Cost effective, hospital based occupational health services. Successful program

1. Development of hospital based occupational health service programs focused on meeting business needs is a response to declining inpatient utilization rates, increasing numbers of physicians, and expanding payer control. 2. Nurse practice models using nurse practitioners have demonstrated high quality, cost effective care. 3. Responsiveness to meeting both employee client and employer needs is the key to successful program development.

Delivering health information services and technologies to urban community health centers: the Chicago AIDS Outreach Project

Health professionals cannot address public health issues effectively unless they have immediate access to current biomedical information. This paper reports on one mode of access, the Chicago AIDS Outreach Project, which was supported by the National Library of Medicine through outreach awards in 1995 and 1996. The three-year project is an effort to link the programs and services of the University of Illinois at Chicago Library of the Health Sciences and the Midwest AIDS Training and Education Center with the clinic services of community-based organizations in Chicago. The project was designed to provide electronic access to AIDS-related information for AIDS patients, the affected community, and their care givers. The project also provided Internet access and training and continued access to library resources. The successful initiative suggests a working model for outreach to health professionals in an urban setting.

Plasma adrenomedullin levels in patients with hepatic cirrhosis

OBJECTIVE

The role of adrenomedullin in cirrhosis is at present unknown. The aim of this study was to investigate plasma levels of adrenomedullin in cirrhosis.

METHODS

We measured plasma adrenomedullin concentrations using radioimmunoassay in 43 patients with cirrhosis (17 in Child-Pugh's class A, 13 in Child-Pugh's class B, and 13 in Child-Pugh's class C) and compared these values with those in 24 age-matched healthy subjects. Renal function, plasma cyclic adenosine monophosphate (cAMP) concentration, plasma renin activity, and plasma aldosterone concentration were measured in each patient.

RESULTS

Plasma adrenomedullin levels were increased significantly in patients with cirrhosis compared with healthy subjects. In addition, plasma adrenomedullin values were higher in patients with cirrhosis and ascites than in those without ascites. Moreover, plasma adrenomedullin levels increased in relation to the severity of cirrhosis. Significant positive correlations also were found between adrenomedullin and cAMP concentrations and plasma renin activity or plasma aldosterone concentrations.

CONCLUSIONS

Plasma adrenomedullin is increased in patients with cirrhosis compared with healthy subjects. The increase in plasma adrenomedullin levels is related at least in part to the severity of cirrhosis and may contribute to the arteriolar vasodilation in patients with cirrhosis. These effects are related in part to a cAMP-dependent pathway.

Hepatitis C virus recurrence after liver transplantation: relationship to anti-HCV core IgM, genotype, and level of viremia

OBJECTIVES

Factors that determine the severity of hepatitis C virus (HCV)-recurrent disease in patients undergoing orthotopic liver transplantation (OLT) for HCV cirrhosis have not been clearly identified. To address this issue, we evaluated the histological and virological outcome in 25 patients who underwent OLT for HCV cirrhosis.

METHODS

HCV-RNA was detected by qualitative and quantitative polymerase chain reaction. The HCV genotype also was determined by polymerase chain reaction. Anti-HCV core IgM was tested by ELISA. Disease severity was expressed as a histological score.

RESULTS

Sixteen patients had evidence of HCV-recurrent disease. HCV-RNA levels before transplantation (p = 0.029) and after transplantation (15 days, p = 0.004; 90 days, p = 0.040; 360 days, p = 0.010) were significantly higher among patients who subsequently developed recurrent hepatitis than among those who did not. The presence of anti-HCV core IgM before (p = 0.044) and after OLT (15 days, p = 0.017; 90 days, p = 0.037; and 360 days, p = 0.040) was significantly related to recurrence of hepatitis. The genotype was not related to the level of viremia, to the prevalence of recurrent hepatitis, to the presence of anti-HCV core IgM, or to disease severity.

CONCLUSIONS

The recurrence of HCV hepatitis in patients undergoing OLT for HCV cirrhosis is related to higher levels of viremia and the presence of anti-HCV core IgM, but not to the HCV genotype. However, disease severity is not related to viremia levels, HCV genotype, or positivity of anti-HCV core IgM.

