Association Between Pharmacy Proximity With Cardiovascular Medication Use and Risk Factor Control in the United States

BACKGROUND

Poor neighborhood-level access to health care, including community pharmacies, contributes to cardiovascular disparities in the United States. The authors quantified the association between pharmacy proximity, antihypertensive and statin use, and blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) among a large, diverse US cohort.

METHODS AND RESULTS

A cross-sectional analysis of Black and White participants in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study during 2013 to 2016 was conducted. The authors designated pharmacy proximity by census tract using road network analysis with population-weighted centroids within a 10-minute drive time, with 5- and 20-minute sensitivity analyses. Pill bottle review measured medication use, and BP and LDL-C were assessed using standard methods. Poisson regression was used to quantify the association between pharmacy proximity with medication use and BP control, and linear regression for LDL-C. Among 16 150 REGARDS participants between 2013 and 2016, 8319 (51.5%) and 8569 (53.1%) had an indication for antihypertensive and statin medication, respectively, and pharmacy proximity data. The authors did not find a consistent association between living in a census tract with higher pharmacy proximity and antihypertensive medication use, BP control, or statin medication use and LDL-C levels, regardless of whether the area was rural, suburban, or urban. Results were similar among the 5- and 20-minute drive-time analyses.

CONCLUSIONS

Living in a low pharmacy proximity census tract may be associated with antihypertensive and statin medication use, or with BP control and LDL-C levels. Although, in this US cohort, outcomes were similar for adults living in high or low pharmacy proximity census tracts.

Glucagon-like peptide-1 receptor agonist and sodium-glucose cotransporter 2 inhibitor use among adults with diabetes mellitus by cardiovascular-kidney disease risk: National Health and Nutrition Examination Surveys, 2015-2020

Objective

Glucagon-like peptide-1 receptor agonists (GLP1-RAs) and sodium-glucose cotransporter 2 inhibitors (SGLT2Is) lower adverse cardiac and kidney events among high-risk patients with diabetes mellitus (DM) and are now guideline-recommended as first-line therapy alongside metformin. However, the adoption of these new treatments from 2015 to 2020 among the highest-risk adults with DM remains unclear.

Methods

We performed a cross-sectional analysis of the National Health and Nutrition Examination Surveys (NHANES) 2015-2020 to estimate the use of GLP1-RAs and SGLT2Is among adults with DM overall and by level of cardiovascular and kidney risk (CKR). We defined high CKR by history of atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), heart failure, or age ≥55 years with at least 2 ASCVD risk factors (i.e., obesity, hypertension, hyperlipidemia, or current smoker).

Results

Overall, 2,432 participants with DM (mean age 60.6 years, 46.8 % female, 58.8 % Non-Hispanic White) were included, of which 1,869 and 563 were with and without high CKR, respectively. Participants with vs. without high CKR were more likely to be older, have higher systolic blood pressure, lower estimated glomerular filtration rate, use oral antidiabetic agents, and have health insurance. Overall, the weighted prevalence of GLP1-RA or SGLT2I was 9.0 % (95 % confidence interval [CI] 6.9-11.0): 4.8 % (95 % CI 3.6-6.1) took GLP1-RAs, and 5.1 % (95 % CI 3.3-7.0) took SGLT2Is. Use of GLP1-RAs or SGLT2Is did not differ between participants with vs. without high CKR (adjusted prevalence ratio [aPR] 1.00; 95 % CI 0.98-1.02). Participants with ASCVD were more likely to be on a GLP1-RA or SGLT2I (aPR 1.28; 95 % CI 1.25-1.31), while adults with CKD were less likely (aPR 0.84; 95 % CI 0.82-0.86).

Conclusion

Among US adults with DM, GLP1-RA and SGLT2I use was low regardless of CKR. Data since 2020 analyzing the utilization of GLP1-RAs and SGLT2Is among high-CKR patients with DM is needed to identify implementation strategies for increased utilization.

Association Between Self-Reported Medication Adherence and Therapeutic Inertia in Hypertension: A Secondary Analysis of SPRINT (Systolic Blood Pressure Intervention Trial)

BACKGROUND

Therapeutic inertia (TI), failure to intensify antihypertensive medication when blood pressure (BP) is above goal, remains prevalent in hypertension management. The degree to which self-reported antihypertensive adherence is associated with TI with intensive BP goals remains unclear.

METHODS AND RESULTS

Cross-sectional analysis was performed of the 12-month visit of participants in the intensive arm of SPRINT (Systolic Blood Pressure Intervention Trial), which randomized adults to intensive (<120 mm Hg) versus standard (<140 mm Hg) systolic BP goals. TI was defined as no increase in antihypertensive regimen intensity score, which incorporates medication number and dose, when systolic BP is ≥120 mm Hg. Self-reported adherence was assessed using the 8-Item Morisky Medication Adherence Scale (MMAS-8) and categorized as low (MMAS-8 score <6), medium (MMAS-8 score 6 to <8), and high (MMAS-8 score 8). Poisson regressions estimated prevalence ratios (PRs) and 95% CIs for TI associated with MMAS-8. Among 1009 intensive arm participants with systolic BP >120 mm Hg at the 12-month visit (mean age, 69.6 years; 35.2% female, 28.8% non-Hispanic Black), TI occurred in 50.8% of participants. Participants with low adherence (versus high) were younger and more likely to be non-Hispanic Black or smokers. The prevalence of TI among patients with low, medium, and high adherence was 45.0%, 53.5%, and 50.4%, respectively. After adjustment, neither low nor medium adherence (versus high) were associated with TI (PR, 1.11 [95% CI, 0.87-1.42]; PR, 1.08 [95% CI, 0.84-1.38], respectively).

CONCLUSIONS

Although clinician uncertainty about adherence is often cited as a reason for why antihypertensive intensification is withheld when above BP goals, we observed no evidence of an association between self-reported adherence and TI.

