Quantitative ultrasound of the calcaneus with parametric imaging: correlation with bone mineral density at different sites and with anthropometric data in menopausal women

OBJECTIVE

To prospectively study the relationship of quantitative ultrasound of the calcaneus with anthromopometric variables and with bone mineral density (BMD) assessed at the level of the calcaneus as well as at other sites.

METHOD

Osteosonography of the non-dominant calcaneus was performed in 135 menopausal women, using a DTU-one device with parametric imaging. Broadband ultrasound attenuation (BUA) and speed of sound (SOS) were assessed. BMD of the calcaneus (BMDcal) was measured using dual energy X-ray absorptiometry (DXA), in a subregion matched with the region of interest for osteosonography. BMD of the lumbar trabecular bone was measured using quantitative computed tomography (BMD QCT) while the non-dominant hip was studied using DXA, which provided the total bone mineral density (BMDhip) and that of the Ward triangle (BMDWard).

RESULTS

The Pearson correlation coefficients between BUA, SOS and the various measurements of BMD ranged from 0.305 (SOS versus BMDhip) to 0.717 (BUA versus BMDcal). BMD QCT and BMDWard were found to depend on age, but not on weight or height, while BUA, SOS, BMDcal, BMDhip were unrelated to age, but correlated with weight (SOS, BMDhip) or with weight and height (BUA, BMDcal). In a multiple stepwise regression analysis, age was a significant predictor for BMD QCT, BMD hip and BMDWard; BMD QCT, BMDWard and BMDhip admitted BUA as sole predictor, while BMDcal was significantly related to both BUA and SOS.

CONCLUSION

BUA and SOS of the calcaneus, assessed in 135 menopausal women using a parametric imaging device, reflected BMDcal, measured with DXA at a matched region of interest, and did not decline significantly with age.

The effect of raloxifene on coronary arteries in aged ovariectomized ewes

BACKGROUND

Ovariectomized sheep are a useful model of postmenopausal osteoporosis and other postmenopausal conditions. Estrogen may have a protective effect on the coronary arteries in postmenopausal women. The effects of raloxifene, a selective estrogen receptor modulator, on coronary arteries in aged ovariectomized ewes was investigated.

METHODS AND RESULTS

Forty eight aged ewes were randomly assigned to undergo sham surgery (Sham, n = 7), ovariectomy (OVX, n = 10), ovariectomy with estradiol supplementation (OVXE, n = 8), ovariectomy with raloxifene supplementation, 0.02 mg/kg per day (RAL1, n = 10), or ovariectomy with raloxifene supplementation, 0.10 mg/kg per day (RAL2, n = 13). Contrast coronary angiography was performed 6 months after intervention. Diameters of the right main and left anterior descending coronary arteries in the RAL1, RAL2 and Sham groups were not different from each other, but were significantly greater than the OVX and OVXE groups. Intracoronary nitroglycerin did not affect the relationships of the diameters in any group. There were no differences in vascular remodeling between the groups.

CONCLUSIONS

The results indicate that raloxifene in this sheep model allows greater dilation of coronary arteries than estrogen. Raloxifene may provide a significant protective functional effect on coronary arteries in postmenopausal heart disease.

Granulomatous skin lesions due to histoplasmosis in a badger (Meles meles) in Austria

We describe the first case of histoplasmosis due to infection with Histoplasma capsulatum var. capsulatum in a wild badger (Meles meles) in Austria. Diagnosis was established by histopathological and immunohistochemical characterization of yeast forms in skin lesions and lymph nodes. Although Austria has yet to be regarded as an endemic region for H. capsulatum, infections of animals and humans exposed to contaminated soil cannot be excluded.

The clinical impact of early gram-positive bacteremia and the use of vancomycin after allogeneic bone marrow transplantation

BACKGROUND

Gram-positive bacteremia (GPB) is an increasing infection after allogeneic bone marrow transplantation (BMT). Our purpose was to identify risk factors for GPB, to evaluate its impact on early mortality and morbidity, and to compare prophylactic with empirical intravenous vancomycin.

