Staphylococcal peptidoglycans induce arthritis

Staphylococcus aureus is one of the most important pathogens in septic arthritis. To analyse the arthritogenic properties of staphylococcal peptidoglycan (PGN), highly purified PGN from S. aureus was intra-articularly injected into murine joints. The results demonstrate that PGN will trigger arthritis in a dose-dependent manner. A single injection of this compound leads to massive infiltration of predominantly macrophages and polymorphonuclear cells with occasional signs of cartilage and/or bone destruction, lasting for at least 14 days. Further studies showed that this condition is mediated by the combined impact of acquired and innate immune systems. Our results indicate that PGN exerts a central role in joint inflammation triggered by S. aureus.

Laparoscopic suturing evaluation among surgical residents

BACKGROUND

Laparoscopic suturing is an integral part of advanced laparoscopic surgery training. The objective of this study was to evaluate the performance and preference of surgical residents performing intracorporeal and extracorporeal knot-tying techniques using conventional and Endo Stitch instruments. The residents were also evaluated on their suturing techniques using conventional instruments, the Endo Stitch, and the Suture Assistant.

METHODS

Using an inanimate laparoscopic trainer model, 39 residents were evaluated as they performed laparoscopic knot tying exercises. Endpoints of the study were execution time and subjective preference of surgical residents with respect to the type of instrument used for knot tying. Forty-three residents were evaluated as they performed laparoscopic suturing exercises with three different types of suturing instruments using the same endpoints.

RESULTS

The intracorporeal technique was the preferred (89%) method of knot tying among surgical residents. The time for completion of laparoscopic suturing was significantly (P < 0.05) shorter with the Endo Stitch (114 +/- 64 s) than with the conventional instrument (206 +/- 107 s) or the Suture Assistant (151 +/- 70 s). Residents preferred the use of the Endo Stitch in all three categories for suturing, knot tying, and handling.

CONCLUSION

The Endo Stitch enhanced laparoscopic skills and was the preferred instrument for laparoscopic knot tying and suturing among surgical residents.

Effect of patient information on the quality of pharmacists' drug use review decisions

OBJECTIVE

To evaluate the effect of incremental increases in patient information on the quality of pharmacists' clinical decisions related to legally mandated prospective drug utilization review (DUR) responsibilities.

DESIGN

Unblinded comparison of two groups.

PARTICIPANTS

28 community pharmacists in Indiana (group 1) and 32 Public Health Service pharmacists employed in the Indian Health Service (IHS) (group 2).

INTERVENTIONS

Clinical cases involving prescribing problems were developed from patient charts. Each case contained four levels of increasing patient information: Level 1 included only information required for a legal prescription in Indiana; Level 2 added the patient's current medication profile, age, and allergies; Level 3 added the diagnosis or reason for use of the prescribed medication; and Level 4 added the physician's progress note. Pharmacists were asked to evaluate the prescribed drug therapy at each level of each case and complete a Dispensing Appropriateness Index (DAI) report, which included all prospective DUR criteria required by the Omnibus Budget Reconciliation Act of 1990. The quality of pharmacists' DUR decisions at each level of patient information was evaluated by comparing pharmacists' responses on the DAI reports with the consensus judgment of two clinical experts.

RESULTS

The quality of both community and IHS pharmacists' DUR decisions improved significantly at each incremental level of patient information.

CONCLUSION

Pharmacists in this study made better decisions when they had access to more complete patient information on which to base their decisions.

An incremental cost-effectiveness analysis of the first, second and third sputum examination in the diagnosis of pulmonary tuberculosis

SETTING

St. Francis Hospital in Katete District, Eastern Province, Zambia.

OBJECTIVE

To compare the incremental cost-effectiveness of examining serial sputum smears for screening suspects for pulmonary tuberculosis at a rural district hospital in Zambia.

DESIGN

An incremental cost-effectiveness analysis of serial sputum smear examinations for diagnosing pulmonary tuberculosis based on laboratory results collected during 1997 and 1998 in a rural district hospital in Zambia. The cost analysis took a health service provider perspective, and used the ingredients approach. The cost-effectiveness is expressed in terms of the incremental cost per tuberculosis case diagnosed. Relevant information was obtained from various sources, including administrative records, interviews and direct observation.

