Flexible monitoring in the management of patient care processes: a pilot study

This article describes a study conducted on the internal medicine, general surgical, and vascular wards of a large metropolitan hospital to assess the impact of a networked monitoring system and portable patient monitors. This pilot study was developed to address the need of hospital patients who require continuous noninvasive vital signs monitoring (including heart rate, noninvasive blood pressure, pulse oximetry, cardiac waveform monitoring) with the addition of surveillance from a cardiac intensive care area. Data were collected from 114 patients over a 3-month period to identify a patient group that could be managed appropriately under the new system and to determine the effect that flexible monitoring had on patient care management. Findings include identification of a specific patient group that can be managed successfully outside the cardiac intensive care area using this system. Other findings suggest a way to improve the management of patient monitoring in the general ward areas.

Complement-resistant Moraxella catarrhalis forms a genetically distinct lineage within the species

Moraxella catarrhalis is a bacterial species that has been implicated in 15-20% of all cases of otitis media in the USA and the complement-resistant variant of M. catarrhalis has been considered particularly pathogenic. A collection of geographically diverse, complement-sensitive (n=28) and -resistant strains (n=47) of M. catarrhalis was assembled in order to analyse the bacterial population structure. All strains were identified as M. catarrhalis by conventional microbiological and biochemical methods. Amplification of the small subunit (ssu) ribosomal RNA gene followed by restriction fragment length polymorphism (RFLP) analysis did not reveal consistent differences between serum-susceptible and -resistant M. catarrhalis isolates. Interestingly, upon automated ribotyping using the Qualicon RiboPrinter(R) microbial characterisation system, the complement-sensitive and -resistant strains segregated into two groups. This suggested the existence of two clearly distinguishable lineages within the species M. catarrhalis. This observation was corroborated by pulsed field gel electrophoresis (PFGE) of DNA macro-restriction fragments, a non-ribosomal PCR RFLP procedure and random amplification of polymorphic DNA (RAPD) analysis. All procedures grouped the two variants similarly. Redefinition of the taxonomic status of complement-resistant M. catarrhalis or even the definition of a new species may be opportune.

Antigenic and genetic characterisation of Newcastle disease viruses isolated from outbreaks in domestic fowl and turkeys in Great Britain during 1997

Antigenic and genetic analyses of viruses from the 11 outbreaks of Newcastle disease in Great Britain, 12 of the outbreaks in Northern Ireland and the single outbreak in the Republic of Ireland which occurred in 1997, indicated that they were all essentially similar. In addition, the viruses from the British Isles were very similar to viruses isolated from three outbreaks in pheasants in Denmark between August and November 1996, from a goosander in Finland in September 1996, from an outbreak in chickens in Norway in February 1997, and from an outbreak in chickens in Sweden in November 1997. Viruses from outbreaks in other countries during 1995 to 1997 could be distinguished antigenically and/or genetically from the 1996 to 1997 Scandinavian/British Isles isolates, as could viruses responsible for two separate outbreaks in caged birds in quarantine premises in Great Britain in March 1997. Minor nucleotide differences in the 413-base region of the fusion gene and the 187-base region of the haemagglutinin-neuraminidase gene sequenced in this study allowed the 1996 to 1997 Scandinavian/British Isles isolates to be divided into groups. These groups broadly corresponded to the clusters of disease outbreaks, but suggested that the discrete outbreak in Scotland was probably the result of virus spread from Northern Ireland. Overall, the antigenic and genetic analyses of these viruses were consistent with the theory that the virus was introduced into the British Isles by migratory birds moving from north-east Europe. However, it was not possible to rule out other sources, such as the movement of pheasants from Denmark.

Glycophorin A mutation Ala65 --> Pro gives rise to a novel pair of MNS alleles ENEP (MNS39) and HAG (MNS41) and altered Wrb expression: direct evidence for GPA/band 3 interaction necessary for normal Wrb expression

We report here a novel Glycophorin A (GPA) mutation Ala65 --> Pro which gives rise to a low-incidence antigen HAG, lack of a high-incidence antigen ENEP and aberrant expression of the high-incidence Wrb antigen. Anti-ENEP was identified in the serum of a transfused male patient (E.H.) who was homozygous for a GPA Ala65 --> Pro mutation and possessed a novel low-incidence antigen which we have called HAG. An unrelated HAG-positive individual, heterozygous for the Ala65 --> Pro mutation, has also been identified. Anti-HAG was present in several multispecific antisera to low-incidence antigens and in one monospecific serum. Normal expression of the Wrb antigen depends on the presence of amino acid Glu658 of band 3 and on the presence of GPA. However, a specific epitope on GPA has not previously been implicated. DNA sequence analysis of band 3 from patient E.H. was normal in the region of Wra/Wrb polymorphism with homozygous presence of Glu658 and therefore the abnormal Wrb expression results from the Ala65 --> Pro mutation in GPA. The ENEP and HAG antigens have been assigned the MNS blood group system numbers 002.039 and 002.041, respectively, by the ISBT Working Party on Terminology for Red Cell Surface Antigens.