METHODS AND RESULTS

We studied 89 consecutive BMTs in adult patients. Early GPB occurred in 29% of posttransplantation episodes. T-cell depletion (odds ratio [OR]: 0.18) and vancomycin-prophylaxis (OR: 0.28) reduced the risk of GPB. Mortality at 6 weeks was not significantly different in patients with GPB (15% vs. 9.5%, P = 0.669). GPB was associated with the development of major complications, the use of amphotericin B, and prolonged neutropenia. Vancomycin prophylaxis led to an increased risk of early renal dysfunction (OR: 18.7).

CONCLUSION

GPB contributes to overall morbidity during the early post-BMT episode but has no impact on mortality. Vancomycin prophylaxis is effective to reduce GPB but has a negative effect on renal function.

Diagnosis of sporotrichosis in a donkey using direct fluorescein-labeled antibody testing

A 4-year-old female donkey residing in an open field in Indiana was admitted for evaluation of facial lesions of 2 years duration. Cytologic and histologic examination of exudate and tissue from the lesions revealed a pyogranulomatous inflammatory reaction with numerous yeasts. Sporothrix schenckii was suspected to be the infectious agent; however, multiple culture attempts did not provide positive identification of the organism. Serologic examination supported infection with S. schenckii. A specific direct immunofluorescent antibody test performed on paraffin-embedded tissue sections confirmed the organism as S. schenckii. Clinical signs resolved after appropriate iodide therapy.

Microbiology of the middle meatus: a comparison between normal adults and children

Middle meatal samples were obtained from 52 carefully selected healthy adults. In 75 per cent of the test subjects bacterial organisms were cultured. However, growth was often poor and the predominant species suggest a commensal flora: coagulase-negative staphylococci were retrieved from 35 per cent, Corynebacterium sp. from 23 per cent and Staphyloccus aureus from eight per cent of the adults. These data are very different from those previously obtained among children where--even in the absence of obvious ENT pathology--the most frequently cultured organisms were typical sinusitis pathogens: Haemophilus influenzae present in 40 per cent, Moraxella catarrhalis in 34 per cent and Streptococcus pneumoniae in 50 per cent of children. Furthermore, Streptococcus viridans and Neisseria sp., both organisms that might be able to inhibit colonization by some of the pathogens and found commonly among children, are virtually absent in healthy adults.

Explaining the moon illusion

An old explanation of the moon illusion holds that various cues place the horizon moon at an effectively greater distance than the elevated moon. Although both moons have the same angular size, the horizon moon must be perceived as larger. More recent explanations hold that differences in accommodation or other factors cause the elevated moon to appear smaller. As a result of this illusory difference in size, the elevated moon appears to be more distant than the horizon moon. These two explanations, both based on the geometry of stereopsis, lead to two diametrically opposed hypotheses. That is, a depth interval at a long distance is associated with a smaller binocular disparity, whereas an equal depth interval at a smaller distance is associated with a larger disparity. We conducted experiments involving artificial moons and confirmed the hypothesis that the horizon moon is at a greater perceptual distance. Moreover, when a moon of constant angular size was moved closer it was also perceived as growing smaller, which is consistent with the older explanation. Although Emmert's law does not predict the size-distance relationship over long distances, we conclude that the horizon moon is perceived as larger because the perceptual system treats it as though it is much farther away. Finally, we observe that recent explanations substitute perceived size for angular size as a cue to distance. Thus, they imply that perceptions cause perceptions.

Outbreak of coccidioidomycosis in Washington state residents returning from Mexico

In July 1996 the Washington State Department of Health (Seattle) was notified of a cluster of a flulike, rash-associated illness in a 126-member church group, many of whom were adolescents. The group had recently returned from Tecate, Mexico, where members had assisted with construction projects at an orphanage. After 1 member was diagnosed with coccidioidomycosis, we initiated a study to identify further cases. We identified 21 serologically confirmed cases of coccidioidomycosis (minimum attack rate, 17%). Twenty cases (95%) occurred in adolescents, and 13 patients (62%) had rash. Sixteen symptomatic patients saw 19 health care providers; 1 health care provider correctly diagnosed coccidioidomycosis. Coccidioides immitis was isolated from soil samples from Tecate by use of the intraperitoneal mouse inoculation method. Trip organizers were unaware of the potential for C. immitis infection. Travelers visiting regions where C. immitis is endemic should be made aware of the risk of acquiring coccidioidomycosis, and health care providers should be familiar with coccidioidomycosis and its diagnosis.

