Cerebrospinal fluid values in the term neonate

BACKGROUND

Cerebrospinal fluid (CSF) values in the noninfected neonate are not well-delineated. Studies analyzing these values are inconsistent in the criteria used to define the noninfected population. The purpose of our study was to examine CSF values in neonates in the first 30 days of life in whom infection was more thoroughly excluded than in previous reports. Stringent inclusion criteria defined the noninfected population, and the recently available polymerase chain reaction (PCR) for enteroviruses was used in addition to cultures to help exclude viral disease. Results were also stratified by age in weeks to evaluate for any variability that occurs in CSF values during the first month of life.

METHODS

Neonates were selected from subjects enrolled in two studies on aseptic meningitis. Noninfected infants were identified by the following criteria: (1) atraumatic lumbar puncture (< or = 1000 red blood cells/mm3); (2) no antibiotic therapy before lumbar puncture; (3) sterile blood, CSF and urine bacterial cultures; (4) negative CSF viral culture; and (5) negative CSF PCR for enteroviruses.

RESULTS

The mean +/- SD total CSF white blood cell count for 108 noninfected neonates was 7.3 +/- 14/mm3 (95% confidence interval 6.6 to 8.0/mm3) with a median of 4/mm3 and a range of 0 to 130/mm3. There were no significant differences in the mean CSF white blood cell counts among age categories.

CONCLUSIONS

The application of stringent inclusion criteria and the use of the PCR yielded a population of infants that better represents the noninfected neonate than earlier reports. These values can be used for reference in evaluating the febrile or ill neonate.

Clindamycin therapy of experimental meningitis caused by penicillin- and cephalosporin-resistant Streptococcus pneumoniae

Although penicillin resistance among Streptococcus pneumoniae strains is increasing in many areas, resistance to clindamycin remains low. In our well-characterized rabbit meningitis model, we conducted experiments to evaluate the bacteriologic efficacy of clindamycin after a penicillin- and cephalosporin-resistant S. pneumoniae strain was intracisternally inoculated. Animals received a loading intravenous dose of 30 mg of clindamycin per kg of body weight and then two doses of 20 mg/kg given 5 h apart. In addition to clindamycin, some animals received dexamethasone (DXM) with or without ceftriaxone. The concentrations of clindamycin in cerebrospinal fluid were from 8.9 to 12.8% of the concomitant concentrations in serum and were unaffected by DXM administration. Mean changes in CFU (log10 per milliliter) at 10 and 24 h were -3.7 and -6.1, respectively, for clindamycin-treated rabbits, -3.6 and -6.3 for clindamycin-DXM-treated rabbits, -3.9 and -5.8, respectively, for clindamycin-ceftriaxone-treated rabbits, and -5.0 and -6.7, respectively, for clindamycin-ceftriaxone-DXM-treated rabbits. By 24 h all but one of the cultures of cerebrospinal fluid (that from a clindamycin-DXM-treated rabbit) were sterile. Because of the potential risk for clindamycin-treated rabbits to develop macrolide-lincosamide resistance, we attempted, unsuccessfully, to induce clindamycin resistance in vitro in two S. pneumoniae strains. Although clindamycin therapy might be effective in selected patients with multiple-drug-resistant pneumococcal meningitis who have failed conventional treatments, clinical experience is necessary before it can be recommended.

Kinetics of cytochrome c2+ oxidation by peroxynitrite: implications for superoxide measurements in nitric oxide-producing biological systems

Cytochrome c3+ has been extensively used for the detection of superoxide produced in biological systems due to its fast superoxide-mediated reduction to cytochrome c2+. However, another biomolecule which is sometimes cogenerated with superoxide, nitric oxide, reacts with superoxide at almost diffusion-controlled rates (6.7 x 10(9) M-1 s-1), leading to the production of a highly oxidizing species, peroxynitrite anion (ONOO-). In this work we report that peroxynitrite readily oxidizes cytochrome c2+ to cytochrome c3+ in an ascorbate-reversible manner. The reaction between peroxynitrite and cytochrome c2+ occurs with a second-order rate constant of 2.3 x 10(5) M-1 s-1. The pH dependence of the apparent second-order rate constants as well as the effect of different scavengers indicated that peroxynitrous acid (ONOOH) in the ground state was the actual species responsible of cytochrome c2+ oxidation. The activation enthalpy, free energy, and entropy were +10.8 kcal mol-1, +11.8 kcal mol-1, and -3.15 cal mol-1 K-1, respectively, in agreement with the proposed reaction mechanism. Additionally, our results imply that when quantitating superoxide by the cytochrome c3+ reduction method, the existence of a simultaneous generation of nitric oxide and peroxynitrite may lead to an underestimation of the rates of superoxide production.

