonographic examination at 18 weeks of gestation revealed protrusion of the heart into the amniotic fluid, ventricular septal defect and omphalocele. The perinatal evaluation and management are discussed.

Long-bone radiographic abnormalities as a sign of active congenital syphilis in asymptomatic newborns

Metaphyseal abnormalities are present in greater than 90% of infants with symptomatic congenital syphilis. The incidence of these lesions in asymptomatic newborns in the present epidemic is not known. To determine the incidence of bone lesions at birth in asymptomatic congenital syphilis, long-bone films were obtained for all babies born during a 9-month period with a positive perinatal serology. Of 2544 newborns, 61 had a positive maternal serology and 40 also had a positive cord serology. Two symptomatic babies had abnormal radiographs and 12 of 59 asymptomatic newborns had metaphyseal changes consistent with congenital syphilis. It is concluded that long-bone radiographs are abnormal in approximately 20% of asymptomatic newborns with positive perinatal treponemal serology. With the increasing incidence of congenital syphilis, radiologic studies should be included in the assessment of all newborns with a positive serology. Indeed, those patients with any sign of active disease should be carefully followed because even treated infants remain at some risk for developing the late sequelae of congenital syphilis.

Multicomponent polyanions. 45. A multinuclear NMR study of vanadate(V)-oxalate complexes in aqueous solution

The two complexes formed in the aqueous vanadooxalate system, V(Ox)- and V(Ox)2(3-), have been characterized using 51V, 13C and 17O NMR. For the V(Ox)2(3-) complex, two peaks are observed in 13C NMR and four in 17O NMR. This leads to the conclusion that each oxalate ligand has two different distances to the VO2 group. This fact, together with the peak integrals and the chemical shifts, indicates strongly that the hexacoordinate complex [VO2(C2O4)2]3- found in single-crystal X-ray structure determinations persists in aqueous solution. The dependence of the 13C NMR linewidths upon temperature reveals two types of dynamic processes: (1) a rearrangement in which the two different V-Oox switch places and (2) an exchange of the oxalate ligands in the [VO2(C2O4)2]3- complex with free oxalate, probably through a dissociative process. Rate constants and activation parameters for the two dynamic processes involving [VO2(C2O4)2]3- have been calculated from the shape of the 13C NMR signals. For the V(Ox)- complex, only one relatively narrow peak is obtained in 13C NMR and three peaks in 17O. This fact, as well as the relative positions of these peaks, is in accordance with a pentacoordinate complex [VO2(C2O4)H2O]-, where the two V-O distances to the oxalate ligand are equal. We also show that, in the pH range 0.8-6.6, there is no protonation of the studied complexes, in agreement with previous potentiometric results.