A description of cutaneous-subcutaneous pythiosis in fifteen dogs

Information regarding signalment, duration of clinical signs, history of swimming, results of CBC and serum biochemical analyses, biopsy findings and mycological results, together with treatments and outcome, was retrieved from the medical records of 15 dogs with a diagnosis of pythiosis made between 1985 and 1995 at the Colleges of Veterinary Medicine, North Carolina State University and the University of Florida. Most of the dogs were young (median age 22 months) and represented larger breeds (> 20 kg). Lesions were characteristically chronic, ulcerated, and nodular with multiple draining tracts on the limbs, thoracic wall or perineal regions. The median duration of these lesions was 3 months with a range of 2 weeks-6 months. Seven dogs had a history of swimming. Peripheral eosinophilia was observed in 14 of the dogs. Cytological evaluation of discharge, aspirates, or impression smears made from biopsy specimens revealed hyphae in five of 11 dogs (45%). Histopathological evaluation using the Gomori Methenamine-Silver (GMS) stain was the most useful test for providing presumptive evidence of cutaneous pythiosis. Immunotherapy or antifungal therapy using either amphotericin B, liposomal nystatin, itraconazole, or ketoconazole were all unsuccessful. The only dog to survive underwent amputation of the affected limb; thus, the prognosis for cutaneous pythiosis in the dog is poor.

Investigation of an outbreak of endemic coccidioidomycosis in Brazil's northeastern state of Piauí with a review of the occurrence and distribution of Coccidioides immitis in three other Brazilian states

An outbreak of coccidioidomycosis is described that involved three individuals and eight of their dogs, who had engaged in a successful hunt for nine-banded armadillos (Dasypus novemcinctus) in the environs of Oeiras, a community in Brazil's north eastern state of Piauí. Diagnosis was based on clinical, serological and cultural findings. Four of 24 soil samples collected in and around the burrow of an armadillo yielded cultures of Coccidioides immitis, thus establishing the endemicity of that mould in the state of Piauí. A literature review revealed that C. immitis, aside from that state, is endemic in three other Brazilian states--Bahia, Ceará and Maranhão. These four contiguous states have semi-arid regions where climatic conditions and their flora are similar to those that exist in C. immitis's endemic regions in North, Central and South America.

Intravenous nitrates for pharmacological stimulation during head-up tilt testing in patients with suspected vasovagal syncope and healthy controls

Nitrates may be used for pharmacological stimulation during tilt testing for the diagnosis of vasovagal syncope. In this study we assessed the diagnostic value of intravenous nitrates during tilt testing in patients with a typical history of vasovagal syncope. Twenty patients and 23 controls were tilted at 700 for a maximum duration of 30 minutes. After a 10-minute baseline supine phase, the test started with a continuous nitrate infusion at 1 microg/kg/min and increased every 5 minutes by 1 microg/kg/min, to a maximum of 6 microg/kg/min at the end of the test. The test was ended if the subjects developed a positive response (syncope or presyncope). Nineteen patients (95%) and 17 (74%) of the controls had a positive response. At test end sensitivity was 95%, but specificity was 26% and accuracy was 58%. Receiver operator characteristics (ROC) analysis revealed a maximum accuracy of 79% at 18 minutes, with a sensitivity of 80% and a specificity of 78%. Intravenous nitrates during tilt testing in patients with typical clinical criteria of vasovagal syncope is highly effective in provoking vasovagal syncope. Based on the ROC analysis, a maximum accuracy of 79% was attained at 18 minutes (at a dose of 4 microg/kg/min), suggesting a good diagnostic performance when tilt duration is limited to this point. A positive result requiring more than 18 minutes of stimulated tilting should be interpreted with caution, due to the accompanying considerable decrease of specificity.