Evaluation of CP-99,219, a new fluoroquinolone, for treatment of experimental penicillin- and cephalosporin-resistant pneumococcal meningitis

CP-99,219 is a new fluoroquinolone that has excellent activity against gram-positive organisms including penicillin- and cephalosporin-resistant Streptococcus pneumoniae strains. In our well-established rabbit model of meningitis, we conducted experiments to determine the concentrations of CP-99,219 in cerebrospinal fluid (CSF) after intravenous administration and its ability to eradicate two penicillin-resistant pneumococcal isolates. The peak and trough concentrations of CP-99,219 in the CSF were from 19 to 25% of the concentrations simultaneously obtained in serum and were unaffected by concomitant dexamethasone administration. Compared with untreated (control) animals, three doses of CP-99,219 given 5 h apart significantly reduced the bacterial count in CSF by 5 to 6 log10 CFU at 10 h. Although 47% of the dexamethasone-treated animals and 18% of those not given the steroid had positive cultures at 24 h (14 h after administration of the last antibiotic dose), the mean bacterial counts did not change from those observed at 10 h. Additionally, only results for animals infected with one of the two pneumococcal strains appeared to be affected by concomitant dexamethasone therapy.

Nitric oxide regulation of superoxide and peroxynitrite-dependent lipid peroxidation. Formation of novel nitrogen-containing oxidized lipid derivatives

Superoxide (O2-.), nitric oxide (.NO), and their reaction product peroxynitrite (ONOO-) have all been shown to independently exert toxic target molecule reactions. Because these reactive species are often generated in excess during diverse inflammatory and other pathologic circumstances, we assessed the influence of .NO on membrane lipid peroxidation induced by O2-., H2O2, and .OH derived from xanthine oxidase (XO) and by ONOO-. Experimental conditions in lipid oxidation systems were adjusted to yield different rates of delivery of .NO, relative to rates of O2-. and H2O2 generation, by infusion of either .NO or via .NO released from S-nitroso-N-acetylpenicillamine or S-nitrosoglutathione. Peroxidation of phosphatidylcholine liposomes was assessed by formation of thiobarbituric acid-reactive products and by liquid chromatography-mass spectrometry. Liposomes exposed to XO-derived reactive species in the presence of .NO exhibited both stimulation and inhibition of lipid peroxidation, depending on the ratio of the rates of reactive oxygen species production and .NO introduction into reaction systems. Nitric oxide alone did not induce lipid peroxidation. Linolenic acid emulsions peroxidized by XO-derived reactive species showed similar dose-dependent regulation of lipid peroxidation by .NO. Mass spectral analysis of oxidation products showed formation of nitrito-, nitro-, nitrosoperoxo-, and/or nitrated lipid oxidation adducts, demonstrating that .NO serves as a potent terminator of radical chain propagation reactions. Electron spin resonance (ESR) analysis of incubation mixtures provided no evidence for formation of paramagnetic iron-lipid-nitric oxide complexes in reaction systems. Peroxynitrite-dependent lipid peroxidation, which predominantly occurs by metal-independent mechanisms, was also inhibited by .NO. Peroxynitrite-mediated benzoate hydroxylation was partially inhibited by .NO, inferring reaction between .NO and ONOOH. It is concluded that .NO can both stimulate O2-./H2O2/.OH-induced lipid oxidation and mediate oxidant-protective reactions in membranes at higher rates of .NO production, with the prooxidant versus antioxidant outcome critically dependent on relative concentrations of individual reactive species. Prooxidant reactions of .NO will occur after O2-. reaction with .NO to yield potent secondary oxidants such as ONOO- and the antioxidant effects of .NO a consequence of direct reaction with alkoxyl and peroxyl radical intermediates during lipid peroxidation, thus terminating lipid radical chain propagation reactions.