RESULTS

Of a total of 166 acid-fast bacilli positive suspects who had three sputum smears examined sequentially, 128 (77.1%) were found on the first smear, a further 25 (15%) on the second smear and 13 (7.9%) additional cases were identified on the third smear. The economic analysis shows that the incremental cost of performing a third test, having already done two, increases rapidly with only a small gain in terms of additional cases of tuberculosis identified.

CONCLUSION

A policy of examining two samples should be considered in resource-poor settings, if the remaining steps of the national diagnostic algorithm can be adhered to with respect to smear-negative suspects.

To pay or not to pay? A decision and cost-utility analysis of angiotensin-converting-enzyme inhibitor therapy for diabetic nephropathy

BACKGROUND

Angiotensin-converting-enzyme (ACE) inhibitor therapy can significantly delay the progression of diabetic nephropathy to end-stage renal failure (ESRF). The main obstacle to successful compliance with this therapy is the cost to the patients. The authors performed a cost-utility analysis from the government's perspective to see whether the province or territory should pay for ACE inhibitors for type I diabetic nephropathy on the assumption that cost is a major barrier to compliance with this important therapy.

METHODS

A decision analysis tree was created to demonstrate the progression of type I diabetes with macroproteinuria from the point of prescription of ACE inhibitor therapy through to ESRF management, with a 21-year follow-up. Drug compliance, cost of ESRF treatment, utilities and survival data were taken from Canadian sources and used in the cost-utility analysis. One-way and two-way sensitivity analyses were performed to test the robustness of the findings.

RESULTS

Compared with a no-payment strategy, provincial payment of ACE inhibitor therapy was found to be highly cost-effective: it resulted in an increase of 0.147 in the number of quality-adjusted life-years (QALYs) and an annual cost savings of $849 per patient. The sensitivity analyses indicated that the cost-effectiveness depends on compliance, effect of benefit and the cost of drug therapy. Changes in the compliance rate from 67% to 51% could result in a swing in cost-effectiveness from a savings of $899 to an expenditure of more than $1 million per additional QALY. A 50% reduction in the cost of ACE inhibitors would result in a cost savings of $299 per additional QALY with compliance rates as low as 58% in the provincial payment strategy.

INTERPRETATION

Provincial coverage of ACE inhibitor therapy for type I diabetes with macroproteinuria improves patient outcomes, with a decrease in cost for ESRF services.

Single element high frequency (<50 MHz) PZT sol gel composite ultrasound transducers

A sol gel composite process has been used to produce lead zirconate titanate coatings in the thickness range of 3 to 100 microm on aluminum substrates. The complex permittivity (epsilon(33)(S )), elastic stiffness (c(33)(D)), and the piezoelectric constant (h(33)) of the coating and the complex elastic stiffness (c(33)(D)) of the substrate have been determined using impedance measurements and a commercially available software program [Piezoelectric Resonance Analysis Program PRAP 2.0, TASI Technical Software, Kingston, Ontario, Canada]. The complex components of the material parameters account for the losses within the film and the substrate. Sol gel composite films on aluminum have a dielectric constant of 220 with an imaginary component of 1% and an electromechanical coupling coefficient of up to 0.24 with an imaginary component of 3%. These films are applied to the fabrication of a high frequency transducers suitable for ultrasound biomicroscopy (UBM). By combining the sol gel composite material with existing transducer fabrication techniques, single-element focusing transducers have been produced that operate in the frequency range of 70 to 160 MHz. Devices have -6-dB bandwidths up to 52% and minimum insertion losses ranging from -47 to -58 dB. Real-time images of phantom materials and ex vivo biological samples are shown.

Reproductive-tract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh

BACKGROUND

In the control of reproductive-tract infections, including sexually transmitted infections (STIs), in low-income and middle-income countries, WHO recommends syndromic management for individuals with symptoms. This intervention was initially developed in areas where prevalence of such infections is high. We investigated the clinical effectiveness and cost of this approach among a group of women with a low prevalence of infection.

