Predicting recovery from acute asthma in an emergency diagnostic and treatment unit

OBJECTIVE

Optimal use of emergency diagnostic and treatment unit (EDTU) resources for treatment of acute asthma should be facilitated by the selection of patients with a high probability of discharge from the EDTU. The study goal was to identify characteristics of the patient or exacerbation that could be used to predict recovery of pulmonary function within 12 hours.

METHODS

Comprehensive cohort design in an urban public hospital. The subjects were 269 patients with moderately severe asthma exacerbations. Data were collected for historical and presenting features and response to treatment over 12 hours. Two outcomes were examined: 1) discharge from the EDTU and 2) achieving 50% predicted peak expiratory flow rate (PEFR) within 12 hours.

RESULTS

The two outcomes showed good concordance. The third-treatment PEFR was found to be predictive of both discharge and reaching 50% predicted PEFR within 12 hours. Since the objective measure of reaching 50% predicted PEFR is more readily defined and thus more generalizable, the authors focused on this outcome when describing prediction zones. Patients with 40% or higher PEFR after third treatment had an 89% probability of reaching 50% predicted in 12 hours, while those with a third-treatment PEFR lower than 32% predicted had only a 22% probability.

CONCLUSIONS

A simple objective measure of pulmonary function early in treatment discriminated among those with high, low, and intermediate probabilities of achieving a specified level of PEFR within 12 hours. Awareness of this probability could assist clinicians attempting to predict discharge from the EDTU and facilitate decision making regarding utilization of EDTU resources.

Microwave absorption in oligomers of ethylene glycol

The dielectric properties of biologically and pharmaceutically important low-molecular weight ethylene glycols H(-OCH2CH2-)n -OH (n = 1,2,4,6) were investigated to clarify the effect of chain length on the dielectric properties. The measurement of dielectric constant and dielectric loss was carried out over the frequency range 200 MHz to 20 GHz at temperatures of 25 degrees C to 55 degrees C. It is found that in these molecules microwave dielectric losses are significant. The dispersion behaviour of these molecules can be represented by Cole-Cole equation. The dielectric properties of these homologous ethylene glycols are discussed in terms of the effects of chain length and intermolecular hydrogen bonds regarding the molecular conformations. These wide frequency range dielectric data have also been discussed in view of the suitable selection of the oligomer of ethylene glycol for cosmetic preparations and other pharmaceutical applications with the intention of protection of the skin from weak microwave radiations present in the surrounding environment. These systematic microwave dielectric data with frequency and temperature variation are not available and are provided in this paper.

Community health centers: unrecognized partners in health professions education

Increasing demand for health professionals with training in ambulatory and primary care practice is placing stress on existing training site capacity. Community health centers can serve as model training sites, offering comprehensive multidisciplinary health care services and teaching clinician role models. In this study, 32 Illinois community and migrant health centers and federally qualified health centers were surveyed to asses their involvement with training in the past three years. Thirty centers had offered training to students from many disciplines, with nursing (27 centers) and medicine (24) the most frequent. Most centers had established formal relationships with training institutions but generally had limited involvement with course planning. Continued participation will likely require adequate funding, with some centers also seeking stronger institutional relationships and better integration of community health issues. Educators and policy makers may need to take a more active role in supporting centers, acquiring funds, and other enabling factors.

Protein adducts of iso[4]levuglandin E2, a product of the isoprostane pathway, in oxidized low density lipoprotein

Levuglandin (LG) E2, a cytotoxic seco prostanoic acid co-generated with prostaglandins by nonenzymatic rearrangements of the cyclooxygenase-derived endoperoxide, prostaglandin H2, avidly binds to proteins. That LGE2-protein adducts can also be generated nonenzymatically is demonstrated by their production during free radical-induced oxidation of low density lipoprotein (LDL). Like oxidized LDL, LGE2-LDL, but not native LDL, undergoes receptor-mediated uptake and impaired processing by macrophage cells. Since radical-induced lipid oxidation produces isomers of prostaglandins, isoprostanes (isoPs), via endoperoxide intermediates, we postulated previously that a similar family of LG isomers, isoLGs, is cogenerated with isoPs. Now iso[4]LGE2-protein epitopes produced by radical-induced oxidation of arachidonic acid in the presence of protein were detected with an enzyme-linked immunosorbent assay. Iso[4]LGE2-protein epitopes are also generated during free radical-induced oxidation of LDL. All of the LGE2 isomers generated upon oxidation of LDL are efficiently sequestered by covalent adduction with LDL-based amino groups. The potent electrophilic reactivity of iso-LGs can be anticipated to have biological consequences beyond their obvious potential as markers for specific arachidonate-derived protein modifications that may be of value for the quantitative assessment of oxidative injury.