Evaluation of Safety and Efficacy of Intravenous Digoxin Loading Doses Based on Ideal Body Weight

BACKGROUND

Intravenous digoxin loading dose recommendations differ between clinical guidelines and Food and Drug Administration packaging for acute rate control.

OBJECTIVE

The objective of this study was to assess the safety and efficacy of intravenous digoxin loading in patients who received ≤12 µg/kg and >12 µg/kg of digoxin using ideal body weight (IBW).

METHODS

This single center retrospective cohort study with exempt status from the local Institutional Review Board included patients who received intravenous digoxin and had a serum digoxin concentration (SDC) drawn. Digoxin doses >36 hours after the first dose were excluded. Patients who received a total of >12 µg/kg and ≤12 µg/kg IBW were compared. The primary endpoint was frequency of SDCs ≥1.2 ng/mL, which have been shown to be associated with increased mortality.

RESULTS

A total of 244 patients were included (144 receiving >12 µg/kg and 100 receiving ≤12 µg/kg). There were significantly more SDC ≥1.2 ng/mL in the >12 µg/kg group than the ≤12 µg/kg group (50.6% vs. 30.0%; adjusted odds ratio, 3.19; 95% confidence interval [CI]: 1.79-5.84), with no difference in rate control failure. Major limitations of the study include retrospective nature and possible selection bias.

CONCLUSION AND RELEVANCE

Compared to patients who received digoxin doses ≤12 µg/kg IBW, patients who received >12 µg/kg IBW had higher rates of SDC ≥1.2 ng/mL. This suggests that appropriate weight-based dosing with 8 to 12 µg/kg IBW has the potential to be a safer approach to digoxin loading, rather than frequently used dosing strategies that result in doses >12 µg/kg.

New Users of Angiotensin II Receptor Blocker-Versus Angiotensin-Converting Enzyme Inhibitor-Based Antihypertensive Medication Regimens and Cardiovascular Disease Events: A Secondary Analysis of ACCORD-BP and SPRINT

BACKGROUND Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) block distinct components of the renin-angiotensin system. Whether this translates into differential effects on cardiovascular disease events remains unclear. METHODS AND RESULTS We used the ACCORD-BP (Action to Control Cardiovascular Risk in Diabetes-Blood Pressure) trial and the SPRINT (Systolic Blood Pressure Intervention Trial) to emulate target trials of new users of ARBs versus ACEIs on cardiovascular disease events (primary outcome) and death (secondary outcome). We estimated marginal cause-specific hazard ratios (HRs) and treatment-specific cumulative incidence functions with inverse probability of treatment weights. We identified 3298 new users of ARBs or ACEIs (ACCORD-BP: 374 ARB versus 884 ACEI; SPRINT: 727 ARB versus 1313 ACEI). For participants initiating ARBs versus ACEIs, the inverse probability of treatment weight rate of the primary outcome was 3.2 versus 3.5 per 100 person-years in ACCORD-BP (HR, 0.91 [95% CI, 0.63-1.31]) and 1.8 versus 2.2 per 100 person-years in SPRINT (HR, 0.81 [95% CI, 0.56-1.18]). There were no appreciable differences in pooled analyses, except that ARBs versus ACEIs were associated with a lower death rate (HR, 0.56 [95% CI, 0.37-0.85]). ARBs were associated with a lower rate of the primary outcome among subgroups of male versus female participants, non-Hispanic Black versus non-Hispanic White participants, and those randomly assigned to standard versus intensive blood pressure (Pinteraction: <0.01, 0.05, and <0.01, respectively). CONCLUSIONS In this secondary analysis of ACCORD-BP and SPRINT, new users of ARB- versus ACEI-based antihypertensive medication regimens experienced similar cardiovascular disease events rates, with important subgroup differences and lower rates of death overall. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01206062, NCT00000620.

Age-based disparities in statin use for primary prevention in US adults: National Health and Nutrition Examination Surveys 2013-2020

Statin use among younger adults at high atherosclerotic cardiovascular disease (ASCVD) risk compared with older adults at the same risk is unclear. We determined prevalent statin use by 10-year ASCVD risk and age among US participants aged 40-75 eligible for risk-indicated primary prevention statins from the 2013-2020 National Health and Nutrition Examination Survey cycles. Among 3,503 participants, statin use by ASCVD risk (5-<7.5%, 7.5-<20%, and ≥20%) was 9.4%, 9.0%, and 12.2% among those age 40-54 compared to 22.0%, 23.9%, and 14.3% among adults 55-64 years and 39.3%, 33.6%, and 38.1% age 65-75 years. After adjusting for sociodemographic and healthcare access, the prevalence ratio (vs. 65-75 years) for statin use among adults with an ASCVD risk of 7.5-<20% age 40-54 years was 0.40 (95% confidence interval [CI] 0.39,0.41) and 0.87 (95% CI 0.87,0.88) for adults 55-64 years. Among high ASCVD-risk adults aged 40-75 years, primary prevention statin use was lower among adults <65 years despite similar ASCVD risk as older adults.

Single-Pill Combination Product Availability of the Antihypertensive Regimens Used for Intensive Systolic Blood Pressure Treatment in the Systolic Blood Pressure Intervention Trial

BACKGROUND

Single-pill combination (SPC) antihypertensive products improve blood pressure control and medication adherence among patients with hypertension. It is unknown to what degree commercially available SPC products could be used to target an intensive systolic blood pressure goal of <120 mm Hg.

METHODS

This cross-sectional analysis included participants randomized to the intensive treatment arm (goal systolic blood pressure <120 mm Hg) of the Systolic Blood Pressure Intervention Trial (SPRINT) using ≥2 antihypertensive medication classes at the 12-month postrandomization visit. Antihypertensive medication data were collected using pill bottle review by research coordinators, and regimens were categorized by the unique combinations of antihypertensive classes. We calculated the proportion of regimens used, which are commercially available as one of the 7 SPC class combinations in the United States as of January 2023.

