Identification to the species level and differentiation between strains of Aspergillus clinical isolates by automated repetitive-sequence-based PCR

A commercially available repetitive-sequence-based PCR (rep-PCR) DNA fingerprinting assay adapted to an automated format, the DiversiLab system, enables rapid microbial identification and strain typing. We explored the performance of the DiversiLab system as a molecular typing tool for 69 Aspergillus isolates (38 A. fumigatus, 15 A. flavus, and 16 A. terreus isolates) had been previously characterized by morphological analysis. Initially, 27 Aspergillus isolates (10 A. fumigatus, 9 A. flavus, and 8 A. terreus isolates) were used as controls to create a rep-PCR-based DNA fingerprint library with the DiversiLab software. Then, 42 blinded Aspergillus isolates were typed using the system. The rep-PCR-based profile revealed 98% concordance with morphology-based identification. rep-PCR-based DNA fingerprints were reproducible and were consistent for DNA from both hyphae and conidia. DiversiLab dendrogram reports correctly identified all A. fumigatus (n = 28), A. terreus (n = 8), and A. flavus (n = 6) isolates in the 42 blinded Aspergillus isolates. rep-PCR-based identification of all isolates was 100% in agreement with the contiguous internal transcribed spacer (ITS) region (ITS1-5.8S-ITS2) sequence-based identification of the respective isolates. Additionally, the DiversiLab system could demonstrate strain-level differentiation of A. flavus and A. terreus. Automated rep-PCR may be a time-efficient, effective, easy-to-use, novel genotyping tool for identifying and determining the strain relatedness of fungi. This system may be useful for epidemiological studies, molecular typing, and surveillance of Aspergillus species.

Clearing the cervical spine in unconscious adult trauma patients: A survey of practice in specialist centres in the UK

A postal questionnaire survey of neurosurgery and spinal injury departments in the UK was conducted to determine how they assessed the cervical spine in unconscious, adult trauma patients, and at what point immobilisation was discontinued. Of the 32 units contacted, 27 responded (response rate, 84%). Most centres had no protocols to guide initial imaging or when immobilisation devices should be removed. Most responding centres performed fewer than three plain radiographs, and most did not use computerised tomography routinely. Routine use of magnetic resonance imaging or dynamic flexion-extension fluoroscopy was rare, and few units regarded the latter as safe in unconscious patients. There was no consensus on when immobilisation of the cervical spine should be discontinued. Most centres that terminated immobilisation immediately after imaging did so on the basis of plain radiographs alone. Unconscious adult trauma patients remain at risk of inadequate assessment of potential cervical spine injuries.

Microbial characterization during the early habitation of the International Space Station

An evaluation of the microbiota from air, water, and surface samples provided a baseline of microbial characterization onboard the International Space Station (ISS) to gain insight into bacterial and fungal contamination during the initial stages of construction and habitation. Using 16S genetic sequencing and rep-PCR, 63 bacterial strains were isolated for identification and fingerprinted for microbial tracking. Of the bacterial strains that were isolated and fingerprinted, 19 displayed similarity to each other. The use of these molecular tools allowed for the identification of bacteria not previously identified using automated biochemical analysis and provided a clear indication of the source of several ISS contaminants. Strains of Bradyrhizobium and Sphingomonas unable to be identified using sequencing were identified by comparison of rep-PCR DNA fingerprints. Distinct DNA fingerprints for several strains of Methylobacterium provided a clear indication of the source of an ISS water supply contaminant. Fungal and bacterial data acquired during monitoring do not suggest there is a current microbial hazard to the spacecraft, nor does any trend indicate a potential health risk. Previous spacecraft environmental analysis indicated that microbial contamination will increase with time and will require continued surveillance.

Total body iron overload in welder's siderosis

Welder's siderosis occurs as a consequence of the inhalation of iron dust. The iron overload of welder's siderosis is usually considered to be confined to the lungs. Here we present three proven cases of welder's siderosis associated with evidence of increased total systemic iron stores, as evidenced by increased serum ferritin levels. Multiple investigations including molecular genotyping for the common mutations found in genetic haemochromatosis failed to prove this was due to haemochromatosis, nor was there any evidence of any other recognised cause of systemic iron overload. Thus the systemic iron overload described seems likely to be due to either occupational exposure, an uncharacterised genetic haemochromatosis, or a combination of both.