METHODS

During a 5-month period, we investigated all women complaining of abnormal vaginal discharge and seeking care at maternal and child health/family-planning centres in Matlab, Bangladesh, for the presence of laboratory-diagnosed reproductive-tract infections and STIs. Syndromic diagnoses made by trained health-care workers were compared with laboratory diagnosis of infection. We then calculated the costs of treating women by means of the recommended WHO algorithm and an adapted algorithm incorporating use of a speculum and simple diagnostic tests.

FINDINGS

The prevalence of endogenous infections among 320 women seen was 30%. Cervical infections (Neisseria gonorrhoeae and Chlamydia trachomatis) were found in only three women. The WHO algorithm had a high sensitivity (100%) but a low specificity (zero for bacterial vaginosis, candida, and Trichomonas vaginalis). The speculum-based algorithm had a low sensitivity (between zero and 59%) but a higher specificity (79-97%). Between 36% and 87% of costs would have been spent on uninfected women.

INTERPRETATION

The high rate of overtreatment in the population studied carries both financial and social costs--the latter in potentially exposing women misdiagnosed as having an STI to threats of domestic disruption or even violence. We make recommendations for management programmes in areas of low STI prevalence and low income.

Communication as social engagement: implications for interactions between deaf and hearing persons

Communication involves sending and receiving signals. However, it is also a form of social engagement. Constraints on communication between deaf and hearing persons often result in strained interactions as well as los of "full" information. In this paper, a meta-ethnographic approach is used to describe the impact of "spoiled" communication on social engagement between deaf and hearing persons.

Mite allergens: significance of enzymatic activity

Ten years ago, the cloning and sequencing of a cDNA encoding the group I allergen of house-dust mites unequivocally determined that protein allergens may have biochemical functions in addition to their ability to bind IgE. Since this discovery, several groups have speculated that the biochemical activities of allergens, or substances associated with allergens, may be involved in their immunogenicity or allergenicity. This paper will focus on just one biochemical function, proteolytic activity, and will be illustrated by examples of our own work that we believe support the hypothesis that this category of molecules are endowed with the properties of proallergic adjuvants.

Theorizing about nurses' work lives: the personal and professional aftermath of living with healthcare 'reform'

In this paper we discuss the impact of healthcare 'reform' on nurses' personal and professional lives. Using a thematic analysis, we interviewed 38 nurses in Nova Scotia, Canada regarding their experiences of job displacement, inability to find full-time employment and job losses. Their stories reflect how they lived day by day and the effects this had on their children, partners, friends and leisure, as well as their financial burdens. We theorize about the relationship between nurses' work and women's work, and particularly about women working in unstable conditions and the impact on their lives and that of the clients with whom they work.

Inclusive instruction and learning for deaf students in postsecondary education

This article explores how students who are deaf and their instructors experience mainstream college classes. Both quantitative and qualitative procedures were used to examine student access to information and their sense of belonging and engagement in learning. Instructors were asked to discuss their approach to teaching and any instructional modifications made to address the needs of deaf learners. Results indicate that deaf students viewed classroom communication and engagement in a similar manner as their hearing peers. Deaf students were more concerned about the pace of instruction and did not feel as much a part of the 'university family' as did their hearing peers. Faculty generally indicated that they made few if any modifications for deaf students and saw support service faculty as responsible for the success or failure of these students. We discuss results of these and additional findings with regard to barriers to equal access and strategies for overcoming these barriers.

A comparative study of differences in the referral behaviour patterns of men and women who have experienced cardiac-related chest pain

Survival and long-term prognosis after a myocardial infarction are directly related to the individuals's decision to seek medical help. Early medical intervention is imperative if thrombolytic therapy is to be effective. Emerging research has indicated that women frequently have longer pre-hospital delays than men. Incorporating a comparative descriptive design, this research compared the pre-hospital admission behaviour patterns of women and men, following the onset of acute chest pain. A convenience sample of 12 women and 12 men were selected following admission to a local coronary care unit. Structured interviews and the examination of medical notes/relevant documentation provided the data. Findings were examined and compared through the use of content analysis and descriptive statistics. Severity of symptoms proved to be the strongest influence in shortening pre-hospital delay. Despite this, overall, men were admitted to hospital more quickly than women. Men were more ready than women to believe that they might be having a heart attack and this belief led them to seek treatment promptly. In order to improve female mortality and morbidity following a myocardial infarction, it is recommended that there is an urgent need to target women, through health promotion and media interventions.