RESULTS

Among the 3833 SPRINT intensive arm participants included (median age, 67.0 years; 35.5% female), participants were using 219 unique antihypertensive regimens. The 7 regimens for which there are class-equivalent SPC products were used by 40.3% of participants. Only 3.2% of all medication class regimens used are available as a class-equivalent SPC product (7/219). There are no SPC products available with 4 or more medication classes, which were used by 1060 participants (27.7%).

CONCLUSIONS

Most SPRINT participants in the intensive arm used an antihypertensive medication regimen, which is not commercially available as a class equivalent SPC product. To achieve the SPRINT results in real-world settings, maximize the potential benefit of SPCs, and reduce pill burden, improvements in the product landscape are needed.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov/ct2/show/NCT01206062; Unique identifier: NCT01206062.

Evidence for Age Bias Contributing to Therapeutic Inertia in Blood Pressure Management: A Secondary Analysis of SPRINT

BACKGROUND

Despite evidence supporting the cardiovascular and cognitive benefits of intensive blood pressure management, older adults have the lowest rates of blood pressure control. We determined the association between age and therapeutic inertia (TI) in SPRINT (Systolic Blood Pressure Intervention Trial), and whether frailty, cognitive function, or gait speed moderate or mediate these associations.

METHODS

We performed a secondary analysis of SPRINT of participant visits with blood pressure above randomized treatment goal. We categorized baseline age as <60, 60 to <70, 70 to <80, and ≥80 years and TI as no antihypertensive medication intensification per participant visit. Generalized estimating equations generated odds ratios for TI associated with age, stratified by treatment group based on nested models adjusted for baseline frailty index score (fit [frailty index, ≤0.10], less fit [0.10

RESULTS

Participants 60 to <70, 70 to <80, and ≥80 years of age had a higher prevalence of TI in both treatment groups versus participants <60 years of age (standard: 59.7%, 60.5%, and 60.1% versus 56.0%; 29 527 participant visits; intensive: 55.1%, 57.2%, and 57.8% versus 53.8%; 47 129 participant visits). The adjusted odds ratios for TI comparing participants ≥80 versus <60 years of age were 1.32 (95% CI, 1.14-1.53) and 1.25 (95% CI, 1.11-1.41) in the standard and intensive treatment groups, respectively. Adjustment for frailty, cognitive function, or gait speed did not attenuate the association or demonstrate effect modification (all Pinteraction, >0.10).

CONCLUSIONS

Older age is associated with greater TI independent of physical or cognitive function, implying age bias in hypertension management.

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Key Words

• frailty
• functional status
• goals
• hypertension
• odds ratio

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MESH Headings

• Aged
• Aged, 80 and over
• Humans
• Middle Aged
• Antihypertensive Agents/therapeutic use
• Antihypertensive Agents/pharmacology
• Blood Pressure/physiology
• Frailty/diagnosis
• Frailty/epidemiology
• Hypertension/diagnosis
• Hypertension/drug therapy
• Hypertension/epidemiology
• Risk Factors

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Grants

• K01 HL133468 NHLBI NIH HHS
• K24 AG080168 NIA NIH HHS
• K01 MD014158 NIMHD NIH HHS
• R01 AG065805 NIA NIH HHS
• R01 AG055606 NIA NIH HHS
• R38 HL143605 NHLBI NIH HHS
• R01 HL139837 NHLBI NIH HHS

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Affiliation(s)

Alexander R Zheutlin Department of Internal Medicine (A.R.Z.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
Daniel K Addo Intermountain Healthcare Department of Population Health Sciences (D.K.A., J.A.J., C.G.D., J.S.H., T.G., A.P.B.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
Joshua A Jacobs Intermountain Healthcare Department of Population Health Sciences (D.K.A., J.A.J., C.G.D., J.S.H., T.G., A.P.B.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
Catherine G Derington Intermountain Healthcare Department of Population Health Sciences (D.K.A., J.A.J., C.G.D., J.S.H., T.G., A.P.B.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
Jennifer S Herrick Intermountain Healthcare Department of Population Health Sciences (D.K.A., J.A.J., C.G.D., J.S.H., T.G., A.P.B.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City Informatics, Decision-Enhancement, and Analytic Sciences Center, Veterans Affairs, Salt Lake City Health Care System, Utah (J.S.H., A.P.B.)
Tom Greene Intermountain Healthcare Department of Population Health Sciences (D.K.A., J.A.J., C.G.D., J.S.H., T.G., A.P.B.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
Eric L Stulberg Department of Neurology (E.L.S.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
Dan R Berlowitz Department of Public Health, University of Massachusetts-Lowell (D.R.B.)
Jeff D Williamson Section on Gerontology and Geriatric Medicine, Department of Internal Medicine (J.D.W.), Wake Forest University School of Medicine, Winston-Salem, NC
Nicholas M Pajewski Department of Biostatistics and Data Science, Division of Public Health Sciences (N.M.P.), Wake Forest University School of Medicine, Winston-Salem, NC
Mark A Supiano Geriatrics Division, Spencer Fox Eccles School of Medicine, University of Utah Center on Aging, Salt Lake City (M.A.S.)
Adam P Bress Intermountain Healthcare Department of Population Health Sciences (D.K.A., J.A.J., C.G.D., J.S.H., T.G., A.P.B.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City Informatics, Decision-Enhancement, and Analytic Sciences Center, Veterans Affairs, Salt Lake City Health Care System, Utah (J.S.H., A.P.B.)