Effects of dietary selenium on biochemical composition of rat testis

Treatment of rats with selenium (6 and 8 ppm in diet) for 6 and 9 weeks resulted in decrease in testicular protein, phospholipid content and LDH activity and an increase in the lipid, cholesterol content and activity of ACP and ALP. These alterations have been discussed in relation to interference of selenium in various metabolic processes of testis. It seems that selenium affects the oxido-reductase activity of glutathione and resulting in oxidative damage to testis.

Determination of rifampicin and its main metabolite in plasma and urine in presence of pyrazinamide and isoniazid by HPLC method

A reversed phase HPLC method is described for the simultaneous estimation of rifampicin and its major metabolite desacetyl rifampicin, in the presence of isoniazid and pyrazinamide, in human plasma and urine. The assay involves simple liquid extraction of drug, metabolite and internal standard (rifapentine) from biological specimens and their subsequent separation on a C18 reversed phase column and single wavelength UV detection. In plasma as well as in urine samples, all the three compounds of interest eluted within 17 min. Using methanol-sodium phosphate buffer (pH 5.2; 0.01 M) (65:35, v/v) as mobile phase under isocratic conditions, it was established that isoniazid, pyrazinamide and ascorbic acid (added to prevent oxidative degradation of analytes) did not interfere with the analyte peaks. Recoveries (extraction efficiency) for drug were greater than 90% in both plasma and urine, whereas for metabolite the values were found to be 79 and 86% in plasma and urine, respectively. The plasma and urine methods were precise (total coefficient of variation ranged from 5 to 23%) and accurate (-7 to 5% of the nominal values) for both the analytes. Individual variance components, their estimates and their contribution to the total variance were also determined. Using the same method, unknown samples supplied by WHO were assayed and good correlations were obtained between the found and intended values. The method developed proved to be suitable for simultaneous estimation of rifampicin and desacetyl rifampicin in plasma and urine samples.

Diagnosing ascitic etiology on a biochemical basis

BACKGROUND/AIMS

The analysis of ascitic fluid has been complicated by several new tests. To simplify its assessment, we evaluated ascitic fluid pH with six other parameters prospectively and simultaneously in blood and ascitic fluid in sixty patients with ascites.

METHODOLOGY

Sixty patients were selected on whom abdominal paracentesis was performed in order to determine which tests were the most reliable for the etiological diagnosis of ascites. Their ascitic fluid pH, cholesterol, albumin, and total proteins were analyzed to distinguish between malignant and cirrhotic ascites. The diagnosis of cirrhosis was based on histological findings, and/or clinical, biochemical, and endoscopic/ultrasonographic findings in whom percutaneous liver biopsy was contraindicated.

RESULTS

The serum-ascites albumin gradient was higher (p<0.001) in cirrhotic as compared to tubercular, malignant or cardiac ascites. We discovered that ascitic fluid lactate dehydrogenase and cholesterol were best for diagnosing malignant ascites, ascitic fluid glucose and ascitic fluid/blood glucose ratio were perfect for diagnosing tubercular ascites, and ascitic fluid pH and lactate dehydrogenase were suitable for diagnosing spontaneous bacterial peritonitis. Correspondingly, ascitic fluid albumin, ascitic fluid/serum albumin, total proteins, and serum ascites albumin gradient were best for diagnosing sterile cirrhotic ascites.

CONCLUSIONS

Diagnostic paracentesis is a useful procedure. The practice of ordering a battery of tests on every ascitic fluid specimen should be abandoned. Rather, an algorithm approach should be adopted in which the results of initial analysis guide us to further relent tests that help in arriving at the etiology of ascites.

