Serum albuterol levels in mechanically ventilated patients and healthy subjects after metered-dose inhaler administration

In mechanically ventilated patients, systemic blood levels of inhaled drugs reflect absorption from the lower respiratory tract alone since, unlike nonintubated patients, oropharyngeal and gastrointestinal absorption cannot occur. To determine the efficiency of aerosol administration by a metered-dose inhaler (MDI), we measured serum albuterol levels after administration by a MDI and spacer to nine mechanically ventilated patients (10 puffs) and to 10 healthy subjects (six puffs). Serum albuterol levels (+/- SEM) quantitated by high-performance liquid chromatography and electrochemical detection were: 0.09 +/- 0.04 mg/ml/puff at baseline, 0.66 +/- 0.10 at 5 min, 0.98 +/- 0.10 at 10 min, 0.56 +/- 0.08 at 15 min, and 0.37 +/- 0.03 at 30 min in mechanically ventilated patients versus zero at baseline, 0.89 +/- 0.12 at 5 min, 1.27 +/- 0.13 at 10 min, 0.84 +/- 0.09 at 15 min, and 0.53 +/- 0.07 at 30 min in control subjects (p > or = 0.07 at 5, 10, and 30 min; p < or = 0.05 at baseline and at 15 min). Area under the curve (AUC0-30) in the mechanically ventilated patients was 16.8 +/- 1.4 versus 23.4 +/- 1.9 ng/ml/puff x min in control subjects (p = 0.014). In summary, administration of albuterol with a MDI achieved a profile of serum levels in mechanically ventilated patients similar to that in healthy control subjects, but the peak serum level and systemic bioavailability (AUC0-30) were lower in the patients. In conclusion, serum levels reliably assess lower respiratory tract deposition of albuterol, and show that MDIs are more efficient for aerosol delivery in mechanically ventilated patients than was previously reported in studies using radiolabeled aerosols.

The management of genital condylomas, intraepithelial neoplasia, and vulvodynia

The natural history of HPV-related disease still is poorly understood. Screening of apparently healthy populations suggests that most HPV exposure results only in latent infection; that is, there is no active HPV DNA replication, but the HPV copy number is held at a steady state because viral replication parallels cell division. Unfortunately, knowledge of the cell-virus interaction and the host-immune response has not yet provided an effective medical therapy or a preventive vaccine. Rather, the management of HPV-induced disease remains rooted to the strategy of repeated local destruction. The physician should work methodically through a series of strategic decisions before committing to a management plan.

A new enzyme superfamily - the phosphopantetheinyl transferases

BACKGROUND

All polyketide synthases, fatty acid synthases, and non-ribosomal peptide synthetases require posttranslational modification of their constituent acyl carrier protein domain(s) to become catalytically active. The inactive apoproteins are converted to their active holo-forms by posttranslational transfer of the 4'-phosphopantetheinyl (P-pant) moiety of coenzyme A to the sidechain hydroxyl of a conserved serine residue in each acyl carrier protein domain. The first P-pant transferase to be cloned and characterized was the recently reported Escherichia coli enzyme ACPS, responsible for apo to holo conversion of fatty acid synthase. Surprisingly, initial searches of sequence databases did not reveal any proteins with significant peptide sequence similarity with ACPS.

RESULTS

Through refinement of sequence alignments that indicated low level similarity with the ACPS peptide sequence, we identified two consensus motifs shared among several potential ACPS homologs. This has led to the identification of a large family of proteins having 12-22 % similarity with ACPS, which are putative P-pant transferases. Three of these proteins, E. coli EntD and o195, and B. subtilis Sfp, have been overproduced, purified and found to have P-pant transferase activity, confirming that the observed low level of sequence homology correctly predicted catalytic function. Three P-pant transferases are now known to be present in E. coli (ACPS, EntD and o195); ACPS and EntD are specific for the activation of fatty acid synthase and enterobactin synthetase, respectively. The apo-protein substrate for o195 has not yet been identified. Sfp is responsible for the activation of the surfactin synthetase.