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Antihypertensive Medication Regimens Used by US Adults With Hypertension and the Potential for Fixed-Dose Combination Products: The National Health and Nutrition Examination Surveys 2015 to 2020

Background Fixed-dose combination (FDC) antihypertensive products improve blood pressure control and adherence among patients with hypertension. It is unknown to what degree commercially available FDC products meet the current hypertension management prescription patterns in the United States. Methods and Results This cross-sectional analysis of the National Health and Nutrition Examination Surveys 2015 to March 2020 included participants with hypertension taking ≥2 antihypertensive medications (N=2451). After constructing each participant's regimen according to antihypertensive classes used, we estimated the extent to which the 7 class-level FDC regimens available in the United States as of January 2023 would match the regimens used. Among a weighted population of 34.1 million US adults (mean age, 66.0 years; 52.8% women; 69.1% non-Hispanic White race and ethnicity), the proportions using 2, 3, 4, and ≥5 antihypertensive classes were 60.6%, 28.2%, 9.1%, and 1.6%, respectively. The 7 FDC regimens were among 189 total regimens used (3.7%), and 39.2% of the population used one of the FDC regimens (95% CI, 35.5%-43.0%; 13.4 million US adults); 60.8% of the population (95% CI, 57.0%-64.5%; 20.7 million US adults) were using a regimen not available as a class-equivalent FDC product. Conclusions Three in 5 US adults with hypertension taking ≥2 antihypertensive classes are using a regimen that is not commercially available as a class-equivalent FDC product as of January 2023. To maximize the potential benefit of FDCs to improve medication adherence (and thus blood pressure control) among patients taking multiple antihypertensive medications, use of FDC-compatible regimens and improvements in the product landscape are needed.

Prevalence of Statin Use for Primary Prevention of Atherosclerotic Cardiovascular Disease by Race, Ethnicity, and 10-Year Disease Risk in the US: National Health and Nutrition Examination Surveys, 2013 to March 2020

Importance

The burden of atherosclerotic cardiovascular disease (ASCVD) in the US is higher among Black and Hispanic vs White adults. Inclusion of race in guidance for statin indication may lead to decreased disparities in statin use.

Objective

To evaluate prevalence of primary prevention statin use by race and ethnicity according to 10-year ASCVD risk.

Design, Setting, and Participants

This serial, cross-sectional analysis performed in May 2022 used data from the National Health and Nutrition Examination Survey, a nationally representative sample of health status in the US, from 2013 to March 2020 (limited cycle due to the COVID-19 pandemic), to evaluate statin use for primary prevention of ASCVD and to estimate 10-year ASCVD risk. Participants aged 40 to 75 years without ASCVD, diabetes, low-density lipoprotein cholesterol levels 190 mg/dL or greater, and with data on medication use were included.

Exposures

Self-identified race and ethnicity (Asian, Black, Hispanic, and White) and 10-year ASCVD risk category (5%-<7.5%, 7.5%-<20%, ≥20%).

Main Outcomes and Measures

Prevalence of statin use, defined as identification of statin use on pill bottle review.

Results

A total of 3417 participants representing 39.4 million US adults after applying sampling weights (mean [SD] age, 61.8 [8.0] years; 1289 women [weighted percentage, 37.8%] and 2128 men [weighted percentage, 62.2%]; 329 Asian [weighted percentage, 4.2%], 1032 Black [weighted percentage, 12.7%], 786 Hispanic [weighted percentage, 10.1%], and 1270 White [weighted percentage, 73.0%]) were included. Compared with White participants, statin use was lower in Black and Hispanic participants and comparable among Asian participants in the overall cohort (Asian, 25.5%; Black, 20.0%; Hispanic, 15.4%; White, 27.9%) and within ASCVD risk strata. Within each race and ethnicity group, a graded increase in statin use was observed across increasing ASCVD risk strata. Statin use was low in the highest risk stratum overall with significantly lower rates of use among Black (23.8%; prevalence ratio [PR], 0.90; 95% CI, 0.82-0.98 vs White) and Hispanic participants (23.9%; PR, 0.90; 95% CI, 0.81-0.99 vs White). Among other factors, routine health care access and health insurance were significantly associated with higher statin use in Black, Hispanic, and White adults. Prevalence of statin use did not meaningfully change over time by race and ethnicity or by ASCVD risk stratum.

Conclusions and Relevance

In this study, statin use for primary prevention of ASCVD was low among all race and ethnicity groups regardless of ASCVD risk, with the lowest use occurring among Black and Hispanic adults. Improvements in access to care may promote equitable use of primary prevention statins in Black and Hispanic adults.

Differentiating Pulmonary Hypertension Associated with Protein Kinase Inhibitors

Protein kinase inhibitors (PKIs) have been implicated in pulmonary vascular toxicities including risk factors for at least three of the five World Health Organization groups of pulmonary hypertension (PH). These toxicities include direct drug‐induced pulmonary arterial hypertension, an increase in cardiomyopathies, and an increase in interstitial lung disease. On‐ and off‐target toxicities are common within multitargeted PKIs leading to cardiopulmonary toxicities. This review highlights the incidence, possible mechanisms, and management strategies for each group of possible PKI‐induced PH. Future identification and clarification of protein kinase pathways for both mechanisms of toxicity and pathophysiology for PH could lead to improvements in patient care in oncology and pulmonary vascular diseases.

Transitioning Between Prostanoid Therapies in Pulmonary Arterial Hypertension

Background: New oral prostacyclin therapies and prostacyclin agonists have become available for the treatment of pulmonary arterial hypertension (PAH). However, methods for transitioning between oral, inhaled, and parenteral formulations are not well-established, except in the form of case reports and case series. Collectively, these emphasize the lack of a standardized process and approach in transitioning patients between PAH prostanoid therapies. In this case series, we report our experience at an accredited Pulmonary Hypertension center in transitioning between various oral, inhaled, and parenteral prostanoids to offer additional guidance on safe transitions in therapy. Methods: All cases of prostanoid transitions at an accredited Pulmonary Hypertension center from March 2018 to September 2019 were included in this report. The transition approach for each case was developed through a review of the literature, extrapolation of available pharmacokinetic data, and collaboration between pharmacists and clinicians. Results: This case series describes the transition of 3 patients from selexipag to parenteral treprostinil; 1 patient transitioning from parenteral treprostinil to selexipag; 1 patient transitioning from oral treprostinil to parenteral treprostinil; and 1 patient transitioning from inhaled treprostinil to selexipag. Four of the 6 patients presented here were transitioned to an alternate prostanoid on account of clinical worsening, while the remaining 2 patients transitioned due to intolerance of parenteral therapy and poor medication adherence. This case series includes patients with various etiologies of PAH including idiopathic PAH, methamphetamine-associated PAH, and scleroderma-associated PAH. All patients successfully completed each transition without serious adverse events. Conclusions: With the increasing utilization and availability of prostanoids, there is a critical need for a standardized approach in transitioning safely between different formulations without compromising treatment efficacy. In this case series, we present our clinical experiences, guided by available pharmacokinetic data, in transitioning between various prostanoid formulations.