Viral replication in patients with concomitant hepatitis B and C virus infections

The aim of this study was to assess the implications of dual infection with hepatitis B virus (HBV) and hepatitis C virus (HCV). The HBV and HCV status in 100 patients with chronic hepatitis was analysed. HBV DNA was studied using liquid hybridization and the polymerase chain reaction (PCR). HCV viremia was measured using qualitative and quantitative PCR. The HCV genotype was determined by PCR. Patients were divided into three groups according to their HCV-RNA and HBsAg status: group I consisted of 40 patients with chronic hepatitis caused by HBV; group II, 40 patients with chronic hepatitis caused by HCV; and group III, 20 patients infected with both viruses. The HBV-DNA level was higher in group I than in group III (66.4 vs. 11.5 pg/ml; p < 0.05). Quantification of HCV viremia revealed mean values of 36.9 copies x 10(5)/ml in group II and 5.5 copies/ml x 10(5) in group III (p < 0.05). The mean aminotransferase level and histological activity were higher in group III. HCV genotype lb was the predominant type. The data suggest that there is reciprocal inhibition of viral replication in patients with dual HBV and HCV infection. Liver disease appears to be more severe in patients with chronic hepatitis B and C.

Line-focusing holographic mirrors for solar ultraviolet energy concentration

We report on the design and the construction of a 1.3-m(2) UV selective solar concentrator intended for photocatalytic water detoxification processes. This concentrator was made by assembling 30 cm x 30 cm line-focusing holographic mirrors. Holograms with an 80% diffraction efficiency concentrate ~40% of the incident solar energy, which is effective for exciting an aqueous suspension of the TiO(2) photocatalyst, and transmit unnecessary longwave radiation. Major problems, such as the low sensitivity of the dichromated gelatin used for recording the holograms and wavelength dispersion, are discussed.

[Chylous ascites in cirrhotic and non-cirrhotic patients]

Chylous ascites is an accumulation of lymph in the abdominal cavity. The diagnosis is established when the concentration of triglycerides in plasma is greater than in ascitic fluid over a level of 200 mg/dl. The clinical and biochemical characteristics of 22 patients with chylous ascites (11 cirrhotics and 11 non cirrhotics) were studied in order to assess differences between patients with and without hepatic cirrhosis. The cirrhotic patients with chylous ascites showed lower protein (1.3 +/- 0.74 mg/dl, p = 0.002) and cholesterol concentration (46.0 +/- 45.2 mg/dl, p = 0.02) in ascitic fluid than non cirrhotic patients (3.1 +/- 1.09 mg/dl, and 100.85 +/- 41.7 mg/dl, respectively). In addition, the cellularity in the ascitic fluid was also lower in cirrhotic patients (209.09 +/- 113.96 cel/mm3) versus (831.8 +/- 945.08 cel/mm3; p < 0.05). Four patients (18.18%) presented high adenosine deaminase levels (ADA) in the ascitic fluid in the absence of tuberculous peritonitis. The authors conclude that the biochemical differences observed in the ascitic fluid of the cirrhotic patients with chylous ascites may be explained by a dilutional mechanism due to the combination of "clear" ascites secondary to portal hypertension and chylous ascites. Furthermore, chylous ascites could be the cause of an elevation in ADA in the absence of tuberculous peritonitis.

Value of endothelin in cellular rejection after liver transplantation

Endothelin-1 is a vasoconstrictor peptide released by the vascular endothelium by various chemical and mechanical factors. Cellular rejection is one of the most common complications following orthotopic liver transplantation, endotheliitis being its most specific and consistent histological feature. To assess the role of endothelin in cellular hepatic rejection, we studied 21 cirrhotic patients undergoing elective liver transplantation. These patients were divided in two groups: Group I comprised 10 patients without cellular rejection, and Group II comprised 11 patients with cellular rejection. Endothelin was measured on day 7 after transplantation, on the day of liver biopsy, and after treatment for rejection. We found a significant increase in the plasma endothelin levels in the early postoperative period in the patients with moderate or severe cellular rejection compared with the non-rejection group. It remained significantly elevated until the clinical diagnosis of rejection was made. This value returned to baseline with successful treatment. So, the monitorization of this peptide may be of help in the diagnosis of rejection, its severity, and the evaluation of its resolution.

[Recurrence of hepatitis caused by hepatitis c virus in patients receiving a liver transplant]

BACKGROUND

Liver disease due to hepatitis C virus (HCV) is an increasingly frequent indication for liver transplantation. We performed a clinical and virological study of 20 HCV-infected liver transplant recipients to correlate virological markers with histological recurrence of disease.

PATIENTS AND METHODS

In ninety-four patients who were given transplants for end-stage cirrhosis, IgG and IgM antibodies to HCV and IgM to HCV tested by ELISA; all samples were further examined in a four-antigen recombinant immunoblot assay (2-RIBA). HCV viremia was measured by the conventional nested PCR, HCV genotype was determined by PCR amplification using type-specific primers. We have analyzed de novo infection by HCV, HCV recurrence and the influence of genotype in these recurrence.

RESULTS

Nineteen of 20 antibody-positive patients (95%) had HCV RNA before transplantation. All 19 patients who were viremic before transplantation had persistent infection after LT. HCV genotype 1b was the predominant type before and after LT (75%). Ten of the 20 (50%) patients developed histological findings of chronic hepatitis (CH) in liver allografts. HCV recurrent liver disease after LT was not related with HCV genotype. Of 4 deaths after transplant in hepatitis C group, only one was related to recurrent disease. We have not found de novo hepatitis C.