Paediatric near-drowning: mortality and outcome in a temperate climate

The decision whether to continue to resuscitate the paediatric victim of near-drowning is influenced by potential poor neurological outcome. A low core body temperature at presentation is frequently cited as a reason to continue resuscitation. We report the case of an 11 month old infant admitted to the intensive care unit following near-drowning and a prolonged resuscitation. The infant's core body temperature was 29 degrees C. Cardiac output was restored, but the child remains in a persistent vegetative state. We present the results of a ten year review of near-drowning in a tertiary referral institution, to evaluate the mortality and outcome in a temperate climate. Thirteen patients were identified in the review. The mortality was 23%. The incidence of a persistent vegetative state was 15%. Asystole, immersion time greater than 15 minutes, resuscitation time longer than 30 minutes, the administration of epinephrine, and a low core body temperature were associated with a poor outcome.

Nutrient processing capacity of a constructed wetland in western Ireland

In Ireland, constructed wetland systems are increasingly being used to perform tertiary treatment on municipal waste effluent from small towns and villages located in areas whose receiving waters are deemed sensitive. The bedrock formation in the west of Ireland is primarily karst limestone and where the overburden-soil cover is very shallow, such waters are highly sensitive to pollution sources, as little or no natural attenuation and/or treatment will occur. Constructed wetland technology has been seen to offer a relatively low-cost alternative to the more conventional tertiary treatment technologies, particularly when dealing with low population numbers in small rural communities. This paper examines the waste treatment performance, in terms of nutrient (P and N) reduction, of a recently constructed surface-flow wetland system at Williamstown, County Galway, Ireland. Performance evaluation is based on more than two years of water quality and hydrological monitoring data. The N and P mass balances for the wetland indicate that the average percentage reduction over the two-year study period is 51% for total N and 13% for total P. The primary treatment process in the wetland system for suspended solids (between 84 and 90% reduction), biological oxygen demand (BOD) (on average, 49% reduction), N, and P is the physical settlement of the particulates. However, the formation of algal bloom during the growing season reduces the efficiency of the total P removal.

Timing and interpretation of tests for diagnosing perinatally acquired hepatitis C virus infection

The diagnosis of hepatitis C virus (HCV) infection in children born to HCV-infected women is based on serologic assays and HCV RNA measurement by PCR. Interpretation of the results of these tests is hampered by uncertainty about the age distribution of loss of maternal antibody and the sensitivity and specificity of PCR at different ages. On the basis of findings from a recent vertical transmission study, we estimated the posttest probability of a child's being infected or uninfected under several test result scenarios. These estimates may assist clinicians in assessing the likelihood of infection in an individual child and in using the currently available assays cost effectively.

Mother-to-child transmission of hepatitis C virus: evidence for preventable peripartum transmission

BACKGROUND

Little information is available about the timing of mother-to-child transmission of hepatitis C virus (HCV), and no interventions to decrease transmission rates have been identified. We examined the effect of risk factors, including mode of delivery, on the vertical transmission rate.

METHODS

Data from HCV-infected women and their infants from three hospitals in Ireland and from a British Paediatric Surveillance Unit study of infants born to HCV-infected mothers were used to estimate the vertical transmission rate and risk factors for transmission. We used a probabilistic model using methods that simultaneously estimated the time to HCV-antibody loss in uninfected infants and the diagnostic accuracy of PCR tests for HCV RNA.

FINDINGS

441 mother-child pairs from the UK (227) and Ireland (214) were included. 50% of uninfected children became HCV-antibody negative by 8 months and 95% by 13 months. The estimated specificity of PCR for HCV RNA was 97% (95% CI 96-99) and was unrelated to age; sensitivity was only 22% (7-46) in the first month but rose sharply to 97% (85-100) thereafter. The vertical transmission rate was 6.7% (4.1-10.2) overall, and 3.8 times higher in HIV coinfected (n=22) than in HIV-negative women after adjustment for other factors (p=0.06). No effect of breastfeeding on transmission was observed, although only 59 women breastfed. However, delivery by elective caesarean section before membrane rupture was associated with a lower transmission risk than vaginal or emergency caesarean-section delivery (odds ratio 0 [0-0.87], p=0.04, after adjustment for other factors).

INTERPRETATION

The low sensitivity of HCV RNA soon after birth and the finding of a lower transmission rate after delivery by elective caesarean section suggest that HCV transmission occurs predominantly around the time of delivery. If the findings on elective caesarean section are confirmed in other studies, the case for antenatal HCV testing should be reconsidered.