Effect of synbiotics on thyroid hormones, intestinal histomorphology, and heat shock protein 70 expression in broiler chickens reared under cyclic heat stress

This study examined effect of a dietary synbiotic supplement on the concentrations of plasma thyroid hormones, expressions of heat shock protein 70 (HSP70), and intestinal histomorphology in broiler chickens exposed to cyclic heat stress (HS). Three hundred and sixty day old male Ross 708 broiler chicks were randomly distributed among 3 dietary treatments containing a synbiotic (PoultryStar meUS) at 0 (control), 0.5 (0.5×), and 1.0 (1.0×) g/kg. Each treatment contained 8 replicates of 15 birds each housed in floor pens in a temperature and lighting controlled room. Heat stimulation was established from days 15 to 42 at 32°C for 9 h daily. The results indicated that under the HS condition, both synbiotic fed groups had lower liver and hypothalamus HSP70 levels (P < 0.001) compared to control group; however, HSP70 mRNA expression was not different among treatments (P > 0.05). There were no treatment effects on the levels of triiodothyronine (T3) and thyroxine (T4) as well as T3/T4 ratio (P > 0.05). Compared to controls, 1.0× HS broilers had greater villus height in the duodenum (P < 0.01), and greater villus height and villus height:crypt depth ratios in the ileum (P < 0.01). There were no differences among treatments on the measured intestinal parameters in the jejunum (P > 0.05). The results suggest that the synbiotic may ameliorate the negative effects of HS on chicken health as indicated by the changes in the intestinal architecture and the levels of HSP70. Dietary synbiotic supplement could be a feasible nutritive strategy for the poultry industry to improve the health and welfare of chickens when exposed to hot environmental temperature.

Effect of a synbiotic supplement on cecal microbial ecology, antioxidant status, and immune response of broiler chickens reared under heat stress

The aim of this study was to examine the effect of a dietary synbiotic supplement on the cecal microflora, antioxidant status, and immune response of broiler chickens under heat stress (HS). A total of 360 one-day-old male Ross 708 broiler chicks were randomly distributed among 3 dietary treatments containing a synbiotic (PoultryStar consists of Bifidobacterium animalis, Enterococcus faecium, Lactobacillus reuteri, Pediococcus acidilactici, and fructooligosaccharides) at 0 (control), 0.5 (0.5X), and 1.0 (1.0X) g/kg. Each treatment contained 8 replicates of 15 birds each housed in floor pens. Heat stimulation was at 32°C for 9 h daily from day 15 to 42. Heat stress-induced changes of cecal bacteria were detected using bacteria-specific agars, and spleen protein concentration and mRNA expression of interleukins and antioxidants were examined using ELISA and real-time PCR, respectively. Under the HS condition, synbiotic fed broilers regardless of dose had lower cecal enumerations of Escherichia coli and coliforms, and a lower heterophil/lymphocyte (H/L) ratio (P < 0.05) compared to controls. 1.0X group also had higher cecal enumerations of Bifidobacterium spp. and Lactobacillus spp., spleen glutathione peroxidase (GPx), and plasma nuclear factor erythroid 2-related factor 2 (Nrf-2), and a lower H/L ratio compared to both control and 0.5X groups (P < 0.05). However, there were no treatment effects on the levels of Enterococcus spp., the circulating monocytes, eosinophils, and basophils, Toll like receptor-4 (TLR-4), interleukin-6 (IL-6), interlukin-10 (IL-10), and their mRNA expression, as well as plasma Kelch-like ECH-associated protein 1 (Keap-1) (P > 0.05). These results suggest that the synbiotic could inhibit the negative effects of HS on broiler health through the reduction of cecal pathogens, regulation of stress reactions, and improvement of antioxidant status.

Temperature Instability in an Infant Treated with Propranolol for Infantile Hemangioma

Infantile hemangiomas are prevalent in the first few months of life and can be associated with risks of scarring, blindness, ulcerations, and airway obstruction depending on the location of lesions. Options for therapy include surgery, laser therapy, or medications. Propranolol is the only US Food and Drug Administration-approved medication option. Propranolol is a nonselective beta-blocker that crosses the blood-brain barrier because of its high lipophilicity, which increases the likelihood of central nervous system effects. In this case, a preterm infant developed infantile hemangiomas on the left forearm, left trunk, left buttock, and nasal tip. The patient was treated with propranolol and concurrently required placement into a heated incubator and was subsequently unable to wean from the incubator. Upon discontinuation of propranolol, temperature instability resolved. Atenolol, a cardioselective beta-blocker that does not cross the blood-brain barrier, was then initiated for the infantile hemangiomas and displayed no adverse effect on the thermoregulation of the infant.