Economics and its contribution to the fight against malaria

About 5% of deaths worldwide are due to malaria, and 5% of the total disease burden among children is due to malaria. The burden is much greater in sub-Saharan Africa, with 15% of all disability-adjusted life-years (DALY) lost to malaria. Malaria is costly, too: an estimated U.S. $1800 million is spent annually on both direct costs of prevention and care, and on indirect costs such as lost productivity, time costs and other indirect costs and losses. There are several economic issues to be addressed with regard to malaria. For example, is malaria control important in comparison with other claims on scarce health resource? Secondly, which approach or strategy for prevention and treatment is most appropriate, given the local circumstances? Thirdly, within each strategy chosen (e.g. diagnosis and treatment of cases), which options are available and which is the best? Within the choice of strategy and design, other issues arise, such as the best options for prevention, and their cost. What strategy is best for case finding? How much should be spent on diagnostics? Under which circumstances does mass treatment make economic sense? When should a new, more expensive drug be used in cases of resistance? Perhaps most importantly, the overall approach needs to be reviewed to ensure that resources are being used to best effect. The role of economics in decision making is the subject of the present review.

A pharmacoeconomic analysis of rimexolone for the treatment of ophthalmic inflammatory conditions

Topical steroids are the standard first-line therapy for treating ophthalmic inflammatory conditions. However, potent ophthalmic steroids can lead to an elevation of intraocular pressure (IOP), which can result in greater medical resource utilization and increased costs. We have developed a decision analysis model from a societal perspective to evaluate the costs and consequences of the treatment of ophthalmic inflammatory conditions with two potent topical steroids: prednisolone and rimexolone. Data for the model are based on information from clinical trials, national data-bases, published literature, and responses by ophthalmologists to a questionnaire on treatment patterns for elevated IOP. Three steroid-responsive conditions are examined separately with the model: uveitis; postoperative inflammation following cataract surgery; and other ophthalmic inflammatory conditions (blepharitis, episcleritis, postoperative refractive surgery, and corneal transplant). The model evaluates patients with acute conditions versus those with chronic conditions and those with mild to moderate elevation of IOP versus those with severe elevation of IOP. Although the unit cost of rimexolone is higher than that of prednisolone, use of rimexolone leads to cost savings because the incidence of elevated IOP is decreased. If rimexolone is used instead of prednisolone for the treatment of ophthalmic inflammatory conditions, the estimated cost saved (at 1995 AWP prices) is approximately $10 million across the entire US population. The savings across the health maintenance organization population on an annualized basis is approximately $3.9 million. Even if rimexolone were priced higher than current market charges (at 130% to 150% of the AWP of prednisolone), cost savings ranging from the $2.9 million to $720,000 would accrue with use of rimexolone compared with prednisolone. However if, rimexolone were priced at 160% of the AWP of prednisolone, its use would incur an additional cost of $300,000. The primary medical resource utilized in treating elevated IOP in ophthalmic inflammatory conditions is physician visits. Medications are responsible for only one-fifth to one-third of the total cost of treating elevated IOP. This analysis indicates that rimexolone is associated with decreased medical resource utilization and cost savings to the entire healthcare system.

5'-Capping enzymes are targeted to pre-mRNA by binding to the phosphorylated carboxy-terminal domain of RNA polymerase II

We have investigated the role of the RNA Polymerase II (Pol II) carboxy-terminal domain (CTD) in mRNA 5' capping. Transcripts made in vivo by Pol II with a truncated CTD had a lower proportion of capped 5' ends than those made by Pol II with a full-length CTD. In addition, the enzymes responsible for cap synthesis, RNA guanylyltransferase, and RNA (guanine-7)-methyltransferase bound directly to the phosphorylated, but not to the nonphosphorylated, form of the CTD in vitro. These results suggest that: (1) Pol II-specific capping of nascent transcripts in vivo is enhanced by recruitment of the capping enzymes to the CTD and (2) capping is co-ordinated with CTD phosphorylation.