CONCLUSIONS

The specificity of ACPS and EntD for distinct P-pant-requiring enzymes suggests that each P-pant-requiring synthase has its own partner enzyme responsible for apo to holo activation of its acyl carrier domains. This is the first direct evidence that in organisms containing multiple P-pant-requiring pathways, each pathway has its own posttranslational modifying activity.

Identification of new RNA modifying enzymes by iterative genome search using known modifying enzymes as probes

The complete nucleotide sequences of the Haemophilus influenzae and Mycoplasma genitalium genomes and the partially sequenced Escherichia coli chromosome were analyzed to identify open reading frames (ORFs) likely to encode RNA modifying enzymes. The protein sequences of known RNA modifying enzymes from three families--m5U methyltransferases, psi synthases and 2'-O methyltransferases--were used as probes to search sequence databases for homologs. ORFs identified as homologous to the initial probes were retrieved and used as new probes against the databases in an iterative manner until no more homologous ORFs could be identified. Using this approach, we have identified two new m5U methyltransferases, seven new psi synthases and four new 2'-O methyltransferases in E. coli. Many of the ORFs found in E.coli have direct genetic counterparts (orthologs) in one or both of H.influenzae and M.genitalium. Since there is a near-complete knowledge of RNA modifications in E.coli, functional activities of the proteins encoded by the identified ORFs were proposed based on the level of conservation of the ORFs and the modified nucleotides.

Functional expression of the dihydrofolate reductase domain of Leishmania major dihydrofolate reductase-thymidylate synthase bifunctional protein

The dihydrofolate reductase (DHFR) domain of the bifunctional dihydrofolate reductase-thymidylate synthase from Leishmania major has been subcloned and expressed as a soluble protein in Escherichia coli strain PA414 harboring plasmid pLMDHFR. Homogeneous L. major DHFR was obtained by chromatography on methotrexate-Sepharose followed by DE52. The purified enzyme migrated as a single 25-kDa protein on SDS-PAGE. The native molecular weight was determined to be 26 kDa, indicating that the isolated domain is a monomer. N-terminal sequence analysis revealed that serine, the second amino acid in the coding sequence, was the N-terminal amino acid of the protein. The enzyme showed a pH optimum similar to that of the bifunctional protein. For purified DHFR, the Km values were <1.0 microM for H2folate and <1.0 microM for NADPH. The kcat of the most active DHFR preparation was 5 s-1. The Km and kcat values were similar to those of the bifunctional enzyme.

Acute renal toxicity after ingestion of Lava light liquid

A 65-year-old man with a history of alcohol abuse and seizure disorder presented to the emergency department with altered mental status, increased anion gap acidosis, phenytoin toxicity, and acute kidney failure. The patient had ingested the liquid contents of a Lava light, which contained chlorinated paraffin, polyethylene glycol (molecular weight 200), kerosene, and micro-crystalline wax. Gas chromatography-mass spectrophotometry of the patient's blood produced results consistent with the same analysis of the Lava light contents. After 3 days of declining mental status and worsening kidney function, the patient required hemodialysis. After a prolonged hospitalization, the patient was discharged home with residual renal insufficiency. Although multifactorial, the associated renal toxicity was most probably related to the low molecular weight polyethylene glycol content of the lamp's liquid contents.

Research in self-monitoring with students with learning disabilities: the present, the prospects, the pitfalls

The amount of research in the use of self-monitoring intervention with students has increased steadily. This article reviews the literature to date on self-monitoring with students with learning disabilities. First, it discusses the results of self-monitoring studies in terms of major dependent measures, such as on-task behavior and academic productivity and accuracy. Next, it analyzes studies comparing the effects of self-monitoring of attention and self-monitoring of performance on on-task behavior and academic responding. Finally, it discusses areas for future research and potential conceptual pitfalls.

Sclerosing epithelioid fibrosarcoma

A case of sclerosing epithelioid fibrosarcoma arising in the thigh of a 40-year-old man is reported. This recently described sarcoma has a distinctive histological appearance which may cause confusion with a variety of other sarcomas with an epithelioid pattern, and indeed with benign soft tissue tumours showing hyalinization. Despite its bland cytology, sclerosing epithelioid fibrosarcoma is capable of metastases, often several years after surgical removal. The patient described here developed lung metastases five years after excision and remains alive a further three years later. The differential diagnosis and possible histogenesis are discussed.