Prevalence and distribution of beta-lactamase coding genes in third-generation cephalosporin-resistant Enterobacteriaceae from bloodstream infections in Cambodia

Resistance to third-generation cephalosporins in Gram-negative bacteria is emerging in Asia. We report the prevalence and distribution of extended-spectrum beta-lactamase (ESBL), AmpC beta-lactamase and carbapenemase-coding genes in cefotaxime-resistant Enterobacteriaceae isolates from bloodstream infections (BSI) in Cambodia. All Enterobacteriaceae isolated from BSI in adult patients at Sihanouk Hospital Centre of HOPE, Phnom Penh, Cambodia (2007–2010) were assessed. Antimicrobial susceptibility testing was carried out by disc diffusion and MicroScan according to Clinical and Laboratory Standards Institute (CLSI) guidelines. Screening for ESBL, plasmidic AmpC and carbapenemase-coding genes was performed by multiplex polymerase chain reaction (PCR) sequencing assays. Identification of the ST131 clone was performed in all CTX-M-positive Escherichia coli, using PCR targeting the papB gene. Out of 183 Enterobacteriaceae, 91 (49.7 %) isolates (84 BSI episodes) were cefotaxime-resistant: E. coli (n = 68), Klebsiella pneumoniae (n = 17) and Enterobacter spp. (n = 6). Most episodes were community-acquired (66/84; 78.3 %). ESBLs were present in 89/91 (97.8 %) cefotaxime-resistant isolates: 86 (96.6 %) were CTX-M, mainly CTX-M-15 (n = 41) and CTX-M-14 (n = 21). CTX-M of group 1 were frequently associated with TEM and/or OXA-1/30 coding genes and with phenotypic combined resistance to ciprofloxacin, sulphamethoxazole–trimethoprim and gentamicin (39/50, 78.0 %). Plasmidic AmpC (CMY-2 and DHA-1 types) were found alone (n = 2) or in combination with ESBL (n = 4). Eighteen E. coli isolates were identified as B2-ST131-O25B: 11 (61.1 %) carried CTX-M-14. No carbapenemase-coding genes were detected. ESBL among Enterobacteriaceae from BSI in Cambodia is common, mainly associated with CTX-M-15 and CTX-M-14. These findings warrant urgent action for the containment of antibiotic resistance in Cambodia.

Dairy cow behavior affects the availability of an automatic milking system

Facility design can affect the accessibility of an automatic milking system (AMS). In particular, gates and alleys positioned around the AMS may affect cow traffic and cow behavior, potentially affecting the duration of time the AMS is available for milking. Eighty-four Holstein cows of various parities and days in milk were randomly divided between 2 groups, each group having access to its own AMS. Cow locations and behaviors in the AMS entrance and exit areas, as well as in the adjacent holding area, were recorded continuously for 14 d. Cows receiving a "no-milking" decision (i.e., cow is rejected from the milking stall due to a recent milking event) took longer to exit the milking stall (18.2±1.33 s), and were more likely to circle and re-enter the AMS (0.8±0.15) compared with cows receiving a milking decision (16.2±1.09 s; 0.2±0.03). Cows exiting the AMS hesitated for long periods when another cow was near the exit gate (192.93±1.11 s) or in the general holding area (101.04±1.07 s). Cows in late lactation had a greater probability of hesitating in the exit alley for long periods (0.55±0.09) compared with cows in early lactation (0.15±0.07), regardless of whether cows were in the holding area. Primiparous cows were more likely to block other cows trying to exit (0.60±0.13) compared with multiparous cows (0.29±0.09). Occasionally, blocking events led to "back-up" events, in which the AMS became unavailable for new cow access due to a back up of cows through the exit alley into the milking stall. The AMS was empty (not occupied) for 10 and 18% (groups 1 and 2, respectively) of the day; therefore, it was possible that back-up events would simply reduce the amount of time the AMS was empty. The duration of back-up events and AMS empty events had a negative relationship in group 1 (r=-0.74), but no such relationship was observed in group 2. The differences in time budgets between the 2 groups suggest that the effect of back-up events on AMS availability may be dependent on group social dynamics.

Inappropriate drug donations: what has happened since the 1999 WHO guidelines?

CONTEXT

Drug donations to developing countries may be part of medical relief operations in acute emergencies, development aid in non-emergency situations, or a corporate donations programme. After a number of documented inappropriate drug donations, the World Health Organization developed the 'Guidelines for Drug Donations', with the second and final version published in 1999.

OBJECTIVES

We reviewed the medical literature on drug donations since the Guidelines publication in 1999.

DESIGN

Literature was retrieved from PubMed and other on-line databases as well as from relevant websites providing medical literature for use in developing countries. We considered the following donations to be inappropriate: (i) essential drugs in excessive quantities; (ii) mixed unused drugs (unsorted medicines and free samples); and (iii) drug dumping (large quantities of useless medicines).

RESULTS

We retrieved 25 publications dated after 1999, including 20 and 5 from the scientific literature and 'grey' literature (technical reports, working papers), respectively. New information concerned emergencies in East Timor, Mozambique, El Salvador, Gujarat State (India), Aceh (Indonesia) and Sri Lanka. Except for East Timor and Gujarat, inappropriate donations still occurred, accounting for 85%, 37%, 70% and 80% of donations in Mozambique, El Salvador, Aceh and Sri Lanka, respectively. Very little information was found on drug donations in non-emergency situations.

CONCLUSION

There are few recent reports on the compliance of drug donations with the World Health Organization guidelines. For emergency situations, there is still room for improvement. Drug donations in non-emergency situations need to be evaluated. A reform of drug donations policy is needed.

Successful treatment of Staphylococcus epidermidis prosthetic valve endocarditis with linezolid after failure of treatment with oxacillin, gentamicin, rifampicin, vancomycin, and fusidic acid regimens

We present a 49-y-old male, with a history of Marfan's disease and aortic and mitral valve replacement surgery, who was operated for a type III thoracoabdominal aneurysm. The postoperative course was compromised by a Staphylococcus epidermidis mitral valve endocarditis, which was successfully treated only after intravenous linezolid was included in the therapy.

