Long-term plasmapheresis and protein A column treatment of recurrent FSGS

Transient or intermittent plasmapheresis with concurrent immunosuppressive therapy is thought to be beneficial in the treatment of recurrent focal segmental glomerulosclerosis (FSGS) in the early post-transplant period. The results of long-term (6-year) plasmapheresis therapy, in a 9-year-old female with an immediate recurrence of FSGS [urinary protein/urinary creatinine (UP/UC)=17.7] after cadaveric renal transplant, are presented. A 4-week plasmapheresis course induced a decline in the proteinuria, but a relapse occurred after cessation of plasmapheresis. Addition of protein A column therapy led to a further decrease in the proteinuria, to a non-nephrotic range. Long-term control of the nephrotic syndrome was established using a chronic treatment regimen consisting of a single-volume plasmapheresis, followed by a protein A column treatment, performed on sequential days every 3-4 weeks. Mean UP/UC values decreased to 1.15+/-0.9. A course of cyclophosphamide was successfully used to control a worsening of proteinuria 4 years post transplant. Although sequential renal biopsies demonstrated progressive glomerular sclerosis, the patient's mean calculated creatinine clearance only modestly declined from 78.3 ml/min per 1.73 m2, at the time of transplantation, to 62.7 ml/min per 1.73 m2, 6 years later. This patient demonstrated dependence on plasmapheresis/protein A column therapy to maintain a clinical remission of her FSGS recurrence. While long-term plasmapheresis and protein A column therapy in combination with immunosuppressive therapy reversed the effects of uncontrolled nephrosis and possibly facilitated long-term renal allograft survival, the glomerular sclerosis continued to progress.

PCR as a diagnostic and quantitative technique in veterinary parasitology

Over the past 15 years, there has been a dramatic evolution in molecular approaches to study parasites and parasitic diseases. Many of these advancements have been brought about through the development of new applications of the polymerase chain reaction (PCR). Enhancements in sensitivity that can be achieved using PCR now permit scientists to investigate changes at the level of a single cell, far below what is often needed for parasite-derived applications. PCR has had a substantial impact on advances made in the areas of parasite systematics and epidemiology, immunology and host-parasite interactions, recombinant DNA vaccine development and most recently, the analysis of whole genomes either through directly sequencing the DNA, the analysis of expressed sequence tags (ESTs) or through the rapidly growing field of functional genomics. This paper, however, focuses on the application of PCR methodology to parasite detection and differentiation, and the diagnosis of disease. Specific attention is given to advances provided by multiplex PCR, fluorescence-based "real-time" PCR, and the utilization of PCR as a quantitative technique.

Health systems. The ghost of a boast

The NHS was introduced to enormous popular acclaim but services always varied markedly and the physical conditions were poor. At the birth of the NHS, two-thirds of the hospitals had been built before 1891. Even today, the NHS is providing care in accommodation built in the 1800s. The NHS is now lagging behind comparable systems on several counts. It is unrealistic to expect the NHS to become the 'envy of the world' in the lifetime of this government, if ever.

Report from the NOAA workshops to standardize protocols for monitoring toxic Pfiesteria species and associated environmental conditions

Long-term monitoring of water quality, fish health, and plankton communities in susceptible bodies of water is crucial to identify the environmental factors that contribute to outbreaks of toxic Pfiesteria complex (TPC) species. In the aftermath of the 1997 toxic Pfiesteria outbreaks in North Carolina and Maryland, federal and several state agencies agreed that there was a need to standardize monitoring protocols. The National Oceanic & Atmospheric Administration convened two workshops that brought together state, federal, and academic resource managers and scientific experts to a) seek consensus on responding to and monitoring potential toxic Pfiesteria outbreaks; b) recommend standard parameters and protocols to characterize water quality, fish health, and plankton at historical event sites and potentially susceptible sites; and c) discuss options for integrating monitoring data sets from different states into regional and national assessments. Workshop recommendations included the development of a three-tiered TPC monitoring strategy: Tier 1, rapid event response; Tier 2, comprehensive assessment; and Tier 3, routine monitoring. These tiers correspond to varying levels of water quality, fish health, and plankton monitoring frequency and intensity. Under the strategy, sites are prioritized, depending upon their history and susceptibility to TPC events, and assigned an appropriate level of monitoring activity. Participants also agreed upon a suite of water quality parameters that should be monitored. These recommendations provide guidance to state and federal agencies conducting rapid-response and assessment activities at sites of suspected toxic Pfiesteria outbreaks, as well as to states that are developing such monitoring programs for the first time.