Characterisation of an avian influenza A virus isolated from a human--is an intermediate host necessary for the emergence of pandemic influenza viruses?

The partial sequencing of the internal and the neuraminidase genes of isolate 268/96 obtained from a woman with conjunctivitis showed all seven to have closest homology with avian influenza viruses. The entire nucleotide sequence of the haemagglutinin gene of 268/96 had close, 98.2%, homology with an H7N7 virus isolated from turkeys in Ireland in 1995. This appears to be the first reported case of isolation of an influenza A virus from a human being infected as a result of direct natural transmission of an avian influenza virus from birds.

Kaposi sarcoma presenting as severe haemoptysis

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Co-presence of a point mutation and a deletion of exon 3 in the glycophorin C gene and concomitant production of a Gerbich-related antibody

BACKGROUND

Antigens of the human blood group system Gerbich (Ge) are located on sialoglycoproteins glycophorin C (GPC) and glycophorin D (GPD).

CASE REPORT

The Ge+ proposita (RW) produced an alloanti-Ge after receiving 2 units of red cells (RBCs) during surgery. Further studies were carried out to characterize the antibody specificity, RBC GPC and/or GPD (GPC/GPD), and the glycophorin C gene (GYPC) from RW and her compatible siblings. RW's serum contained an alloanti-Ge that did not react with RBCs from RW or four of her siblings or with RBCs with Ge-negative phenotypes. An eluate of RW's antibody reacted weakly with GPC in Western blotting. RW's RBCs were positive with 20 alloanti-Ge2, 1 autoanti-Ge2, 4 alloanti-Ge3, and 1 alloanti-Ge4. Titrations revealed weak expression of these antigens on her RBCs and those of her compatible siblings as compared with controls. In contrast, titrations of mouse and rat monoclonal antibodies specific for GPC/GPD showed no differences. Western blotting of RBC membranes using GPC/GPD specific monoclonal antibodies showed a broad diffuse band corresponding to GPC.Ge in addition to GPC and GPD. Blotting of membranes from trypsin-treated RBCs from these individuals revealed an increase of 1500 in M(r) of membrane-bound tryptic fragment over that in the membranes from typsin-treated RBCs from persons with normal GPC/GPD. In RT-PCR, two products were obtained for RW and her compatible siblings: one had a complete deletion of exon 3 and the other had a base change (A-->T) in nucleotide 173 in exon 3 (confirmed by genomic DNA sequencing of exon 3). This point mutation has resulted in the loss of restriction enzyme Tth111 I-sensitive site in the mutant GYPC.

CONCLUSION

The specificity of antibody in RW's serum was serologically anti-Ge2. Two genetic events occurred in exon 3 in GYPC of RW and her compatible siblings. The exon 3 deletion confirmed a Ge:-2,-3,4 haplotype. The abnormal tryptic fragment obtained was due to the (A173-->T) base change in exon 3 that resulted in Asp58-->Val in the deduced amino acid sequence at the membrane boundary.

Anti-major histocompatibility complex antibody responses to simian B cells do not protect macaques against SIVmac infection

Macaques have been protected against infection with human cell-grown SIVmac by immunization with antigens encoded by the human major histocompatibility complex (MHC). Here, we investigated the efficacy of alloimmunization with simian B cells expressing high levels of MHC class I and class II molecules to confer protection against systemic challenge with simian-grown SIVmac. Eight rhesus macaques were vaccinated with glutaraldehyde-fixed and beta-propiolactone-inactivated herpesvirus papio-transformed B cells. Four of the macaques received 5 doses, the others 10. Animals were challenged with rhesus macaque spleen-derived cell-free SIVmac. Allogeneic B cells elicited antibody responses to rhesus MHC class I and II but failed to protect animals against infection. Anti-MHC class I antibodies were restricted in specificity and failed to recognize MHC class I from some B lymphoblastoid cell lines (B-LCLs) including a B-LCL from the animal in whose cells the challenge virus was grown. Vaccinated animals responded to self-MHC class I antigens but not to self-MHC class II antigens from peripheral blood mononuclear cells (PBMCs). Animals that underwent the shorter immunization regimen had transiently enhanced PBMC-associated virus loads after challenge, whereas the average virus-infected cell load was reduced in animals that underwent the more extensive immunization. These results suggest that antibody responses to allogeneic MHC molecules do not protect against infection with immunodeficiency lentiviruses.