Metastatic prolactinoma: effect of octreotide, cabergoline, carboplatin and etoposide; immunocytochemical analysis of proto-oncogene expression

A 49-yr-old woman presented with an extensive prolactinoma (serum PRL > 10,000 mU/L, normal range < 450 mU/L). Over a 5-yr period following transsphenoidal surgery and pituitary irradiation, she became increasingly resistant to high doses of bromocriptine and underwent transfrontal surgery followed by stereotactic radiotherapy. In spite of these treatments, serum prolactin estimations rose progressively to > 100,000 mU/L. Magnetic resonance imaging scanning demonstrated a massive cystic tumor invading the temporal lobes, extending into the cervical and thoracic spine, with metastases to cervical lymph nodes. High-dose cabergoline administration resulted in a 30% decrease in serum PRL. Octreotide was administered as a continuous sc infusion with a profound analgesic effect on facial pain but with no effect on tumor progression. She was treated with a course of chemotherapy consisting of carboplatin and etoposide without any noticeable effect. The patient died 6 months following chemotherapy. Immunocytochemical analysis demonstrated positive nuclear staining for WAF-1, Rb protein, c-myc, and p53 both in the original and metastatic tumors. The metastases but not the primary tumor stained for c-jun. Metastatic prolactinoma remains a therapeutic challenge. It is associated with a variable proto-oncogene expression, which may be coincidental or causal. Cabergoline had no advantage over bromocriptine. Octreotide relieved facial pain but did not alter tumor progression. An effective therapy for metastatic prolactinoma remains to be identified.

Nasopharyngeal cryptococcosis

Naturally occurring cryptococcosis in five cats, a dog and a koala is described. Involvement of the nasopharynx was documented in all patients, and nasopharyngeal mass lesions accounted for the major presenting complaints in four. Signs referable to nasopharyngeal disease included snoring, stertor, inspiratory dyspnoea and aerophagia. Diagnoses were made by caudal rhinoscopy using a retroverted flexible endoscope, vigorous orthograde flushing with saline, or at necropsy. Concurrent cryptococcal rhinitis was present in all cases, although involvement appeared limited to the caudal nasal cavity in most cases. Typical signs of nasal cavity disease, such as sneezing and nasal discharge, were often absent. Treatment of nasopharyngeal cryptococcosis should include physical dislodgement or debulking of lesion(s) to provide immediate alleviation of upper airway obstruction, followed by systemic antifungal therapy to eliminate residual infection from the nasal cavity. Infections caused by Cryptococcus neoformans var gattii accounted for a disproportionately large number of these cases.

Modelling the economic benefits of tuberculosis preventive therapy for people with HIV: the example of Zambia

OBJECTIVE

To assess the economic benefits and costs of providing isoniazid preventive therapy for tuberculosis (TB) in HIV-infected persons in Zambia.

DESIGN

A spreadsheet model incorporating variables drawn from published studies and unpublished data.

SUBJECTS

Data drawn from a number of different studies and published literature involving a range of subjects.

SETTING

Zambia.

RESULTS

Using data primarily from Zambia we have modelled the costs and benefits of a TB preventive therapy programme using daily isoniazid for 6 months. The basecase scenario assumes recruitment at a voluntary testing and counselling site where HIV seroprevalence is 30%; persons with HIV have a 25% probability of developing active TB during their lifetime; two additional cases of TB would be prevented per person completing a course of preventive therapy; compliance would be 63%, and the efficacy of the isoniazid in preventing active TB of 60%. The costs under this scenario would exceed the benefits by a factor of 1.16 [benefit: cost ratio (BCR) of 0.86]. However, if preventing one case of TB prevented an additional five cases, the benefits would exceed the costs by a significant margin (BCR of 1.71). Other scenarios indicate that the targeted preventive therapy of persons with HIV whose occupation or living situation places them in contact with a large number of others (teachers and students, health personnel, military and police, miners, prisoners, etc.) would yield significant net benefit. The operational challenge for TB preventive therapy is thus to identify and target large numbers of such persons.