Hospital inquiries. The listening blank

The major failures reported in the Bristol inquiry have been highlighted in most hospital inquiry reports over the past 30 years. The tendency to victimise the whistleblower has characterised virtually all inquiries. Inadequate leadership, isolation, system failures, poor communication and disempowerment of staff and service users are the common themes. While organisational reform is essential, the real challenge is to change behaviour. And this depends on the example of senior staff.

Responsiveness and predictability of gait speed and other disability measures in acute stroke

OBJECTIVES

To identify the most responsive method of measuring gait speed, to estimate the responsiveness of other outcome measures, and to determine whether gait speed predicts discharge destination in acute stroke.

DESIGN

A prospective cohort study.

SETTING

Five acute-care hospitals.

PATIENTS

Fifty subjects with residual gait deficits after a first-time stroke.

INTERVENTIONS

Five- (5mWT) and 10-meter walk tests (10mWT) at comfortable and maximum speeds, with 2 evaluations conducted an average +/- standard deviation (SD) of 8 +/- 3 and 38 +/- 5 days poststroke.

MAIN OUTCOME MEASURE

Standardized response mean (SRM = mean change/SD of change) was used to estimate responsiveness for each walk test, the Berg Balance Scale, the Barthel Index, the Stroke Rehabilitation Assessment of Movement (STREAM), and the Timed Up and Go (TUG).

RESULTS

The SRMs were 1.22 and 1.00 for the 5mWT, and.92 and.83 for the 10mWT performed at a comfortable and maximum pace, respectively. The SRMs for the Berg Balance Scale, the Barthel Index, the STREAM, and the TUG were 1.04,.99,.89, and.73, respectively. The probability of discharge to a rehabilitation center for persons walking at < or = 0.3m/s or > 0.6m/s at the first evaluation was.95 and.22, respectively.

CONCLUSIONS

The 5mWT at a comfortable pace is recommended as the measure of choice for clinicians and researchers who need to detect longitudinal change in walking disability in the first 5 weeks poststroke.

Development of a real-time PCR assay for detection of Toxoplasma gondii in pig and mouse tissues

A highly sensitive and specific method has been developed to reproducibly detect and quantitate Toxoplasma gondii burden in animal tissue samples using T. gondii ITS1-derived primers and a fluorogenic probe via real-time PCR. Assay specificity was confirmed against a panel of DNA samples from T. gondii and other common protozoa as well as host animal tissue. This Toxo TaqMan assay was able to detect as little as 0.1 pg of T. gondii genomic DNA, which is equivalent to 1 T. gondii bradyzoite, and has a dynamic range of detection of from 100 ng to 100 fg of T. gondii DNA. Tissues from experimentally infected mice and pigs as well as bradyzoite-spiked pig muscle samples were used to test and standardize this technique. Positive signals were obtained with T. gondii parasite concentrations ranging from 4 to 3.7 x 10(5) parasites per g of spiked pig tissue, with excellent linearity (R(2) = 0.9776). All T. gondii-infected animals were correctly identified by this technique. Results indicate that this assay is applicable to swine carcasses and commercial pig products, is compatible with automation technology for potential slaughterhouse use, and will enable scientists to diagnose and quantitate T. gondii in animal tissues.

Time- and depth-dependent changes in crosslinking and oxidation of shelf-aged polyethylene acetabular liners