Partially unfolded species populated during equilibrium denaturation of the beta-sheet protein Y74W apo-pseudoazurin

Apo-pseudoazurin is a single domain cupredoxin. We have engineered a mutant in which a unique tryptophan replaces the tyrosine residue found in the tyrosine corner of this Greek key protein, a region that has been proposed to have an important role in folding. Equilibrium denaturation of Y74W apo-pseudoazurin demonstrated multistate unfolding in urea (pH 7.0, 0.5 M Na(2)SO(4) at 15 degrees C), in which one or more partially folded species are populated in 4. 3 M urea. Using a variety of biophysical techniques, we show that these species, on average, have lost a substantial portion of the native secondary structure, lack fixed tertiary packing involving tryptophan and tyrosine residues, are less compact than the native state as determined by fluorescence lifetimes and time-resolved anisotropy, but retain significant residual structure involving the trytophan residue. Peptides ranging in length from 11 to 30 residues encompassing this region, however, did not contain detectable nonrandom structure, suggesting that long-range interactions are important for stabilizing the equilibrium partially unfolded species in the intact protein. On the basis of these results, we suggest that the equilibrium denaturation of Y74W apo-pseudoazurin generates one or more partially unfolded species that are globally collapsed and retain elements of the native structure involving the newly introduced tryptophan residue. We speculate on the role of such intermediates in the generation of the complex Greek key fold.

Recurrence of Langerhans' cell granulomatosis following lung transplantation

A case is presented of pulmonary Langerhans' cell granulomatosis which recurred following lung transplantation and responded to cyclophosphamide. This suggests that the primary abnormality in this condition lies in the Langerhans' cell or precursor dendritic cell.

Vitamin D-fortified liquid milk: benefits for the elderly community-based population

To assess the efficacy and acceptability of vitamin D-fortified liquid milk in the management of hypovitaminosis D we carried out a double-blind, randomized, controlled trial on 51 community-based, elderly subjects with serum 25 hydroxyvitamin D (25OHD) levels of less than 12.9 ng/ml (normal range 10-80 ng/ml). Each subject had a dietary assessment, mental test score, outdoor score, serum 25 hydroxyvitamin D level, and a general biochemical screening at baseline in April 1993 which was repeated in September 1993, April 1994, and September 1994. All subjects received 500 ml of milk per day, delivered to their homes in specially manufactured, blank, tetrapak cartons, from June 1993 to June 1994: 23 subjects received unfortified milk (control group) and 28 subjects received fortified milk (active group). Our results showed a baseline mean 25OHD level in the active group of 9.6 (range < 5.5-12.7) ng/ml and in the control group of 10.0 (range < 5.5-12.9) ng/ml (P < 0.4). One year later the mean 25OHD level in the active group had risen significantly from its baseline to 18.5 (range 9.6-26.7) ng/ml (P < 0.001) and was significantly different from the control group with a 1-year mean of 12.7 (range < 4-24.1) ng/ml (P < 0.001). Serum calcium levels in the active group also showed a significant rise over the 1-year period (P < 0.001) whereas those in the control group did not. We conclude that vitamin D-fortified liquid milk is a safe, effective, and acceptable method of administering vitamin D to the elderly, community-based population.

Tanner-Whitehouse bone age reference values for North American children

On the basis of 1090 x-ray films from 225 boys and 225 girls ages 8 to 16 years-participants in the Project Heartbeat longitudinal study who were living in a generally above-average income environment near Houston, Tex.-we provide Tanner-Whitehouse Mark 2 RUS (radius, ulna, and selected metacarpals and phalanges) bone age reference values for North American children of European origin. We designate these values as US90 (for the 1990s) reference values, in contrast to the original British bone age standards, called UK60 (for the 1960s). The US90 children matured considerably earlier than those on which the UK60 standards were based, though only about 3 months earlier than contemporary Spanish children. A study of 190 x-ray films from a research longitudinal series of 23 healthy boys in Virginia yielded values very close to the Houston values, confirming that our US90 reference values should be used in North America, pending a more extensive survey.

The effect of tourniquet release time on the analgesic efficacy of intraarticular morphine after arthroscopic knee surgery