Screening for childhood physical and sexual abuse among outpatient substance abusers

Research demonstrates that substance-abusing individuals report substantially higher rates of childhood sexual and physical abuse than the general population. This study sought to test a method of identifying substance-abusing clients with histories of childhood sexual and/or physical abuse and to explore the differences between those reporting childhood abuse and those not. Files of substance abusing clients from two distinct time periods were examined for reports of childhood abuse. At Time 1 (n = 399) clients were not systematically asked about experiences of childhood abuse, and at Time 2 (n = 305) clients were routinely asked about this issue. Results indicate that significantly more male and female clients disclosed childhood abuse at Time 2. Additionally, male clients reporting childhood abuse appeared more distressed than those not reporting abuse; female clients reporting childhood abuse did not appear more distressed than their counterparts.

The development of health knowledge in low-income Mexican-American children

Children growing up in poverty are at risk for various health problems. For low-income, Mexican-American children, these risks include obesity, diabetes, and accidental injuries, 3 conditions that can largely be prevented by healthy life-styles. Despite the potential for prevention through education leading to health-promoting behaviors, very little is known about the development of health knowledge in this population. The present study examined low-income, Mexican-American children's understanding of the relation between health behavior and health status in 3 areas: nutrition, hygiene, and safety. 79 children (41 boys, 38 girls) ages 4 to 8 years participated. Children's knowledge was assessed in a structured play situation conducted in a laboratory setting. Results revealed that children knew the least about the relation between food consumption and their health, and knew the most about beneficial and harmful practices in the areas of safety and hygiene. Age and gender differences were also significant, with girls and older children more likely to provide elaborate and complex rationales for their responses. Implications of the findings for understanding the role of cognitive development and experience in the development of health knowledge are considered.

The processing pathway of prelamin A

The conversion of mammalian prelamin A to mature lamin A proceeds through the removal of 18 amino acids from the carboxyl terminus. The initial step in this processing is the isoprenylation of a CAAX box cysteine. This proteolytic event is distinctive for prelamin A among the known prenylated mammalian proteins. Since the carboxyl terminus of prelamin A is removed during maturation, it is not obvious that this protein would undergo the two reactions subsequent to prenylation observed in other CAAX box proteins--the endoproteolytic removal of the carboxyl-terminal 3 amino acids and the subsequent methylation of the now carboxyl-terminal cysteine. To characterize the maturation of prelamin A further, we have developed a CHO-K1 cell line that possesses a dexamethasone-inducible human prelamin A against a genetic background of high mevalonate uptake. Utilizing this cell line in association with antibodies specific to the transgenic prelamin A, we have been able to demonstrate directly in vivo that prelamin A undergoes farnesylation and carboxymethylation prior to conversion to lamin A, as is the case for other prenylated proteins. We have demonstrated previously that in the absence of isoprenylation, conversion of prelamin A to lamin A is blocked, but that unprocessed prelamin A is transported to the nucleus where it can still undergo maturation. Consistent with the implications of these prior studies, we now demonstrate the presence of both subunits of farnesyl-protein transferase in the nucleus.

The use of fetal echocardiography for predicting intrapartum fetal heart rate patterns in the post-term pregnancy