Antibiotikaprophylaxe bei geschlossenen Frakturen und Prothesen

Antibiotic prophylaxis can be administered systemically or locally when bone cement is used for the implantation of prosthesis. In closed fracture surgery parenteral broad spectrum antibiotics are advised with 1 dose (in case of a long halflife) or for at least 12 hours when an antibiotic with a shorter half life is used. With such a prophylaxis a reduction of the infection rate to about 3% can be achieved, and also an important reduction of the postoperative nosocomial infections. Such a prophylaxis is highly cost effective. In primary prosthesis implantation, a 24 hours prophylaxis is needed. The use of antibiotic loaded bone cement, used as prophylaxis in primary prostheses is effective too, and this kind of cement should be used in combination with systemic antibiotics. In prosthesis an infection rate of 0.2% should be achieved.

Tinea incognito due to Trichophytom rubrum after local steroid therapy

The term "tinea incognito" refers to dermatophyte infections with clinical presentations that have been modified by the administration of corticosteroids. We describe a patient who had pustular inflammatory skin lesions due to Trichophyton rubrum after receiving treatment with potent topical corticosteroid creams.

Computer program supporting the diagnostic accuracy of cellular BALF analysis: a new release

Recently we developed a validated computer program based on polychotomous logistic regression analysis using bronchoalveolar avage fluid (BALF) results to distinguish between the three most common interstitial lung diseases (ILD): sarcoidosis, idiopathic pulmonary fibrosis (IPF) and extrinsic allergic alveolitis (EAA) or drug-induced pneumonitis. One of the limitations of this program was that it was not useful in discriminating between infectious disorders and non-infectious disorders. Therefore, we added BALF samples obtained from patients with a confirmed bacterial pulmonary infection based on culture results > or = 10(4) cfum l(-1) (group I: n=31) to the study population mentioned above (group II: n=272). Notably, just one variable, i.e. the percentage of polymorphonuclear neutrophils, allowed us to distinguish between infectious and non-infectious disorders. The agreement of predicted with the actual diagnostic group membership was 99.67% (groups I and II). Additionally, 91.2% of the cases with ILD were correctly classified. In conclusion, this updated Windows version 2000 of the validated computer program provides a very reliable prediction of the correct diagnosis for an arbitrary patient with suspected pneumonia or with ILD given information obtained from BALF analysis results, and is thought to improve the diagnostic power of BALF analysis.

Prevalence of macrolide resistance genes in clinical isolates of the Streptococcus anginosus ("S. milleri") group

Twenty-two unrelated erythromycin-resistant anginosus group strains (3.2% resistance rate) were assessed for mechanisms of resistance. Streptococcus anginosus accounted for 16 of the 22 isolates. Fifteen isolates harbored the erm(B) gene. The erm(TR) and the mef(E) genes were carried by two isolates each. In three isolates, none of these resistance genes was detected by PCR.

Clinical value of bacteriological examinations of nasal and paranasal mucosa in patients with chronic sinusitis

Although many investigations on the bacteriology of chronic sinusitis have been reported, there is still much discussion about the physiological flora of the nose and paranasal sinuses, the role of the various aerobic and anaerobic "pathogenic" bacteria, and the influence of the anatomical location from which samples for bacteriology are taken. We conducted a qualitative and semi-quantitative bacteriological examination of patients with chronic sinusitis undergoing a transnasal sinus operation (patient group), and of patients without chronic sinusitis undergoing a septoplasty (control group). In both groups brush smears of the inferior nasal turbinate and biopsies of the middle nasal turbinate were taken, with additional biopsies of the maxillary sinus and ethmoidal bulla in the chronic sinusitis group. In both groups coagulase-negative staphylococci were identified in almost all samples. Staphylococcus aureus was found in 22% (middle turbinate) to 33% (inferior turbinate) of the samples from the control group and in 33% (maxillary sinus, middle turbinate) to 50% (inferior turbinate) of the samples from the patient group. Other (pathogenic) aerobic bacteria were found much more rarely and only slight distinctions between control and patient group were observed. The concentrations of the different bacterial species (colony-forming units) were comparable in both groups. Strictly anaerobic bacteria and fungi were not identified. Only small discrepancies between the various methods and/or locations of sampling were found. Based on our bacteriological findings a differentiation between patients with and without chronic sinusitis was not possible. These results shed doubt on the clinical value of bacteriological examinations of nasal and paranasal mucosa in patients with chronic sinusitis.

Bronchoalveolar lavage fluid cytology in patients with Pneumocystis carinii pneumonia

OBJECTIVE

To evaluate bronchoalveolar lavage (BAL) cytology and organism burden in patients with Pneumocystis carinii pneumonia (PCP) who were infected with the human immunodeficiency virus (HIV) and in those with other immunodeficiencies.

STUDY DESIGN

BAL fluid samples from patients with PCP were selected (HIV-infected patients, n = 15; patients with other immunodeficiencies, n = 11). May-Grünwald-Giemsa-stained cytocentrifuge preparations were evaluated. Foamy alveolar casts (FACs) and P carinii clusters were counted.

RESULTS

The numbers of FACs and P carinii clusters in BAL fluid samples of HIV-infected patients were significantly higher as compared to those in samples from patients with other immunodeficiencies. Striking cytologic findings observed in half the samples from both patient groups included the presence of foamy alveolar macrophages, activated lymphocytes, plasma cells and reactive type II pneumocytes. Furthermore, a peculiar cell type, "nonidentified cell" (NIC), was observed almost exclusively in BAL fluid samples from HIV-infected patients.

CONCLUSION

BAL fluid samples from HIV-infected patients with PCP displayed higher organism burdens as compared to those from patients with other immunodeficiencies. Moreover, cytologic findings suggestive of noninfectious lung conditions were common in BAL fluid samples obtained from patients with PCP. Further study is required to elucidate the identity of the NIC cell type.

Correlation of leukocyte esterase detection by reagent strips and the presence of neutrophils: a study in BAL fluid

STUDY OBJECTIVE

In the present study, we evaluated the leukocyte esterase (LE) area of a reagent strip designed for urinalysis for the semiquantitative measurement of the percentage of polymorphonuclear neutrophils (PMNs) in BAL fluid.