A randomized, controlled study was conducted in patients undergoing elective arthroscopic knee surgery to assess the effects of tourniquet release time on analgesia after intraarticular (I.A.) injection of morphine. Standardized general anesthetic and surgical techniques were used for all patients, including a thigh tourniquet inflated at pressures between 300 and 350 mm Hg. At the conclusion of the arthroscopic procedure, 5 mg morphine in 25 mL saline was administered I.A. Patients were then randomized to one of two treatment groups. In Group 1 (n = 20), the tourniquet was kept inflated for 10 min after I.A. injection, whereas in Group 2 (n = 20), the tourniquet was deflated immediately after I.A. injection. Postoperative pain was assessed using a visual analog scale in the recovery room when the patients were awake and at 2, 4, 6, 8, and 24 h after I.A. injection. Patients who complained of pain in the recovery room received increments of intravenous meperidine 25-50 mg. On discharge from the recovery room, patients received oral mefenamic acid 250-500 mg for pain relief. The time and quantity of analgesics required were recorded. Patients in Group 1 had significantly (P < 0.05) lower pain scores than those in Group 2 at 2, 4, 6, and 8 h postoperatively. These low pain scores were associated with lower requirements of supplementary analgesics. We conclude that, as compared with releasing the tourniquet immediately after I.A. injection of morphine, maintaining the tourniquet inflated for 10 min provides superior analgesia and decreases the need for supplemental analgesics.

Intrathecal morphine: one year's experience in cardiac surgical patients

OBJECTIVES

This study was designed to assess the benefits and complications associated with the use of intrathecal morphine (ITM) in patients undergoing coronary artery bypass surgery (CABG).

DESIGN

This was a retrospective chart review.

SETTING

The study was performed in a single hospital that is affiliated with a university medical school.

PARTICIPANTS

The charts of all patients who presented for CABG in a 12-month period were reviewed.

INTERVENTIONS

All patients entered into the study had received ITM (0.03 mg/kg) at induction of anesthesia.

MEASUREMENTS AND MAIN RESULTS

Complete data were available for 152 patients (86%). Median duration of ventilation postoperatively was 12 hours, and median duration of stay in the ICU was 72 hours. All patients received additional postoperative opioid analgesia, many by the epidural route. Fifteen percent developed respiratory complications, and the incidence of respiratory depression was 1.9%. Thirty-five percent required inotropic support; 17% percent were treated for hypertension; and 49% received antiarrhythmic therapy. The re-infarction rate was 2.6%, and 3% developed cardiac tamponade. Three patients developed neurologic complications unrelated to lumbar puncture. There were no in-hospital deaths.

CONCLUSIONS

ITM is safe and provides effective pain relief after cardiac surgery. The high incidence of respiratory depression confirms the need for close observation of these patients postoperatively.

Hypovitaminosis D in the healthy elderly

Hypovitaminosis D is a common finding in the healthy elderly population and has significant sequelae. No clear dietary or sunlight-related risk factors were identified by dietary assessment and modified outdoor score. Fortified liquid milk and vitamin supplements were associated with significantly higher serum 25-hydroxyvitamin D levels. These results emphasise the need for foodstuff fortification and supplement use in the healthy elderly, as well as the 'high-risk' housebound and institutionalised elderly.

Swedish population reference standards for height, weight and body mass index attained at 6 to 16 years (girls) or 19 years (boys)

Swedish population reference standards for height, weight and body mass index (BMI) attained at 6 to 16 years (girls) or 19 years (boys) are presented. Data were obtained from two independent nationwide samples of Swedish children; one (740 children) born in 1955, the other (2907 children) born in 1967. The weights of the children born in 1955 were adjusted to equal those born in 1967; heights did not differ. These reference standards refer therefore to Swedish children born at around 1970. The observations were fitted by the power transformation, or L, M, S method of Cole and Green. Weights and BMIs were thus normalized and valid SD scores for individuals obtained. Centile charts are given for clinical use. The means of the present, nationwide standards were 1-2 cm and 1-2 kg greater than those of the Solna-based standards currently in use.

An immunohistochemical method for the detection of tumour necrosis factor alpha in cytospins of human bronchoalveolar lavage cells

An immunohistochemical method for assessing the level of tumour necrosis factor-alpha in alveolar macrophages obtained by brochoalveolar lavage is described. Cytospins of mixed populations of lung cells were incubated first with a monoclonal antibody to CD68 and then with a specific peroxidase-labelled second antibody in a two-step reaction for the detection of the macrophage marker CD68. A second similarly based two-step reaction for the detection of tumour necrosis factor-alpha followed. Both reactions were visualized, on completion, using different coloured peroxidase substrates which produced a third colour in the event of dual deposition of the substrates. Dual substrate deposition was indicative of alveolar macrophages positive for tumour necrosis factor-alpha. This method has provided a specific and reproducible semi-quantitative test for the presence of tumour necrosis factor-alpha in human activated alveolar macrophages, which can be performed retrospectively on clinical material. A range of concentrations of the cytokine has been demonstrated in individual samples. This dual detection method has the potential for detection of any cell-associated protein product by minor modification of the described method.