Amniotic fluid culture failure: clinical significance and association with aneuploidy

OBJECTIVE

To characterize clinical aspects associated with second-trimester amniotic fluid (AF) culture failure.

METHODS

The reports of all amniocentesis samples received in our cytogenetic laboratory over a 9-year period were reviewed to identify cases in which culture failure of amniocytes occurred. Medical records were then reviewed for the prenatal ultrasonographic findings, karyotype when available, and clinical outcome.

RESULTS

During the study period, 4134 second-trimester AF samples were processed, of which 42 (1%) failed to yield a result. Complete information was available in 41 pregnancies, which are the basis of this report. Karyotyping was done ultimately in 32 of the 41 cases (78%). The frequency of an abnormal karyotype was greater in those pregnancies in which AF culture failure occurred in comparison with those in which a cytogenetic result was obtained (six of 32 [19%] versus 149 of 4092 [4%], P < .001). There was also a greater prevalence of fetal abnormalities detected on prenatal ultrasonography, mainly oligohydramnios, hydrops, and fetal growth restriction, in the AF culture failure group compared with the successful AF culture group (17 of 41 [41%] versus 351 of 4092 [9%1, P < .001). All chromosomally abnormal fetuses had anomalies detected at ultrasonography.

CONCLUSION

Our findings confirm the previously reported association between karyotype abnormality and AF culture failure, but suggest that this association is probably due to fetal anomalies, detectable on prenatal ultrasonography, that lead to decreased fetal cell shedding.

Second-trimester echogenic bowel and intraamniotic bleeding: association between fetal bowel echogenicity and amniotic fluid spectrophotometry at 410 nm

OBJECTIVE

Our purpose was to determine whether the presence of heme pigments in amniotic fluid is associated with the ultrasonographic findings of increased fetal bowel echogenicity in the second trimester.

STUDY DESIGN

Spectrophotometric analysis of amniotic fluid for optical density at 410 nm was prospectively performed to study the presence of heme pigments in (1) 104 pregnancies undergoing second-trimester amniocentesis for routine cytogenetic indications and (2) in 14 pregnancies undergoing amniocentesis for prenatal karyotyping because of fetal strongly echogenic bowel. In the routine amniocentesis group the fetal small bowel echogenicity was assessed immediately before amniocentesis and classified as nonechogenic (n = 64), mildly echogenic (n = 36), or hyperechogenic (n = 4) with the fetal iliac wing and liver used as references. Only amniotic fluid specimens that were obtained at the first attempt and that were not blood-stained were included in this study, with the first milliliter being discarded in all samples.

RESULTS

In the routine amniocentesis group abnormal amniotic fluid optical density readings were significantly more frequent in fetuses with increased bowel echogenicity compared with those with nonechogenic bowel (8/40 [20%] vs 3/64 [5%], respectively; p < 0.001). In the hyperchogenic bowel group abnormal amniotic fluid optical density readings were found in four samples (29%). Overall, 12 of 54 fetuses (22%) with increased bowel echogenicity had a detectable peak at 410 nm. Three of the 12 (25%) fetuses with echogenic bowel and positive readings for hemoglobin were chromosomally abnormal.

CONCLUSIONS

Fetal small bowel echogenicity is associated with the presence of heme pigments in amniotic fluid as determined by amniotic fluid optical density at 410 nm. Swallowing of amniotic fluid after intraamniotic bleeding seems implicated in the etiology of second-trimester echogenic bowel in both euploid and aneuploid fetuses.

Treatment of attention deficit hyperactivity disorder: a multi-modal model for schools

Treatment of ADHD in schools has received comparatively little attention, even though children spend more time in school than in most other structured environments and have their most consistent, extensive contact with a variety of trained professionals there. Because schools could play a strategic role in treating ADHD children, a multi-modal treatment model for children with ADHD in school settings is presented, and logistic factors likely to increase its effective implementation are reviewed. Then, a functional approach to the assessment and treatment of ADHD that focuses on identifying individual-specific deficiencies and environmental factors that may prevent these children from performing appropriate behavior is discussed.