Knowledge and self-care practices of diabetics in a resettlement colony of Chandigarh

Self-care is an important component of diabetes control programme. A cross-sectional survey was carried out in a resettlement colony of Chandigarh and 60 diabetics aged 20 years and above were identified. Their knowledge and practices regarding diet, genital hygiene, care of foot, wound, complications of diabetes and medication was assessed using a semistructured interview schedule. Most of them (60%) opined that diabetic should consume whatever is cooked in the family. Forty eight diabetics knew that sweets and fatty foods should be avoided but only 18.3% were avoiding them. Genital hygiene was maintained by 51.7% and foot care was done by 63.3% through regular washing. Monitoring of blood sugar was poor (46.7%), only 3 knew and were continuing self testing of urine. Oral anti-diabetic drug compliance rate was 62.9%. None of the patients on insulin injections knew about self therapy. Knowledge regarding diabetic complications was partial. There is a need to reorient and motivate health personnels in educating diabetics about self-care.

NO decreases phosphorylation of focal adhesion proteins via reduction of Ca in rat aortic smooth muscle cells

Our laboratory has previously reported that the antimitogenic effect of nitric oxide (NO) in primary cultures of rat aortic smooth muscle cells may be attributed to activation of protein tyrosine phosphatase and dephosphorylation of protein phosphotyrosine [G.S. Dhaunsi, C. Matthews, K. Kaur, and A. Hassid, Am, J. Physiol. 272 (Heart Circ. Physiol. 41): H1342-H1349, 1997]. The goal of the current study was to investigate the role of cytoplasmic Ca in this process and to identify protein substrates that are dephosphorylated by treatment with NO. Treatment of primary rat aortic smooth muscle cell cultures with the NO donor S-nitroso-N-acetylpenicillamine (SNAP) decreased cytoplasmic Ca levels and elicited phosphotyrosine dephosphorylation. Both effects were mimicked by the extracellular and intracellular Ca chelators ethylene glycol-bis(beta-aminoethyl ether)-N,N,N',N'-tetraacetic acid (EGTA) and 1,2-bis(2-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid (BAPTA), respectively, and by the Ca channel blocker nifedipine. Conversely, elevation of cytoplasmic Ca via the use of the Ca ionophore A-23187 or high extracellular K+ prevented or attenuated SNAP-induced dephosphorylation. Both BAPTA and nifedipine also decreased DNA synthesis, providing further evidence to link dephosphorylation to antimitogenesis. Two of the proteins dephosphorylated by treatment of cells with NO or EGTA were identified as the focal adhesion proteins, cortactin and paxillin. These results indicate that NO-induced dephosphorylation of protein phosphotyrosine is mediated by reduction of cytoplasmic Ca and suggest that dephosphorylation of focal adhesion proteins may be of relevance to the antimitogenic effect of NO.

Plants obtained from the Khair tree (Acacia catechu Willd.) using mature nodal segments

An in vitro method for obtaining plants of Acacia catechu has been developed using nodal explants from mature `elite' trees growing in the field. Maximum shoot bud development (eight to ten) from a single explant was achieved on Murashige and Skoog (MS) medium supplemented with 6-benzylaminopurine (BAP) (4.0 mg/l) and α-naphthaleneacetic acid (0.5 mg/l). Addition of adenine sulphate (25.0 mg/l), ascorbic acid (20.0 mg/l) and glutamine (150.0 mg/l) to the medium was found beneficial for maximum shoot bud induction. The shoot buds developed into healthy and sturdy shoots on MS medium containing BAP and kinetin at 1.0 mg/l. Excised shoots were rooted on 1/4-strength MS medium with indole-3-acetic acid at 3.0 mg/l and 1.5% sucrose to obtain complete plants.