One of the shortcomings of antepartum testing in the post-term pregnancy is that it does not identify the majority of fetuses who develop abnormal intrapartum fetal heart rate changes. The purpose of this study was to determine whether antenatal cardiovascular evaluation could aid in the identification of post-term fetuses at risk for intrapartum heart rate abnormalities. Seventy-five patients with a gestational age greater than 41 weeks underwent a non-stress test, amniotic fluid index and real-time assessment of the heart for the presence or absence of a pericardial effusion. M-mode measurements of the right ventricular inner dimension (RVID), left ventricular inner dimension (LVID), biventricular outer dimension (BVOD) and Doppler velocimetry of the umbilical artery (S/D) were performed. Group I (n = 32) had normal intrapartum heart rate tracings. Group II (n = 20) had abnormal intrapartum fetal heart rate tracings but did not undergo emergency delivery. Group III (n = 23) had abnormal intrapartum fetal heart rate tracings but underwent emergency delivery. When comparing Group I with Group II, the latter had significant differences for abnormal RVID, RVID/LVID ratio, and pericardial effusion. When comparing Groups I and III, there were significant differences for RVID, RVID/LVID ratio, pericardial effusion, BVOD, LVID and amniotic fluid index. Neither the non-stress test nor S/D predicted abnormal intrapartum fetal heart rate patterns. For prediction of abnormal intrapartum heart rate patterns, the sensitivities of the RVID (0.79), LVID (0.33), RVID/LVID ratio (0.72) and BVOD (0.63) were 1.7-4 times greater than the non-stress test (0.19) and the sensitivities of the RVID, RVID/LVID ratio and BVOD were 2 times greater than the amniotic fluid index (0.28). The positive (0.50-0.86) and negative (0.42-0.68) predictive values were similar for all groups. To predict emergency delivery associated with abnormal heart rate tracings, the sensitivities of the RVID (0.83), RVID/LVID ratio (0.70) and BVOD (0.65) were 2.5-3 times greater than the non-stress test (0.26) and 1.5 times greater than the amniotic fluid index (0.39). The positive (0.36-0.56) and negative (0.70-0.86) predictive values were similar. The presence of pericardial effusion had a higher sensitivity than the non-stress test and amniotic fluid index for predicting abnormal intrapartum heart rate patterns but not emergency delivery. Doppler velocimetry of the umbilical artery had a lower sensitivity than the non-stress test and amniotic fluid index for predicting intrapartum heart rate patterns as well as identifying the fetus needing emergency delivery. The results of this study would suggest that there is initially dilatation of the right ventricle which may be associated with abnormal intrapartum fetal heart rate patterns. However, when the left ventricle dilates, leading to cardiomegaly, there is a greater incidence of abnormal intrapartum fetal heart rate changes and associated emergency delivery. The amniotic fluid index appears to be a later finding for predicting abnormal intrapartum fetal heart rate changes.

Brief psychotherapy of personality disorders

Thirty-two patients with personality disorder diagnoses were randomly assigned to two treatment conditions that vary on several techniques of brief dynamic psychotherapy. Seventeen patients constituted a waiting list control group. The two brief psychotherapies showed significant improvement on target complaints, SCL-90, and Social Adjustment Scale-SR compared with the control subjects. The two therapy groups were similar in overall outcome but showed interesting differences on several subscale measures. Process measurements of videotaped sessions revealed significant variations in frequencies of therapist interventions across the two treatment conditions, which validated planned differences in the treatment techniques.

Change in patient affect/defense ratio from early to late sessions in brief psychotherapy

The current study examined changes in the ratio of patients' affective and defensive behaviors during the course of brief psychodynamic psychotherapy. Treatments of 16 patients were videotaped. For each patient, four sessions were evaluated with a minute-by-minute coding system of process variables. When patients were grouped according to outcome scores, significant differences between the high outcome and the average-to-low outcome groups emerged. During the early phase of treatment, patients in both groups showed an average of one affective response per five defensive responses. By the late phase of treatment, the high outcome patients showed a marked shift to one affective response per two defensive responses, while the low outcome patients remained the same. An incidental finding was a negative correlation between good outcome and the ratio of defensive behavior to total patient activity.

Change in patient affect/defense ratio from early to late sessions in brief psychotherapy

The current study examined changes in the ratio of patients' affective and defensive behaviors during the course of brief psychodynamic psychotherapy. Treatments of 16 patients were videotaped. For each patient, four sessions were evaluated with a minute-by-minute coding system of process variables. When patients were grouped according to outcome scores, significant differences between the high outcome and the average-to-low outcome groups emerged. During the early phase of treatment, patients in both groups showed an average of one affective response per five defensive responses. By the late phase of treatment, the high outcome patients showed a marked shift to one affective response per two defensive responses, while the low outcome patients remained the same. An incidental finding was a negative correlation between good outcome and the ratio of defensive behavior to total patient activity.