Educating every teacher, every year: the public schools and parents of children with ADHD

This article reports findings from interviews with 20 parents about their experiences in obtaining services for their ADHD children in school systems. Grounded theory methods were used to analyze data at both individual and organizational levels. Parents saw school personnel as varying widely in their knowledge about ADHD and their acceptance of its associated problems. At the individual level, parents felt that they had to educate a succession of different school personnel each year. At the organizational level, they had to work actively to obtain continuity of services for their children from year to year and school to school, but for most parents, this outcome was desired more often than realized. On the whole, parents perceived schools as having failed to respond adequately to their children's educational needs.

Reducing surgical length of stay: quantifying the impact

Length-of-stay (LOS) reduction is a strategy encouraged at all levels of health care to manage within a resource limited environment. However, few organizations have attempted to quantitatively understand the impact of reducing LOS. This study examines the relationship between reducing LOS and cost through a retrospective, medical records analysis of three surgical procedures (appendectomy, cholecystectomy and caesarean section) at an Ontario community hospital Department of Surgery. Hypotheses are presented and a methodology is described. The results are discussed with a focus on the factors that hospitals, administrators and physicians might consider in a LOS reduction program.

Customer complaints in the National Health Service

This paper addresses the role of consumer complaints in the flourishing quality assurance industry within the National Health Service (NHS), and considers the traditional ethos of complaints within the service. The advent of the internal market is considered as one of a range of factors which may change attitudes of NHS staff to complaints. In evaluating how complaints services might develop relevant literature is reviewed and recent national data on complaints procedures are cited.

Activation and preferential expansion of rat cytotoxic (CD8) T cells in vitro and in vivo with a bispecific (anti-TCR alpha/beta x anti-CD2) F(ab')2 antibody

We show that a bispecific F(ab')2 Ab (BsAb), which cross-links the TCR to CD2 ([anti-CD2 x anti-TCR]) and is highly mitogenic in vitro, also induces marked T cell activation and proliferation when given as a small single dose (50 to 100 micrograms) to rats. Interestingly, the proliferation appeared selective for CD8 cells, increasing this compartment more than 20 times over 72 h. This resulted in a three- to fourfold increase in spleen weight, with histologic evidence of T-zone and red pulp expansion by CD8+ blast cells. Such changes were in striking contrast to those seen after a similar amount of the parent IgG anti-TCR mAb, R73, which, while inducing a transient increase in CD25+ cells, failed to alter the lymphocyte composition. The mitogenic activity of the BsAb was totally dependent on its ability to cross-link CD2 and the TCR, hence a mixture of anti-CD2 and anti-TCR F(ab')2 fragments was without effect in vitro or in vivo. Unlike normal rat T cells or those taken from R73 IgG-treated rats, blood and splenic T cells recovered from BsAb-treated rats were highly cytotoxic against R73 hybridoma targets that express surface anti-TCR mAb and consequently trigger the lytic activity of activated CTL or a rat lymphoma line, LAMA (Thy-1+), using a second BsAb, [anti-TCR x anti-Thy-1], to retarget the CTL. This latter assay provides the basis for a future two-stage targeting strategy for cancer immunotherapy in which a mitogenic BsAb would be given to patients to activate CTL nonspecifically, and then, at an appropriate time, a second BsAb [anti-TCR x antitumor] would be given to deliver activated cells to the tumor target cells.