Indigenous disseminated Penicillium marneffei infection in the state of Manipur, India: report of four autochthonous cases

We describe four cases of disseminated infection caused by endemic Penicillium marneffei in human immunodeficiency virus (HIV)-infected patients from the Manipur state of India. The most common clinical features observed were fever, anorexia, weight loss, hepatosplenomegaly, and, more importantly, skin lesions resembling molluscum contagiosum. The diagnosis in each of the four cases was achieved by direct examination of smears, observance of intracellular yeast-like cells multiplying by fission in biopsied tissue from skin lesions, and isolation of the dimorphic P. marneffei in pure culture in each case. In one case, fluorescent antibody studies allowed specific diagnosis. This report documents a new area in which P. marneffei is endemic, located in eastern India, and describes the first occurrence in India of P. marneffei in HIV-infected patients as well as the extension of the areas of P. marneffei endemicity westward to the northeastern state of Manipur.

Maintaining abstinence from cigarette smoking: effectiveness of group counselling and factors predicting outcome

The aim of the study was to assess the effectiveness of worksite group counselling interventions designed to prevent smoking relapse after abstinence has been achieved following 3 months therapy using group support and/or transdermal nicotine replacement therapy. After 3 months, abstinent subjects were randomly allocated either to a counselling group led by professional psychologists (PG), to a counselling group led by former smokers (SG) or to no intervention group (NG). The 3 and 12 months abstinence were defined, respectively, as a sustained smoking cessation during the last month, and the last 9 months. Complete abstinence was confirmed by expired carbon monoxide and by urine cotinine concentrations. The abstinence rate at 3 months was 35.1%. After 12 months abstinence rates were not statistically different in the PG, the SG and the NG (respectively 57.8, 53.4 and 49.6% of those randomised). In multivariate analyzes, baseline variables associated with 12 months abstinence were non-smoking family, gender (male), lower daily intake of nicotine and better psychological adjustment. Mean weight gain at 3 months in abstinent versus relapsed subjects, was respectively, 4.1 and 2.4 kg. Baseline variables associated with weight gain at 3 months were higher Fagerström score, gender (male) and professional status (blue collar worker). Group support after abstinence has been achieved did not significantly improve the abstinence. This study shows the difficulty of preventing smoking relapse with monthly group counselling. The results indicate the need to investigate further specific programmes focusing on factors such as gender, family, nicotine dependence, psychological and weight concerns/issues which may precipitate relapse.

Outbreak of histoplasmosis among cavers attending the National Speleological Society Annual Convention, Texas, 1994

In June 1994, 18 people developed serologically confirmed histoplasmosis following cave exploration associated with the annual National Speleological Society Convention in Bracketville, Texas. Six others had an undiagnosed illness suspected to be histoplasmosis. Two persons were hospitalized. We conducted a survey of convention attendees and a nested case-control study of those entering caves. We also conducted a histoplasmin skin test survey of a subgroup of the society, the Texas Cavers Association, who were attending a reunion in October 1994. Among the national convention attendees, exposure to two caves was identified as responsible for 22 (92%) of the 24 cases; 12 (75%) of 16 people exploring one cave (Cave A) and 10 (77%) of 13 exploring a separate cave (Cave B) developed acute histoplasmosis. Additional risk-factors included fewer years of caving experience, longer time spent in the caves, and entering a confined crawl space in Cave A. Of 113 participants in the separate skin test survey, 68 (60%) were found to be skin test positive, indicating previous exposure to Histoplasma capsulatum. A positive skin test was significantly associated with male sex and more years of caving experience. Those less experienced in caving associations should be taught about histoplasmosis, and health care providers should pursue histories of cave exposure for patients with bronchitis or pneumonia that does not respond to initial antibiotic therapy.

Bacteriology of the middle meatus in children

Little is known about the bacteriology of the middle meatus in children. Therefore, middle meatal samples were obtained from 50 children who underwent adenoidectomy or adenotonsillectomy, while a group of 50 children submitted to minor non-ENT surgical procedures, were used as a control group. Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae were the most frequent cultured organisms, not only in the ENT group (in 68, 50 and 60% of the children respectively) but also in the control group (40, 34 and 50%). These three potential pathogens were more frequently seen among the children of the ENT group but only for H. influenzae was the observed difference statistically significant (P = 0.009). On semiquantitative analysis, there seemed to be more negative cultures or cultures with only a few colonies in the control group, while the richer cultures were obtained from the ENT group. Again, only for H. influenzae, these differences reached a statistical significance (P = 0.003). Streptococcus viridans and Neisseria species, both organisms that might be able to inhibit colonisation by some of the pathogens, were more frequently cultured in the control than in the ENT group: Strep. viridans 30 vs. 10% (P = 0.025) and Neisseria species 14 vs. 2% (P = 0.069).