Since crosslinking and oxidation of ultrahigh-molecular-weight polyethylene (UHMWPE) have important roles in determining the wear resistance of UHMWPE total joint components, the time and depth dependence of crosslinking and oxidation of new shelf-aged (2-11 years), ready-to-implant acetabular liners were studied by using solvent extraction and Fourier transform infrared spectroscopy. The ultrastructure of these materials also was examined by using low-voltage scanning electron microscopy in an oil-free vacuum. Oxidation levels increased with time and with depth (p < 0.0001) from the surface of the older liners to a maximum value at about 1-2 mm below the surface, then decreased. They were minimal at the midsection of the liners. The crosslinking of these liners decreased with time and depth (p < 0.0001) and was inversely proportional to the level of oxidation. High and depth-dependent oxidation levels were observed in all older liners made from GUR 415 and 412 resins but were distinctly absent from a comparably aged (i.e., 9 years) liner made from 1900 CM-resin. Some liners showed varying degrees of inhomogeneous and discontinuous morphologic ultrastructure in addition to varying amounts of porosity while others had a more homogeneous ultrastructure. Oxidation and crosslinking of polyethylene are time- and depth-dependent processes that are mutually competitive. We suggest that resin choice and perhaps consolidation-related variables lead to differences in polyethylene's ultrastructure. These ultrastructural differences in polyethylene's inhomogeneities, that is, the type (interconnected or closed-cell) or extent may affect the oxidation resistance of polyethylene. While oxygen diffusion to free radicals in polyethylene already is known to explain some of these time- and depth-dependent effects, perhaps such ultrastructural variations also may facilitate or retard oxygen diffusion in this material. Resin-based ultrastructural variability partially may explain the variability in the clinical performance of polyethylene total joint implant components. Thus resin choice or processing modifications related to polyethylene's ultrastructure may increase its oxidation resistance and ultimately improve the clinical wear performance of polyethylene total joint orthopedic implants.

Virulence differences between two field isolates of feline immunodeficiency virus (FIV-APetaluma and FIV-CPGammar) in young adult specific pathogen free cats

The goal of this study was to identify a strain of feline immunodeficiency virus (FIV) that would be more virulent for adult cats than the prototype FIV-APetaluma and, thereby, enhance the FIV infection model for HIV-1 related research. Diehl et al. reported that one clade C strain of FIV, FIV-CPGammar, was more virulent than other known FIV isolates. Mortalities from 58 to 100% were reported for kittens 12 weeks of age and less following intravenous inoculation. A more variable and somewhat less virulent disease course was observed in neonatal to 8-10-week-old kittens infected orally, intravaginally or intrarectally with this same isolate (Obert and Hoover, 2000). However, no studies have been done with FIV-CPGammar in adult cats. Therefore, the virulence of FIV-CPGammar for young adult cats was compared to that of FIV-APetalulma, the original FIV isolate. One group of five cats were inoculated intraperitoneally with 470 TCID(50) of FIV-CPGammar in the form of pooled plasma from acutely infected cats, while a second group was infected with plasma containing the 750 TCID50 of FIV-APetaluma. The cats were observed for 20 weeks for gross signs of disease, hematologic abnormalities, time of antibody appearance, and plasma and peripheral blood mononuclear cell (PBMC) associated virus levels. Viral RNA and proviral DNA were measured by a real-time PCR, sensitive to 50 copies per milliliter. The only outward sign of disease was lymphadenopathy, which occurred at a similar time and intensity in both groups of cats. Cats infected with FIV-CPGammar were more likely to be neutropenic and lymphopenic during the first 10-12 weeks of infection than cats infected with FIV-APetaluma. Both groups of cats showed similar overall declines in absolute mean CD4 cell counts and identical concomitant increases in CD8 cells. CD4/CD8 cell ratios were also similar. Antibody, as measured by an ELISA against recombinant FIV-TM antigen, appeared in all cats by 4 weeks post-infection. The most significant differences were in plasma viral RNA and PBMC proviral DNA levels. Cats infected with FIV-CPGammar had up to 100 times higher mean levels of viral RNA during the first few weeks of infection than cats infected with FIV-APetaluma. This difference was also mirrored in levels of proviral DNA in PBMC, which were significantly higher in the FIV-CPGammar infected cats. Plasma viral RNA and PBMC proviral DNA levels were virtually identical in both groups of cats at 20 weeks post-infection. However, proviral DNA in tissues such as thymus and popliteal lymph nodes was 10-fold or so higher in FIV-CPGammar infected cats at 20 weeks and histopathologic lesions were more severe. Based on these various parameters, we concluded that FIV-CPGammar was more virulent than FIV-APetaluma in young adult cats during the 20-week study period. However, we were not able to recreate the severe and rapidly progressive disease previously reported for kittens, suggesting an age-related resistance similar to that observed previously for FIV-APetaluma (George et al., 1993).

A comprehensive policy analysis of and recommendations for senior center gambling trips

Gambling is one of the fastest growing industries in America. Public support is high for legalized gambling among all age groups. Because gambling is growing in popularity as an activity among those 65 and over, many senior centers are beginning to offer group trips to casinos and other gambling attractions such as dog tracks. This paper analyzes senior center casino gambling trips, with particular attention to the number of trips offered, how trips are funded, the policy implications of offering trips, and policy alternatives for state and local policymakers. Data for the study come from personal interviews with activity directors of 16 senior centers across Massachusetts and a formal survey of 30 additional senior centers in Central Massachusetts. Benefits of a new policy option, a public education strategy, are also reviewed.