(Carboxyalkyl)pyrroles in human plasma and oxidized low-density lipoproteins

Free-radical oxidation of human plasma low-density lipoprotein (LDL) produces (carboxyalkyl)pyrrole (CAP) epitopes that were detected with enzyme-linked immunosorbent assays using antibodies raised against keyhole limpet hemocyanin (KLH)-bound 2-(omega-carboxyheptyl)-pyrrole (CHP) and 2-(omega-carboxypropyl)pyrrole (CPP). These antibodies exhibit high structural selectivity (< 0.5% cross-reactivity) in competitive binding inhibition assays with the corresponding human serum albumin (HSA)-bound pyrroles. No cross-reactivity was detected for HSA-bound 2-pentylpyrrole, an epitope that is generated by a reaction of 4-hydroxy-2-nonenal (HNE) with protein lysyl residues. Oxidation of either arachidonic or linoleic acid in the presence of HSA produced an HNE-derived 2-pentylpyrrole epitope. However, only oxidation of linoleic acid formed HSA-bound CHP, while only oxidation of arachidonic acid generated HSA-bound CPP. Since ester hydrolysis with KOH markedly elevated levels of immunoreactive epitopes detected in oxidized LDL, the CAPs are presumably generated by reactions of oxidized cholesteryl esters, triglycerides, and phospholipids with LDL protein, and only some of these oxidized esters are hydrolyzed, e.g., by phospholipase activity associated with LDL. Protein-bound CHP immunoreactivity was detected in human plasma, and levels are significantly elevated in renal failure and atherosclerosis patients compared with healthy volunteers. This provides the first evidence for the biological occurrence of protein-bound CAPs in vivo and further suggests that free-radical oxidation of polyunsaturated lipids produces hydroxyalkenal carboxylate esters whose gamma-hydroxy-alpha,beta-unsaturated aldehyde functionality and reactivity resemble that of HNE.

A comparison between emergency diagnostic and treatment unit and inpatient care in the management of acute asthma

BACKGROUND

Emergency diagnostic and treatment units (EDTUs) may provide an alternative to hospitalization for patients with reversible diseases, such as asthma, who fail to adequately respond to emergency department therapy.

OBJECTIVE

To evaluate the medical and cost-effectiveness, patient satisfaction, and quality of life of patients receiving EDTU care for acute asthma compared with inpatient care.

METHODS

A prospective, randomized clinical trial performed at 2 urban public hospitals enrolled patients with acute asthma (age range, 18-55 years) not meeting discharge criteria after 3 hours of emergency department therapy. Patients were treated with inhaled adrenergic agonists and steroids in an EDTU for up to 9 hours after randomization or with routine therapy in a hospital ward. Patients were followed up for 8 weeks.

MAIN OUTCOME MEASURES

Discharge rate from the EDTU, length of stay, relapse rates, days missed from work or school, days incapacitated during waking hours, symptom-free days and nights, nocturnal awakenings, direct medical costs, patients satisfaction, and patient quality of life.

RESULTS

The study consisted of 222 patients with asthma. Sixty-five patients (59%) treated in an EDTU were discharged home; the remainder were admitted to the hospital. There were no differences during the follow-up period in relapse rates (P = .74) or in any other morbidities between the EDTU and inpatient groups. There were significant differences in the length of stay, patient satisfaction, and quality of life favoring EDTU care. The mean (+/-SD) cost per patient in the EDTU group was $1202.79 +/- $1343.96, compared with $2247.32 +/- $1110.18 for the control group (P < .001).

CONCLUSIONS

Treatment of selected patients with asthma in an EDTU results in the safe discharge of most such patients. This study suggests that quality gains and cost-effective measures can be achieved by the use of such units.

Levuglandin E2-protein adducts in human plasma and vasculature

The prostaglandin endoperoxide PGH2 rearranges nonenzymatically to generate prostaglandins and secoprostanoic acid levulinaldehyde derivatives such as PGE2 and levuglandin (LG) E2, respectively. Direct detection of LGE2 in biological samples is complicated because it is rapidly sequestered by covalent adduction to endogenous nucleophiles including proteins, which produces LGE2-derived protein-bound pyrroles. Therefore, to detect LGE2-protein adducts in vivo, antibodies were raised against a covalent adduct of LGE2 with keyhole limpet hemocyanin (KLH). This antigen enabled the production of high-titer antibodies that exhibit minimal cross-specificity and are sensitive for detecting LGE2-derived pyrroles. Although pyrrole yields are low at LG/protein ratios found in vivo, an enzyme-linked immunosorbent assay with the LGE2-KLH antibodies detects LGE2-derived protein-bound pyrrole immunoreactivity in human plasma from specific patient populations. Furthermore, prominent immunocytochemical staining of human brain thin sections revealed the presence of LGE2-derived pyrrole immunoreactivity, especially in the meningeal vessels of some patients. This demonstration of LG-protein adducts in human plasma and vasculature provides the first evidence for the biological occurrence of levuglandins in vivo and further suggests that these antibodies might prove useful in diagnostic and mechanistic studies of various disease conditions.