Efficacy of lorazepam and haloperidol for rapid tranquilization in a psychiatric emergency room setting

The efficacy of a benzodiazepine was compared with that of a neuroleptic for the rapid tranquilization of patients presenting at a psychiatric emergency room service. Thirty-seven highly agitated patients exhibiting psychotic symptoms were randomly assigned to receive either 2 mg lorazepam or 5 mg haloperidol as needed every 30 min for 4 h. Administration route was either intramuscular injection or oral concentrate. Symptom ratings were conducted each hour using double-blind procedures. Both medications reduced symptom ratings on the Brief Psychiatric Rating Scale and Global Clinical Impression of Overall Symptom Severity Scale. Global Clinical Impression scores for the two medication groups did not differ significantly either at baseline or at 4 h after entry into the study. However, Global Clinical Impression scores of patients in the lorazepam group were less severe at intermittent ratings. The groups did not differ on the Brief Psychiatric Rating Scale at any rating time. No differences were found either in the number of doses administered or in the administration route selected. Given the potential for severe extrapyramidal symptoms developing hours or days after a single dose of haloperidol, lorazepam may provide an excellent alternative for the rapid tranquilization of the acutely agitated psychotic patient in the emergency room setting.

G protein and thyrotropin receptor mutations in thyroid neoplasia

The cAMP pathway plays a central role in thyroid follicular cell growth and function. Mutations of the TSH receptor (TSHR) or G proteins (gsp) that activate adenylyl cyclase have been identified in autonomously functioning thyroid nodules. Gsp mutations have been identified also in other forms of thyroid neoplasia, but their reported prevalence has been extremely variable. We have studied the prevalence of gsp mutations and activating mutations of Gi2 alpha (gip) in a series of 66 benign and 34 malignant thyroid tumors. Thirty-six tumors were from Boston and 64 from the UK. In addition, we examined the 64 UK tumors for mutations of the TSHR gene. DNA extracted from fresh-frozen or paraffin-embedded tissue was amplified by PCR and examined for mutations using oligonucleotide-specific hybridization and single-strand conformation polymorphism analysis. No G protein gene mutations were identified in the Boston tumors. One gsp mutation, R201C, in a Hürthle cell adenoma and 1 gip mutation, R179C, in a follicular adenoma were demonstrated in tumors from the UK. Oligonucleotide-specific hybridization and single-strand conformation polymorphism analysis of the UK tumors did not demonstrate any mutations of the TSHR gene. Eleven normal thyroid tissue samples were wild-type for Gs alpha, Gi2 alpha, and the TSHR gene.

Magnetic resonance venography versus contrast venography to diagnose thrombosis after joint surgery

Magnetic resonance venography is a recently developed, noninvasive means of visualizing the proximal veins of the lower extremity and pelvis. Magnetic resonance venography is compared with standard contrast venography in the diagnosis of proximal deep vein thrombosis after total joint arthroplasty. Two hundred seven extremities were evaluated in a blinded study 5 to 7 days after surgery. Standard contrast venography identified 11 proximal deep vein thromboses. Initial interpretations of the magnetic resonance venographies by staff radiologists identified 5 of the proximal vein thromboses (sensitivity 45%). Two patients with negative standard contrast venographies were identified as positive (specificity 99%). A retrospective review of all magnetic resonance venographies by a dedicated magnetic resonance angiographer identified 10 of 11 deep vein thromboses seen on standard contrast venography (sensitivity 91%). Both false negatives were identified as positives. Standard contrast venography remains the gold standard for identifying proximal vein thromboses. Emerging magnetic resonance imaging techniques have created a potential alternative modality by which to identify deep vein thrombosis. The present study suggests that standard contrast venography continues to be the most accurate modality currently available. Although magnetic resonance venography seems to be accurate, its interpretation requires experience. As costs diminish and experience increases, magnetic resonance venography will have increased importance in the clinical recognition of deep vein thrombosis.

Significant savings achieved by implementing event related outdating

The event related outdating(ERO) theory is based on the assumption that items that are properly cleaned, wrapped, sterilized, stored and handled will remain sterile indefinitely unless the integrity of the package becomes compromised. The authors describe how one Surgical Suite (performing approximately 600 cases/month) implemented an ERO program with estimated annual savings of almost $10,000/year.