Primary care trusts. Back to the future

Primary care trusts, which went live last year, have had some success in attracting additional funding for new initiatives and tackling long-standing problems. There have been considerable delays in appointing executive committees. Management capacity is a huge problem. Many feel they do not have the staff to carry out basic administration. GPs find chairing PCTs very stressful. Major issues of development, roles and resources need to be addressed.

Prevalence of metronidazole-resistant Trichomonas vaginalis in a gynecology clinic

OBJECTIVE

To determine the prevalence of in vitro resistance to metronidazole among unselected isolates of Trichomonas vaginalis and correlate in vitro findings with response to metronidazole therapy.

STUDY DESIGN

Vaginal fluid from women attending a gynecology clinic at an urban hospital was cultured, isolates were tested for in vitro resistance to metronidazole, and these results were correlated with therapeutic outcome.

RESULTS

Among 911 women, T vaginalis was detected by culture in 82 (9.0%). Of the 82 isolates, 2 (2.4%; 95% CI, 0.3-8.5%) had low-level in vitro resistance (minimum lethal concentration, 50 micrograms/mL). Women with positive wet mount examinations were treated with metronidazole, 2 g, once and asked to return in one week. Of the 42 infected women agreeing to return for a repeat examination and culture, 26 (61.9%) did, and all (including one woman with a resistant isolate) were cured.

CONCLUSION

Isolates of T vaginalis resistant to metronidazole occur widely throughout the United States. Although the in vitro susceptibility of T vaginalis to metronidazole has been very poorly studied, our study is consistent with a decade-old prevalence estimate of in vitro resistance (5%), and suggests that high-level resistance is uncommon. This study confirmed, in the absence of reinfection, the continuing clinical effectiveness of single-dose metronidazole for the large majority of trichomoniasis cases.

Pulse methylprednisolone, cyclosporine, and ace inhibitor therapy decreases proteinuria in two siblings with familial focal segmental glomerulosclerosis

Familial focal segmental glomerulosclerosis (FSGS) is a heterogeneous renal disease characterized by proteinuria and an unremitting deterioration of renal excretory function. Previous studies showed corticosteroid unresponsiveness and a variable response to cyclophosphamide therapy. We hypothesized that treatment with pulse methylprednisolone therapy (PMT), alternate-day corticosteroids, and cyclosphosphamide or cyclosporine would decrease proteinuria in patients with familial FSGS. Two adolescent brothers, 13 and 16 years old, presented with nephrotic range proteinuria, but with normal renal excretory function. Both brothers had renal biopsies that showed FSGS with mesangial hypercellularity and tubular atrophy. Intravenous PMT, at doses of 1 g, was initiated per the Tune-Mendoza protocol. Both patients received lisinopril therapy. One brother (case 1) was treated with PMT, alternate-day corticosteroids, and cyclophosphamide (total cumulative cyclophosphamide dose was 154.3 mg/kg). Urinary protein-to-urinary creatinine (UP/UC) ratios decreased from 6.79 to 3.79. Cyclosporine therapy decreased the UP/UC further from 2.48 to 0.76 at the end of PMT. The other brother (case 2), treated with PMT, alternate-day corticosteroids, and cyclosporine, experienced a decrease in UP/UC from 7.27 to 1.14. At the time of last evaluation, approximately 7 months after the last PMT dose, the UP/UC ratios were 0.27 (case 1) and 0.37 (case 2). PMT-attributable adverse effects were not severe. Both patients continued to receive oral cyclosporine and lisinopril after completion of PMT. PMT and cyclosporine therapy may reduce proteinuria, without decreasing renal excretory function, in some patients with familial FSGS. Further evaluation of cyclosporine therapy and PMT of patients with familial FSGS is warranted.

NHS regions. They were the weakest link

The role and autonomy of regional chairs has been eroded since they were established in 1974. Regional chairs became increasingly anomalous after the abolition of regional health authorities in 1996. In recent years they have been caught between the NHS and the civil service. The shift from RHA to an outpost of the civil service was profound. Experience as a regional chair suggests that really imaginative initiatives come from local enthusiasm rather than top-down directives.