CONCLUSIONS

Our results indicate the general persistence of hepatitis C virus infection and the excellent short-term prognosis after liver transplantation. Chronic hepatitis by HCV in liver transplant was not related with HCV genotype.

A JAVA-based multimedia tool for clinical practice guidelines

We have developed a specific language for the representation of Clinical Practice Guidelines (CPGs) and Windows C++ and platform independent JAVA applications for multimedia presentation and edition of electronically stored CPGs. This approach facilitates translation of guidelines and protocols from paper to computer-based flowchart representations. Users can navigate through the algorithm with a friendly user interface and access related multimedia information within the context of each clinical problem. CPGs can be stored in a computer server and distributed over the World Wide Web, facilitating dissemination, local adaptation, and use as a reference element in medical care. We have chosen the Agency for Health Care and Policy Research's heart failure guideline to demonstrate the capabilities of our tool.

ARMEDA: accessing remote medical databases over the World Wide Web

We have created a computer system to access medical information located at remote databases over the World Wide Web, for epidemiological ad health services research. We made a preliminary prototype where a specific database model could be searched and information be retrieved. We are currently working on a new component-based architecture, where different databases scheme from various sites can be used to create a unified model, giving users a "virtual" vision of a single, local database. Different software engineering and artificial intelligence methods are used to access, integrate, filter and deliver information to users.

Anti-interleukin 4 antibody and indomethacin synergistic effect on B16 melanoma tumor progression

B16 melanoma-bearing mice were treated with anti-interleukin 4 antibody, indomethacin or its combination to evaluate the ability of the primary tumor to induce lung metastasis and the antitumor host response. Flow cytometry of tumor cells incubated with sera from tumor-bearing mice showed B16 melanoma to induce a significant antitumor humoral response (39.0 +/- 1.1% positive cells versus 1.8 +/- 0.9% in the control). The treatment of tumor-bearing mice with antimouse anti-interleukin 4 monoclonal antibody plus indomethacin significantly increased (P < .01) the mean value of lung metastasis (from 6.1 +/- 3.0 in the controls to 50.8 +/- 21.8). Also, a significant increase in natural cytotoxicity against tumor cells was observed when both peripheral blood mononuclear cells and splenocytes were used as effector cells. In contrast, an antibody-dependent cellular cytotoxicity decrease was found with effector cells from both normal and tumor-bearing mice. In the former, the antibody-dependent cellular cytotoxicity decrease was 49.4% and 58.4% (P < .05) for peripheral blood mononuclear cells and splenocytes, whereas in the second case the decrease was 40.7% (P < .05) and 29.1% (P < .01), respectively. These results suggest that an efficient antibody-dependent cellular cytotoxicity response might be necessary to secure an effective host antitumor immune response.

Value of plasma P-selectin for vascular complications in liver transplantation

Recent data suggest that plasma P-selectin, an adhesion molecule, may be a clinically useful marker for thrombosis. Hepatic vessel thrombosis is one of the most serious complications following liver transplantation. To assess the contribution of the soluble P-selectin to this complication, we measured plasma P-selectin levels in 32 orthotopic liver transplantations, pre-, intra-, and post-operatively. We found that levels of circulating P-selectin were not different between cirrhotic patients and healthy subjects. Of the 32 patients, 8 had vascular complications. We found a significant increase in the plasma P-selectin concentration in the thrombotic group in early postoperative period compared with the non-thrombotic group (p < 0.002). It measurement may facilitate the diagnosis of thrombosis in the early postoperative period after liver transplantation, and therefore the management of these patients.

Human alpha 1-antitrypsin gene transfer to in vivo mouse hepatocytes

The in vivo gene transfer to mouse hepatocytes of pTG 7101, a plasmid containing the full-length gene encoding human alpha 1-antitrypsin (alpha 1-AT) DNA, has been studied by iv administration of recombinant DNA (100 ng/mouse) encapsulated in large and small liposomes. Our results from immunohistochemical liver sections and cytophotometric analysis of hepatocyte chromophore absorbance indicate that human alpha 1-AT was expressed in liver parenchymal cells from mice treated (48 hr before) with DNA encapsulated in small liposomes, and this effect remained for at least 2 weeks. In contrast, the efficiency was greatly limited when large liposomes were used as a vehicle for gene transfer. Additional experiments were performed to study using an ELISA procedure the presence in mouse plasma of human alpha 1-AT from mice treated with encapsulated plasmid in small liposomes or small empty liposomes plus free DNA. According to the immunohistochemical data, the results indicate that detectable alpha 1-AT can only be observed in plasma from mice treated with encapsulated plasmid in small liposomes.