Management of school leavers given a diphtheria and tetanus vaccine intended for children instead of the intended low dose preparation

In November 1995, 102 school leavers in two North Staffordshire schools were given high dose diphtheria and tetanus vaccine (intended for primary immunisation of children) rather than a preparation with a low dose of diphtheria vaccine intended for adults and adolescents. We describe the management of the incident and the action taken to minimise the risk of such an error being made again. Pupils who had received the high dose vaccine and a control group were surveyed with a self-administered questionnaire. Thirteen children out of 67 given the higher dose diphtheria vaccine consulted their general practitioner and the same number had time off school, compared with none of 25 from a control school. This excess morbidity was probably attributable to the higher dose of diphtheria vaccine.

Stratum corneum lipids: the effect of ageing and the seasons

Stratum corneum lipids play a predominant role in maintaining the water barrier of the skin. In order to understand the biological variation in the levels and composition of ceramides, ceramide 1 subtypes, cholesterol and fatty acids, stratum corneum lipids collected from tape strippings from three body sites (face, hand, leg) of female Caucasians of different age groups were analysed. In addition, we studied the influence of seasonal variation on the lipid composition of stratum corneum from the same body sites. The main lipid species were quantified using high-performance thin-layer chromatography and individual fatty acids using gas chromatography. Our findings demonstrated significantly decreased levels of all major lipid species, in particular ceramides, with increasing age. Similarly, the stratum corneum lipid levels of all the body sites examined were dramatically depleted in winter compared with spring and summer. The relative levels of ceramide 1 linoleate were also depleted in winter and in aged skin whereas ceramide 1 oleate levels increased. The other fatty acid levels remained fairly constant with both season and age, apart from lignoceric and heptadecanoic acid which showed a decrease in winter compared with summer. The decrease in the mass levels of intercellular lipids and the altered ratios of fatty acids esterified to ceramide 1, are likely to contribute to the increased susceptibility of aged skin to perturbation of barrier function and xerosis, particularly during the winter months.

DNA-confirmed Taenia solium cysticercosis in black bears (Ursus americanus) from California

Three cases of cysticercosis in black bears (Ursus americanus) in three northern California counties between 1990 and 1994 have been identified as due to the tapeworm Taenia solium. Both morphologic characteristics as well as the presence of T. solium mitochondria cytochrome oxidase I gene sequences, as detected by the polymerase chain reaction, confirmed the diagnosis. The number and geographic separation of the cases suggests that infection of the bears was not due to a single contamination. Humans infected with the definitive stage of T. solium are the probable source of cysticercosis for bears, as well as other humans. This is the first confirmation of cysticercosis due to T. solium in a black bear in North America.

Identification and deletion of sequences required for feline leukemia virus RNA packaging and construction of a high-titer feline leukemia virus packaging cell line

Sequences required for specific encapsidation of feline leukemia virus (FeLV) genomic RNA have not yet been defined. Deletion of 107 nucleotides between the splice donor (SD) and the gag coding region of a prototypic subgroup A FeLV, 61E, resulted in an approximately 200-fold reduction of packaged viral RNA. Virus particle production was not disrupted by the deletion, although viral infectivity was dramatically reduced. These data indicate that the 107-nucleotide sequence comprises a portion of the FeLV packaging signal. FeLV particles expressed from the deleted genome were able to efficiently package murine leukemia virus vectors, resulting in high-titer G418R virus production. This system can be easily adapted to produce FeLV particles that contain envelope proteins from other feline leukemia virus subgroups and will be broadly useful for studies of FeLV envelope/receptor interactions.

Bileaflet valve replacement: complications and costs

A meta-analysis of the available literature on the CarboMedics and St. Jude Medical valves was conducted to compare their clinical performance. Frequency of valve-related complications for aortic, mitral, and double-valve replacements served as a measure of performance. An economic model was created to estimate the economic impact of valve-related complications. Overall, fewer events occurred with the St. Jude Medical valve than with the CarboMedics valve. As a result, use of the St. Jude Medical valve is expected to save up to $13,201 over 10 years.