A map of human genome sequence variation containing 1.42 million single nucleotide polymorphisms

We describe a map of 1.42 million single nucleotide polymorphisms (SNPs) distributed throughout the human genome, providing an average density on available sequence of one SNP every 1.9 kilobases. These SNPs were primarily discovered by two projects: The SNP Consortium and the analysis of clone overlaps by the International Human Genome Sequencing Consortium. The map integrates all publicly available SNPs with described genes and other genomic features. We estimate that 60,000 SNPs fall within exon (coding and untranslated regions), and 85% of exons are within 5 kb of the nearest SNP. Nucleotide diversity varies greatly across the genome, in a manner broadly consistent with a standard population genetic model of human history. This high-density SNP map provides a public resource for defining haplotype variation across the genome, and should help to identify biomedically important genes for diagnosis and therapy.

Real-time TaqMan PCR as a specific and more sensitive alternative to the branched-chain DNA assay for quantitation of simian immunodeficiency virus RNA

We developed a rapid and highly reproducible assay based on real-time PCR (TaqMan, Applied Biosystems, Foster City, CA) to quantitate simian immunodeficiency virus (SIV) RNA in plasma samples. This assay was compared with the current branched-chain DNA assay (Bayer, Emeryville, CA). Results obtained with the real-time TaqMan PCR assay were comparable to those obtained with the branched-chain DNA assay in overlapping ranges of sensitivities (r = 0.9429, p < 0.05). However, the real-time TaqMan PCR assay was capable of detecting as few as 50 copies of RNA/ml, whereas branched-chain DNA was only sensitive to 1,500 copies of RNA/ml. Therefore, several animals that tested negative by branched-chain DNA were positive by realtime TaqMan PCR. Two false positive tests were also recorded for the branched-chain DNA test. False negative and positive tests were confirmed by cell culture isolation and conventional nested RT-PCR. The SIV TaqMan assay detected a wide range of wild-type, cloned, and recombinant SIV strains with similar amplification efficiency, including SIVmac251, SIVmac239, SIVmac239 containing the 184V mutation in RT, SIV1A11, SIVmac239 delta3, SIVmac-M4, and chimeras (SHIVs) containing specific HIV-1 genes, such as reverse transcriptase (RT-SHIV) or Env (SHIV-E). In conclusion, the high sensitivity, increased specificity, wide dynamic range, simplicity, and reproducibility of the real-time SIV RNA quantitation allow the screening of large numbers of samples and make this method especially suitable for measuring both viral DNA and RNA levels during vaccine and therapy studies.

Private healthcare. Let's drink to that

The Commission for Health Improvement will have authority to monitor private hospitals treating NHS patients. The private sector will be subject to the NHS complaints procedure. The issue of medical staffing for private hospitals needs to be addressed. The uneven spread of private facilities across the country undermines the partnership. Arrangements to cut NHS waiting lists will reduce demand for private medical insurance.

Estimating viability of Cryptosporidium parvum oocysts using reverse transcriptase-polymerase chain reaction (RT-PCR) directed at mRNA encoding amyloglucosidase

The purpose of the present study was to determine if reverse transcriptase-polymerase chain reaction (RT-PCR) directed at mRNA encoding the enzyme amyloglucosidase (CPAG) could serve as a indicator for C. parvum oocyst viability. Oocysts were stored for 1-11 months in the refrigerator and at monthly intervals extracted for total RNA for RT-PCR analysis. An aliquot of these C. parvum oocysts was inoculated into neonatal mice which were necropsied 4 days later for ileal tissue that was analyzed by semi-quantitative PCR to determine the level of parasite replication. The CPAG RT-PCR assay detected RNA from as few as 10(3) C. parvum oocysts. An effect of storage time on both RT-PCR signal and mouse infectivity was observed. RNA from oocysts stored for 1-7 months, unlike oocysts stored for 9 or 11 months, contained CPAG mRNA that was detectable by RT-PCR. A gradual decrease in the RT-PCR signal intensity was observed between 5 and 7 months storage. The intensity of RT-PCR product from oocysts and the signal from semi-quantitative PCR of ileal tissue DNA from mice infected with these same aged oocysts were comparable. The RT-PCR assay of CPAG mRNA in cultured cells infected with viable C. parvum oocysts first detected expression at 12 h with highest expression levels observed at 48 h post-infection. These results indicate that CPAG RT-PCR may be useful for differentiating viable from non-viable C. parvum oocysts and for studying the expression of the gene for amyloglucosidase in vitro.