Penicilliosis marneffei and pythiosis: emerging tropical diseases

Penicilliosis marneffei and pythiosis insidiosi are emerging infections in subtropical, tropical, and temperate areas of the world. Penicilliosis marneffei is endemic in several Southeast Asian countries and may be carried to other areas of the world by residents of these countries or visitors. Pythiosis occurs in humans and animals who frequent the aquatic habitats that harbor Pythium insidiosum. Although early diagnosis is important because of the high morbidity or mortality associated with these two diseases, the diagnosis of these infections can be difficult because their clinical and histologic features are not pathognomonic. Prompt diagnosis is a prerequisite to their appropriate treatment. Laboratory testing, involving cultural, histologic and immunologic methods, is necessary to establish an unequivocal diagnosis. The clinical presentation, epidemiology, diagnosis and treatment of these diseases are discussed.

Evolution of the ribosomal RNA internal transcribed spacer one (ITS-1) in cichlid fishes of the Lake Victoria region

The nucleotide sequences of the first internal transcribed spacer (ITS-1) of the ribosomal RNA gene cluster have been determined for 11 species of closely related endemic cichlid fishes of the Lake Victoria region (LVR) and 6 related East African cichlids. The ITS-1 sequences confirmed independently derived basal phylogenies, but provide limited insight within this species flock. The line leading to Pseudocrenilabrus multicolor arose early, close to the divergence event that separated the tilapiine and haplochromine tribes of the "African Group" of the family Cichlidae. In this phylogeny, Astatoreochromis alluaudi and the riverine Astatotilapia burtoni are sister taxa, which together are a sister group to a monophyletic assemblage including both Lake Victoria and Lake Edward taxa. The ITS-1 data support the monophyly of haplochromine genera across lakes. Since Lake Victoria is believed to have been dry between 14, 500 and 12,400 BPE, the modern assemblage must have been derived from reinvasion by the products of earlier cladogenesis events. Thus, although the regional superflock is monophyletic, the haplochromines of Lake Victoria itself did not evolve in situ from a single ancestor.

Apolipoprotein B genetic variability in Brazilian Indians

Three apolipoprotein B restriction fragment length polymorphism (RFLPs) (XbaI, MspI, and EcoRI) and the signal peptide insertion-deletion polymorphism were investigated using the polymerase chain reaction in 140 individuals from 5 Brazilian Indian tribes. All studied markers were polymorphic in this ethnic group. The insertion allele 5' beta SP*29 at the signal peptide previously observed in Mexican Americans was detected in about 8% of the chromosomes of 2 tribes (Gavião and Zoró), therefore confirming the Amerindian origin of this allele. Negative linkage disequilibrium was observed between alleles at the signal peptide and the EcoRI polymorphism in all tribes. In 3 populations (Gavião, Suruí, and Zoró) a negative disequilibrium was also detected between the insertion-deletion signal peptide markers and the XbaI polymorphism. In the whole sample of Amerindians 14 of the 24 (58%) possible 4-marker extended haplotypes were identified, but only haplotype 2 (5' beta SP*24/*X+/*M+/*E+) and haplotype 5 (5' beta SP*27/*X-/*M+/*E+) were shared by all tribes. No associations between plasma lipid levels or body mass index and these polymorphisms were observed in this sample.