Treatment of paracoccidioidomycosis with itraconazole

Forty-seven patients with active paracoccidioidomycosis were treated with itraconazole. The majority of the patients (45) had the chronic adult form of the disease while the remaining exhibited the juvenile form. All of the patients received itraconazole, 100 mg day-1, with the exception of two for whom the clinical condition necessitated a larger dose. The mean duration of therapy was 6 months, with a range of 3-24 months. Clinically, the skin and mucous membrane lesions as well as abdominal pain, auscultatory alterations and dysphonia improved markedly during treatment with a concomitant increase in weight. However, other symptoms (cough, expectoration and dyspnoea) persisted as sequelae in some cases. As expected adrenal insufficiency also persisted. The radiological lesions showed a gradual decrease of both scattered and confluent infiltrates, present in 67% of patients before, and in 13% at the end of treatment. On the other hand, fibrosis became more evident at the termination of therapy, increasing from 62% of patients at the beginning of therapy to 81% at the end. The mycological tests (direct examination and cultures) became negative during the first month of treatment in 42 patients (87%). A decline in specific antibody titres was observed in 72% of patients by the end of treatment. Evaluation of therapy by means of a scoring system indicated complete resolution of the disease in one patient (2%), marked improvement in 42 (89%) and minor improvement in four (8.5%); none of the patients showed a deterioration of their disease during therapy. Of fifteen patients who were followed up for 12 months post-therapy none showed clinical relapse during this period. The results of this study confirm the efficacy of itraconazole in the treatment of paracoccidioidomycosis.

IFN-mediated differential regulation of the expression of HLA-B7 and HLA-A3 class I genes

The regulation by IFN of the expression of HLA-B7 and HLA-A3 class I molecules was studied in Jurkat human T lymphoma cells, HHK EBV-transformed human B lymphocytes, and murine HLA-B7 HLA-A3 co-transfected L fibroblasts. Jurkat cells express constitutively low level of HLA class I molecules and treatment with human IFN resulted in preferential increase of the expression of HLA-B7 molecules, the expression of the HLA-A3 molecules being relatively unchanged. Similar treatment of HHK cells, which express constitutively large amount of HLA class I molecules, resulted in a marginal increase of the expression of both HLA-B7 and HLA-A3 molecules. HLA-B7 HLA-A3 co-transfected L cells express relatively low level of HLA class I molecules, expression of both however was significantly increased after treatment with murine INF-alpha, the augmentation being more accentuated for HLA-B7 molecules. In all cases, variations of cell surface expression were related to parallel modifications of the level of HLA-B7 and HLA-A3 RNA transcripts. Important nucleotide differences exist between the IFN consensus sequences associated with the HLA-B7 and HLA-A3 class I genes. Using oligonucleotides corresponding to these sequences two patterns of retarded bands were observed by the gel mobility shift assay, suggesting that the IFN-mediated differential regulation of the expression of the HLA-B7 and HLA-A3 genes could be due to different nuclear regulatory factors.

Inapparent lung involvement in patients with the subacute juvenile type of paracoccidioidomycosis

Three patients with the diagnosis of subacute juvenile paracoccidioidomycosis who, at the time of their first visit, had no signs or symptoms of lung involvement were studied. Initially the diagnosis was confirmed by the observation of P. brasiliensis in biopsy material obtained from clinically involved lymphadenopathies. The lung X-rays done in all patients, did not reveal pathologic changes, although it was possible to observe and isolate the fungus from sputum samples obtained from the three patients. This fact reinforces the pulmonary genesis of the mycosis and proofs the existence of a pulmonary primary infection, even in patients with the juvenile manifestations, in whom the lung component is obscured by the predominant lymph node involvement.

IFN-mediated differential regulation of the expression of HLA-B7 and HLA-A3 class I genes

The regulation by IFN of the expression of HLA-B7 and HLA-A3 class I molecules was studied in Jurkat human T lymphoma cells, HHK EBV-transformed human B lymphocytes, and murine HLA-B7 HLA-A3 co-transfected L fibroblasts. Jurkat cells express constitutively low level of HLA class I molecules and treatment with human IFN resulted in preferential increase of the expression of HLA-B7 molecules, the expression of the HLA-A3 molecules being relatively unchanged. Similar treatment of HHK cells, which express constitutively large amount of HLA class I molecules, resulted in a marginal increase of the expression of both HLA-B7 and HLA-A3 molecules. HLA-B7 HLA-A3 co-transfected L cells express relatively low level of HLA class I molecules, expression of both however was significantly increased after treatment with murine INF-alpha, the augmentation being more accentuated for HLA-B7 molecules. In all cases, variations of cell surface expression were related to parallel modifications of the level of HLA-B7 and HLA-A3 RNA transcripts. Important nucleotide differences exist between the IFN consensus sequences associated with the HLA-B7 and HLA-A3 class I genes. Using oligonucleotides corresponding to these sequences two patterns of retarded bands were observed by the gel mobility shift assay, suggesting that the IFN-mediated differential regulation of the expression of the HLA-B7 and HLA-A3 genes could be due to different nuclear regulatory factors.