[Hepatita B and C virus infections in patients with hepatocellular carcinoma]

BACKGROUND

The prevalence of HBV and HCV infections in patients with hepatocellular carcinoma may be related to variations in the geographic area of study. For this reason, we have analized the relative prevalence of HBV and HCV infections in 94 patients with hepatocellular carcinoma from Cantabria (North of Spain).

PATIENTS AND METHODS

We have studied 94 patients with hepatocellular carcinoma from January 1988 to December 1993. Commercially available radioimmunoassay or ELISA were used for detection of HBsAg, anti-HBs and anti-HBc. The HBV DNA was analized by PCR. The HCV infection was assayed by ELISA-2 and RT-PCR.

RESULTS

The HBV infection was detected in 27 patients: 19 patients were HBsAg positive and 8 patients HBsAg negative, anti-HBc positive, DNA HBV positive by PCR. The HCV infection was found in 57 patients. Forty patients were infected with both viruses. Of the remain twenty-four, forty were alcoholics. We found in 61 patients more than one etiological factor. Hepatoma was the first manifestation of liver disease in 24 cases and these were more frequently in HCV than in those with HBV infection. Moreover, the first group were older and have lower alcohol intake.

CONCLUSIONS

1) In Cantabria, Spain, the majority of cases of hepatocellular carcinoma are related to HBV, HCV and alcohol. 2) Analysis of DNA HBV and RNA HCV by PCR allows the diagnosis of cryptic infections by both viruses, especially in the cases of HBV and HCV coinfection. 3) Hepatoma is the first manifestation of liver disease in a high percentage of cases.

Cost considerations of implementing OSHA tuberculosis regulations

The resurgence of tuberculosis and the enforcement of the Occupational Safety and Health Administration (OSHA) regulations has health care organizations struggling to budget for the cost of implementing The Enforcement Guidelines for Occupational Exposure to Tuberculosis in Health Care Facilities. One acute care hospital spent approximately $102,487 implementing the OSHA standards. Nurses and other health care providers need to become more aware of the regulation requirements to assist the institution in maintaining compliance, minimizing occupational exposure, and containing health care spending.

Antimetastatic effect of immunization with liposome-encapsulated tumor cell-membrane proteins obtained from experimental tumors

Immunization of C57BL/6 mice with tumor-derived membrane-proteins encapsulated in sized liposomes (0.2 microgram/mouse) and composed by phosphatidylcholine or sphingomyelin, significantly reduced the mean values of spontaneous lung metastasis from both B16 (0.7 +/- 0.5 and 1.2 +/- 0.6, respectively) and 3LL (4.8 +/- 2.5 and 7.2 +/- 4.1, respectively) tumors, with respect to control (HEPES) groups (4.8 +/- 1.1 and 19.0 +/- 4.4, respectively). However, no significant antimetastatic effect was observed using free tumor-derived proteins (2 micrograms/mouse) or liposome vehicle alone. Specific humoral immune response after the vaccination was studied by flow cytometry of tumor cells incubated with a pooled sample from each group of immunized mice and FITC-conjugate antimouse immunoglobulins. The results showed that the highest number of positive tumor cells was identified using sera from immunized mice with sized liposomes encapsulating tumor-derived proteins whereas the immunization with the protein fraction in free form failed to induce this effect. In addition, an increased cytotoxicity towards 3LL and B16 tumor cells can also be observed when tumor cells were incubated with spleen effector cells plus specific immunosera. In conclusion, our results show that antitumor active vaccination, using sized liposomes as adjuvants, induces an antitumor host response and a significant inhibition of tumor progression.

[Thrombophlebitis of the cavernous sinus secondary to polysinusitis. Report of a new case]

Cavernous sinus thrombophlebitis syndrome is uncommon nowadays. Despite the wide range of antimicrobial agents it carries a high mortality. The disease frequently arises from infection of face, mouth, nose and paranasal sinuses, reaching the cavernous sinus by venous spread. Involvement of adjacent anatomic structures accounts for most of the clinical findings. Meningeal involvement, bilateral orbital edema and ocular cranial nerves palsy are very helpful in the differential diagnosis. Streptococcus spp., Staphylococcus spp., Haemophilus influenzae and anaerobic organisms are considered to be the most frequent etiological agents. In the present paper we report a case of cavernous sinus thrombophlebitis following left side polysinusitis. The patient presented with the main clinical features of the syndrome along with Streptococcus equisimilis and Fusobacterium necrophorum bacteremia. Urgent surgery of infected sinuses and appropriate antibiotic therapy led to a favorable outcome. The patient made and excellent progress and was discharged completely recovered two weeks after admission.