Activation and preferential expansion of rat cytotoxic (CD8) T cells in vitro and in vivo with a bispecific (anti-TCR alpha/beta x anti-CD2) F(ab')2 antibody

We show that a bispecific F(ab')2 Ab (BsAb), which cross-links the TCR to CD2 ([anti-CD2 x anti-TCR]) and is highly mitogenic in vitro, also induces marked T cell activation and proliferation when given as a small single dose (50 to 100 micrograms) to rats. Interestingly, the proliferation appeared selective for CD8 cells, increasing this compartment more than 20 times over 72 h. This resulted in a three- to fourfold increase in spleen weight, with histologic evidence of T-zone and red pulp expansion by CD8+ blast cells. Such changes were in striking contrast to those seen after a similar amount of the parent IgG anti-TCR mAb, R73, which, while inducing a transient increase in CD25+ cells, failed to alter the lymphocyte composition. The mitogenic activity of the BsAb was totally dependent on its ability to cross-link CD2 and the TCR, hence a mixture of anti-CD2 and anti-TCR F(ab')2 fragments was without effect in vitro or in vivo. Unlike normal rat T cells or those taken from R73 IgG-treated rats, blood and splenic T cells recovered from BsAb-treated rats were highly cytotoxic against R73 hybridoma targets that express surface anti-TCR mAb and consequently trigger the lytic activity of activated CTL or a rat lymphoma line, LAMA (Thy-1+), using a second BsAb, [anti-TCR x anti-Thy-1], to retarget the CTL. This latter assay provides the basis for a future two-stage targeting strategy for cancer immunotherapy in which a mitogenic BsAb would be given to patients to activate CTL nonspecifically, and then, at an appropriate time, a second BsAb [anti-TCR x antitumor] would be given to deliver activated cells to the tumor target cells.

Fluoxetine in the treatment of premenstrual dysphoria. Canadian Fluoxetine/Premenstrual Dysphoria Collaborative Study Group

BACKGROUND

Premenstrual dysphoria shares certain features with depression and anxiety states, which have been linked to serotonergic dysregulation. We evaluated the efficacy and safety of fluoxetine (which selectively inhibits the reuptake of serotonin) in the treatment of premenstrual dysphoria.

METHODS

The trial consisted of a single-blind, placebo washout period lasting two menstrual cycles, followed by a randomized, double-blind, placebo-controlled trial of fluoxetine at a dose of either 20 mg or 60 mg per day or placebo for six menstrual cycles. Healthy women meeting criteria for what was then called late-luteal-phase dysphoric disorder were recruited at seven university-affiliated women's health clinics in Canada. The primary outcome measure consisted of visual-analogue scales for tension, irritability, and dysphoria during the late luteal phase of each cycle.

RESULTS

Of 405 women enrolled in the placebo washout period, 313 subsequently entered the randomized phase of the study, which lasted six menstrual cycles, and 180 completed it. Fluoxetine at a dose of 20 or 60 mg per day was significantly superior to placebo in reducing symptoms of tension, irritability, and dysphoria, as measured by the visual-analogue scales (P < 0.001). The women who received 60 mg of fluoxetine per day reported significantly more side effects than those who received 20 mg per day or placebo (P < 0.001).

CONCLUSIONS

Fluoxetine is useful in the treatment of premenstrual dysphoria. Treatment with fluoxetine at a dose of 20 mg per day reduces the potential for side effects while maximizing therapeutic efficacy.

Synteny-mapping horse microsatellite markers using a heterohybridoma panel

A panel of horse-mouse heterohybridoma cells was tested for genetic markers using biochemical and polymerase chain reaction-(PCR-) based tests. Biochemical markers included phosphoglucomutase (PGM), glucose phosphate isomerase (GPI) and 6-phosphogluconate dehydrogenase (PGD). Markers detected using PCR-based tests included microsatellite markers HTG2-15, HMS 1-3, 5-8, VHL20, ECA2 and genes for equine major histocompatibility gene ELA-DRA, tumour necrosis factor alpha (TNFA) and transferrin. The results were analysed for correlation and concordance. Based on the results, five synteny groups were identified, specifically between ELA-DRA, TNFA, HMS5 and HTG5; between HTG3 and HTG13; between HTG4, HTG8 and HMS3; between HTG6 and HMS1; and between HTG7, HTG9 and HMS6. Evidence was also found for synteny between HTG12, HMS7 and ECA2, however, confirmation requires further testing. Cytogenetic evaluation of the cell lines making up the panel indicated that large metacentric chromosomes were preferentially lost or tended to break at the centromere. Consequently, the results from this analysis can be used to identify synteny, but not to exclude synteny.