A two-year experience of an acute pain service in Singapore

The first anaesthesia-based acute pain service in Singapore is described. The benefits, risks and resource implications of such a service during its first two years are reviewed. One thousand two hundred and sixty-eight (1,268) post-operative patients were treated with either patient-controlled analgesia (310 patients) or epidural opioid analgesia (958 patients). Retrospective analysis of the data revealed good patient satisfaction with a low incidence of potentially life threatening side-effects: more than 79% of patients reported satisfaction with pain control while only 0.2% of patients receiving epidural opioid analgesia experienced clinically significant respiratory depression. There were no reports of respiratory depression in the patient-controlled analgesia group. The authors conclude that the provision of an acute pain service in the local context was safe and resulted in excellent post-operative patient satisfaction.

NO increases protein tyrosine phosphatase activity in smooth muscle cells: relationship to antimitogenesis

We investigated the mechanisms of NO-induced antimitogenesis in primary aortic smooth muscle cells from newborn rats. S-nitroso-N-acetylpenicillamine (SNAP), an NO-releasing agent, decreased basal and growth factor-stimulated DNA synthesis with a threshold effectiveness of 0.3-3 microM. A second NO-releasing agent, 3-morpholinosydnonimine-N-ethylcarbamide, a hydrolysis-resistant cyclic nucleotide, 8-bromo-guanosine 3',5'-cyclic monophosphate (8-BrcGMP), and atrial natriuretic peptides elicited a similar effect, whereas 8-bromo-adenosine 3',5'-cyclic monophosphate (8-BrcAMP) was ineffective, supporting the view that NO and cGMP, but not cAMP, mediated at least some of SNAP's antimitogenic effect. SNAP and 8-BrcGMP decreased the levels of phosphotyrosine, especially in proteins of 70-85 kDa and approximately 215 kDa molecular mass. SNAP decreased protein phosphotyrosine levels with a threshold effectiveness similar to that of its antimitogenic effect. Moreover, SNAP increased protein tyrosine phosphatase (PTPase) activity in cell homogenates, indicating that phosphotyrosine dephosphorylation was likely to be the result of increased PTPase activity. Peroxovanadate, a selective PTPase inhibitor, blocked the antimitogenic effect of 8-BrcGMP, suggesting that loss of protein phosphotyrosine and antimitogenesis were causally linked. These findings describe a potential mechanism for NO-induced antimitogenesis in aortic smooth muscle cells in primary culture.

Serum immunoglobulin estimation in 30 cases of cutaneous vasculitis

Clinically diagnosed and histopathologically proved 30 cases of cutaneous vasculitis (CV) were collected from Dermatovenereology department. Serum immunoglobulins (Igs) estimation was done in all cases. Nineteen cases showed increased levels of Igs, 4 had decreased levels, while in 7 cases Igs levels remained normal. Seventeen had increase in IgG, 17 cases had in IgA and 10 in IgM and decrease in levels of IgM was seen in 3, and IgA in 2 cases. But the fluctuation in levels of Igs was statistically insignificant.

Immunochemical evidence supporting 2-pentylpyrrole formation on proteins exposed to 4-hydroxy-2-nonenal

Previous model studies suggested the formation of lysine-based 2-pentylpyrroles as novel late adduction products formed upon exposure of proteins to the lipid peroxidation product 4-hydroxy-2-nonenal (HNE). Two 2-pentylpyrrole immunogens were prepared, one by treating keyhole limpet hemocyanin (KLH) directly with 4-oxononanal and the other by preformation of 6-(2-pentylpyrrol-1-yl)hexanoic acid from 6-aminocaproic acid and 4-oxononanal, followed by carbodiimide coupling to KLH. Pyrrole content and lysine modification in KLH were assayed independently. Following immunization of rabbits, antibody titer increased and plateaued over a 4 month period. The structural specificity of the IgG fractions of the antisera was evaluated through comprehensive competitive ELISA studies. These antibodies were used to verify the time-dependent appearance of the 2-pentylpyrrole epitope in protein exposed to HNE. Potential advantages of antibodies recognizing "advanced lipid peroxidation end products" over those recognizing "early" HNE adduction products are discussed.