Evaluation of a western blot test in an outbreak of acute pulmonary histoplasmosis

A western blot (WB) test was evaluated for detection of antibodies against native glycosylated and chemically deglycosylated M and H antigens of Histoplasma capsulatum in serum obtained from patients during the acute phase of pulmonary histoplasmosis that occurred during an outbreak. Of 275 serum samples tested by immunodiffusion and complement fixation (CF) samples from 40 patients affected during this outbreak and from 37 negative controls were tested by WB test. A group of patients whose sera were negative for CF antibodies and precipitins early in the acute stage of histoplasmosis but who all seroconverted during convalescence 6 weeks later were tested with the WB test. Antibodies against untreated H and M antigens were detected at a 1:100 dilution by WB test in 45% of the 20 acute-phase serum samples and in all 20 of the convalescent-phase specimens. The WB test's sensitivity for acute-phase specimens increased to 90% (18 of 20 specimens) when H and M antigens were treated by periodate oxidation to inactivate susceptible carbohydrate epitopes. When native glycosylated antigens were used in the WB test, positive reactions were observed in negative control serum specimens (3 of 37 specimens; 8%) and in serum specimens obtained from asymptomatic persons screened as part of the outbreak investigation (13 of 20 specimens; 65%). These positive reactions were also attributed to glycosidic epitopes since the specificity of the WB test increased from 78 to 100% when periodate-treated H and M antigens were used. WB test with deglycosylated H and M antigens of histoplasmin provides a rapid, sensitive, and specific test to diagnose acute pulmonary histoplasmosis before precipitins can be detected.

Successful medical therapy for deeply invasive facial infection due to Pythium insidiosum in a child

Pythiosis occurs in animals and humans who encounter aquatic habitats that harbor Pythium insidiosum. Drug therapy for deeply invasive infections with this organism has been ineffective in humans and animals; patients have been cured only by radical surgical debridement. A 2-year-old boy developed periorbital cellulitis unresponsive to antibiotic and antifungal therapy. The cellulitis extended to the nasopharynx, compromising the airway and necessitating a gastrostomy for feeding. P. insidiosum was isolated from surgical biopsy specimens of the affected tissue. On the basis of in vitro susceptibility studies of the isolate, the patient was treated with a combination of terbinafine and itraconazole. The infection resolved over a period of a few months. The patient remained well 1.5 years after completing a 1-year course of therapy. Cure of deep P. insidiosum infection is feasible with drug therapy.

Sporotrichosis in a nine-banded armadillo (Dasypus novemcinctus)

An adult female nine-banded armadillo (Dasypus novemcinctus) died in the quarantine station of a private Swiss zoo. Multifocal ulcerative skin lesions and multiple hemorrhages in the lungs were found at necropsy. The spleen was enlarged and dark red. Histologically, there was diffuse granulomatous infiltration, including multinucleated giant cells, of the skin lesions, lungs, spleen, liver, heart, and kidneys. Abundant periodic acid-Schiff-positive yeastlike cells were demonstrated intracellularly in giant cells and extracellularly scattered throughout the tissues. Morphology of the cells varied, with some nonbudding cells resembling Cryptococcus neoformans and others resembling Sporothrix schenckii. A diagnosis of sporotrichosis was confirmed by immunofluorescence studies. This is the first report of sporotrichosis in an armadillo in a zoological garden and the third report of sporotrichosis in D. novemcinctus.

Immunodominant Nocardia asteroides antigens: isolation and characterisation by enzyme-linked immunoelectrotransfer blotting, and the value of immunoblot strips

Concentrated cell-free filtrates (nocardins) were prepared from Nocardia asteroides cultures grown on Sauton's synthetic broth. Nocardins from 10 strains of six N. asteroides serotypes were produced and the proteins separated by isoelectric focusing. N. asteroides antigens among these proteins were tested for specificity using rabbit antisera and monoclonal antibodies (MAbs) against N. asteroides and Mycobacterium tuberculosis by the enzyme-linked immunoelectrotransfer blot test. At least 15 protein antigens were identified from each of the 10 nocardins. The immunodominant antigens were one serotype-specific N. asteroides protein with an isoelectric point (pI) of 4.0 (factor 1) and two group antigens with pIs of 4.43 (factor 6) and 4.68 (factor 8). The nitrocellulose strips prepared with these antigens did not react with antibodies to M. tuberculosis, nor with normal sera from humans, rabbits, or mice, but reacted specifically with anti-N. asteroides MAbs and polyclonal antibodies. Four purified protein derivatives of tuberculin were tested and did not cross-react with the three anti-N. asteroides MAbs. These reactions suggest that the antigens identified as factors 1, 6 and 7 are specific to N. asteroides and that factor 1 is specific for serotype 2, while factors 6 and 8 are species-specific.