Continuing role of the nonstress test in the management of postdates pregnancy

A retrospective analysis of 239 postdate patients who delivered within seven days of their last nonstress test between 1 July 1980 and 30 June 1981 was done to determine whether or not there was a relationship between variable fetal heart rate (FHR) decelerations, a decline in the FHR of at least 15 beats per minute and lasting 15 seconds, on the nonstress test and pregnancy outcome. Of the 505 nonstress tests, the results were considered either reactive (424 to 84%) or nonreactive (81 to 16%). Variable FHR decelerations or bradycardias were encountered on 95 nonstress tests (18.8%) in 80 (33.5%) postdate patients. Fetal heart rate bradycardia was encountered in nine patients (3.8%). Based on the last nonstress test, pregnancy outcome for the nonreactive group was less favorable than for the reactive group. However, when the reactive group was separated as to whether FHR decelerations or bradycardias were present or absent on the last test, the reactive group with FHR decelerations had a significant increase in meconium passage, cesarean delivery for fetal distress, and Apgar scores less than 7 at one minute. This group also had a similarly poor outcome as the nonreactive group of postdates patients. These data suggest that the nonstress test, when reactive without evidence of FHR decelerations, is a reliable indicator of fetal well-being in the postdate pregnancy. However, a reactive nonstress test with evidence of FHR decelerations is associated with a significant increase in perinatal morbidity.

Spontaneous encephalocele of the middle ear

Mature glial tissue was seen in the middle ear of a patient with no previous pathologic precedents, and a clinical diagnosis of serous otitis media was made. That anomaly was detected, and its corresponding clinical, roentgenographic, and pathologic findings are described. The results led us to diagnose it as a congenital (spontaneous) encephalocele of the middle ear. To our knowledge, other case of pure congenital encephalocele of the middle ear has been reported.

The role of nonstress tests, fetal biophysical profile, and contraction stress tests in the outpatient management of insulin-requiring diabetic pregnancies

Antepartum fetal surveillance methods applicable in a home glucose-monitored population of pregnant diabetic women have been evaluated. A testing sequence of nonstress heart rate testing, backed up by either the fetal biophysical profile or contraction stress testing employed at a twice weekly interval, in 107 outpatients was compared with the management of 140 historic control patients by weekly nonstress tests and daily plasma estriols. There were 617 of 672 (91.8%) reactive nonstress tests in outpatients compared to 566 of 626 (90.4%) reactive tests in hospitalized control patients. Of 13 contraction stress tests performed in the outpatient group, only one was positive. Although 2,670 estriol determinations were done on hospitalized control patients, none was used for outpatients. No losses were attributed to unexplained antenatal stillbirth in either group. A fetal biophysical score of 8 was found to be at least as reliable as a reactive nonstress test. Antenatal surveillance in the well-controlled, insulin-requiring diabetic woman can be safely achieved with a testing sequence that consists of twice weekly nonstress tests backed up by the fetal biophysical profile and contraction stress tests.

Tolerance and sensitization to the biphasic effects of low doses of morphine in the hamster

Two experiments investigated the dose and time related effects of morphine sulfate on wheel running behavior in golden Syrian hamsters. In Experiment 1, within-subject comparisons were made of the acute effects of 5, 20, and 40 mg/kg doses of morphine sulfate on running wheel activity. Compared with saline, morphine produced a dose related decrease in activity followed by a dose related recovery. At the lowest dose, the time effect curve was biphasic, with sustained hyperactivity following the recovery. In Experiment 2, the effects of low doses of morphine sulfate (0.5, 1.0, 2.5, 5.0 mg/kg) on running wheel activity were monitored for three days. Biphasic time effect patterns were evident at each dose: An initial period of hypoactivity was followed by recovery and subsequent hyperactivity. Moreover, repeated administration produced both tolerance and sensitization to morphine's effects on activity. Implications for mechanisms underlying the biphasic response pattern are discussed.