Co-expression of tissue inhibitor and matrix metalloproteinase in myocardium

Matrix metalloproteinases (MMP) are present in the latent form in normal myocardium. To examine the stringent balance between MMP and tissue inhibitor of metalloproteinase (TIMP) and to determine whether MMP are secreted simultaneously and in co-ordination with their inhibitors, we analysed MMP and TIMP by immunological, isolation by gel-permeation and affinity chromatography, and enzymatic assays in tissues and extracts. Using antibodies to MMP-1 and TIMP-1, we found strong in situ staining of MMP-1 and TIMP-1 in tissues. The staining was uniform in the endo- and subendomyocardium as well as in the interstitial space. TIMP-1 was present wherever MMP-1 was localized. From the tissue extract, proteins were separated on a gel-filtration column (Sephacryl S-200) and analysed for MMP and TIMP activity by zymography as well as by using succinyl-Gly-Pro-Leu-Gly-Pro-4-amido-7-methyl coumarin (Suc-GPLGP-AMC) as a selective fluorogenic substrate for collagenase. TIMP and MMP were further purified on collagen-Sepharose affinity column. The results indicated that MMP activity was co-eluted with TIMP activity. MMP-1, MMP-2 and TIMP-1 were further analysed by Northern blot for mRNA levels in the heart, skin, lung, liver and kidney. Results suggested co-expression of MMP-1 and TIMP-1 at the transcription level in all tissues. The level of MMP-2 mRNA was specifically higher in the heart tissue, which suggests a role of MMP-2 in the integrity of cardiovascular structure. The study indicated that myocardium as well as other tissue have an endogenous inhibitory system, suggesting that the MMPs activity is co-ordinated by their inhibitors at both the gene and protein levels. Furthermore, MMP and TIMP were co-expressed and were tightly regulated in maintaining the architecture of the interstitial tissue.

The effect of glycerol and humidity on desmosome degradation in stratum corneum

Moisturizers are known to have occlusive, emollient and humectant properties, all of which help to alleviate the symptoms of skin xerosis. Although the biological mode of action of moisturizers is poorly understood, the recent observation that skin xerosis is associated with incomplete desmosome digestion suggests that moisturizers improve the desquamation process in such conditions. To examine the possibility that certain moisturizers act by facilitating desmosomal digestion, we investigated the ability of glycerol, a common humectant, to influence this process in stratum corneum in vitro. Examining desmosome morphology in isolated stratum corneum by electron microscopy, it was observed that the desmosomes were in more advanced stages of degradation in glycerol-treated tissue compared with control tissue. This enhanced desmosomal degradation in glycerol-treated tissue was confirmed by significant decreases in the levels of immunoreactive desmoglein 1, a marker of desmosome integrity. Desmosomal degradation was also shown to be a humidity-dependent event, being significantly reduced at low relative humidity. The effect of glycerol on desmosome digestion was emphasized further in two in vitro model systems. Firstly, glycerol increased the rate of corneocyte loss from the superficial surface of human skin biopsies in a simple desquamation assay. Secondly, measurement of the mechanical strength of sheets of stratum corneum, using an extensiometer, indicated a dramatic reduction in the intercorneocyte forces following glycerol treatment. These studies demonstrated the ability of glycerol to facilitate desmosome digestion in vitro. Extrapolating from these results, we believe that one of the major actions of moisturizers in vivo is to aid the digestion of desmosomes which are abnormally retained in the superficial layers of xerotic stratum corneum.

Effective water model for Monte Carlo simulations of proteins

We present an effective theory for water. Our goal is to formulate an accurate model for the effects of solvation on protein dynamics, without incurring the huge computational cost and the slow temporal evolution typical of molecular dynamics simulations of liquids. We replace the individual water molecules in an all-atom potential with a local dielectric density field, with self-interactions given by the Landau-Ginzburg free energy and external interactions by Lennard-Jones forces at the surface of the protein atoms. We explore conformational space with finite temperature Monte Carlo dynamics, using parallel Langevin and Fourier acceleration algorithms well suited to data-parallel computer architectures such as the Connection Machine. To establish the validity of our approximations, we compare our electrostatic contribution to the solvation energy with the results of Lim, Bashford, and Karplus using a conventional static continuum dielectric cavity model, and the nonelectrostatic contributions with estimates of hydrophobic surface free energy. Our model can also accommodate ionic charges and temperature fluctuations. We propose future investigations extending our effective theory of solvation to include explicit orientational entropy and hydrogen-bonding terms.

Case report: anti-Cra in pregnancy

A 39-year-old Grenadian multiparous patient presented in the 12th week of pregnancy. Her red cells were found to have the rare Cr(a-) (ISBT Number 202001) phenotype within the Cromer complex, and her serum contained anti-Cra. To date, anti-Cra has not been implicated in hemolytic disease of the newborn (HDN), but there are very few published reports on this topic. This case provided an excellent opportunity for study. The patient's serum showed no detectable functional activity in in vitro antibody-dependent, cell-mediated cytotoxicity assays, and no increase in the strength of the antibody during the pregnancy. The newborn infant showed no clinical signs of HDN, and was of normal weight. This case study suggests that anti- Cra is not implicated in HDN.

Pulmonary embolism and lupus anticoagulant in a woman with renal cell carcinoma

We report on a woman in whom pulmonary embolism and positive lupus anticoagulant occurred 9 months before the diagnosis of renal cell carcinoma. To our knowledge this association has been described previously with other malignant neoplasms but not with a renal tumor, and it may represent an autoimmune paraneoplastic event.