DESIGN

Prospective. The relative PMN counts (obtained by conventional microscopy and expressed as a percentage of a 500 cell count) of consecutive BAL fluid samples were compared with the corresponding LE categories as read with a urine chemistry reader. LE categories were graded as follows: negative, trace, +, + +, and + + +.

RESULTS

A total of 153 BAL fluid samples were included. The mean PMN counts of the negative LE category (4.1 +/- 4.3%; n = 43) and the + + + category (81.8 +/- 16.3%; n = 37) differed significantly from each other and from the mean PMN counts of the other categories. Within the trace, +, and + + categories, a considerable overlap of PMN counts was noted. Assignment of a BAL fluid to the negative LE category consistently predicted a PMN count < 20%. At a threshold value of 50% PMNs, the + + + LE category predicted the BAL fluid samples to the correct group (PMNs > 50% vs < 50%) with a sensitivity of 70.8% and a specificity of 97.1%.

CONCLUSIONS

The reagent strips proved to be useful as a rapid test for semiquantitative measurement of the relative PMN counts in BAL fluid. However, the low predictive value for the exclusion of a high PMN count may limit their application.

Cytocentrifugation conditions affecting the differential cell count in bronchoalveolar lavage fluid

OBJECTIVE

To investigate variations in speed, duration and acceleration rate of the Cytospin 3 cytocentrifuge (Shandon Scientific Ltd., Astmoor, England) on the differential cell count of bronchoalveolar lavage (BAL) fluid samples.

STUDY DESIGN

BAL fluid samples (n = 51) were cytocentrifuged at various combinations of speed (500, 1,200 and 2,000 rpm), acceleration rate (low, medium and high) and duration (5, 10, 15 and 20 minutes). The preparations were May-Grünwald-Giemsa stained and differentiated on 500 cells. Data were analyzed by mixed model repeated measurements ANOVA.

RESULTS

The mean lymphocyte count was significantly higher at 1,200 rpm than at 500 rpm, whereas the macrophage count decreased. Between 1,200 and 2,000 rpm, the number of both cell types stabilized. Significantly higher numbers of lymphocytes were recorded at 10 and 15 minutes of cytocentrifugation than at 5 minutes. The acceleration rate did not influence the differential cell count. Seventeen BAL fluid samples were selected to test the diagnostic impact of cell damage using a validated computer program. In 1 of 17 samples the predicted diagnosis did not correspond between two different speeds (500 and 2,000 rpm).

CONCLUSION

Variations in cytocentrifugation speed and duration affected the mean lymphocyte and macrophage counts of BAL fluid samples.

Accuracy and precision of quantitative calibrated loops in transfer of bronchoalveolar lavage fluid

Quantitative cultures of bronchoalveolar lavage (BAL) fluid are important in the diagnosis of ventilator-associated pneumonia, and calibrated loops are commonly used to set up these cultures. In this study, the performances of calibrated 0.010- and 0.001-ml loops in the transfer of BAL fluid were determined. Five loops of one lot from seven manufacturers were tested. Calibrations were performed by the gravimetric method (0.010-ml loops) and the colorimetric method (0.001-ml loops). Most of the 0.010-ml loops displayed a precision that was less than 10%, but six of them showed very poor accuracies as they transferred a deficiency (nichrome loops) or an excess (disposable loops) of BAL fluid that exceeded +/-10%. The mean maximum and minimum BAL fluid volumes delivered by the 0.010-ml loops differed by a factor 3. The 0.001-ml loops displayed acceptable precision. Five of them showed inaccuracies of </=+/-10%, and mean maximum and minimum BAL fluid volumes had a range of a factor of 2. For all loops, the volumes of BAL fluid sampled were larger than the volumes of reagent-grade water sampled. Results of the colony counting experiments confirmed these findings and revealed a high intra-assay variability for the 0.001-ml loops. We conclude that, when BAL fluid samples are cultured with calibrated loops, (i) proper verification of the calibration of these loops is mandatory, (ii) calibrations should be performed with BAL fluid as the test solution, and (iii) borderline quantitative culture results should be interpreted with knowledge of the inaccuracy values of these loops.

The Streptococcus anginosus species comprises five 16S rRNA ribogroups with different phenotypic characteristics and clinical relevance

A collection of 267 consecutively isolated Streptococcus anginosus strains was screened for the prevalence of previously described 'motile' strains by hybridization with oligonucleotide probes in a reverse line blot assay. The motile strains represented 101 (37.8%) of the S. anginosus strains. The vast majority of these strains fermented mannitol and raffinose, whereas most other S. anginosus strains did not (P<0.001). Most (83/101) of the motile strains were recovered from the urogenital tract (including five strains from neonatal surveillance cultures) and only a minority (36) of them were associated with infection-related samples (P<0.001). Strains that hybridized with the same oligonucleotide probes as the type strain S. anginosus ATCC 33397T (= NCTC 10713T) were designated ATCC-like strains. They accounted for 74 (27.7%) of the strains examined, were commonly distributed among the different body parts and were significantly more associated with infection-related samples. Three other hybridization patterns were recognized in the reverse line blot assay, ribogroup I (n = 51), ribogroup II (n = 21) and ribogroup III (n = 19). Ribogroup II strains were significantly more frequently recovered from the abdominal cavity and were associated with infection-related samples. Ribogroup I included the majority of the S. anginosus strains that carried Lancefield group C. Comparison of the nearly complete 16S rRNA sequence of two representative strains of each ribogroup revealed that all five ribogroups were closely related (>97% sequence similarities), and that most sequence divergences between the ribogroups occurred in the 1024-1064 bp region of the 16S rRNA gene. The present data confirm the heterogeneity within the S. anginosus species.

Differential cell analysis of cytocentrifuged bronchoalveolar fluid samples affected by the area counted

OBJECTIVE

To investigate variations in the differential cell counts between the quadrants of cytocentrifuged bronchoalveolar lavage (BAL) fluid preparations and to evaluate the diagnostic impact of these differences in interstitial lung diseases (ILD).

STUDY DESIGN

BAL fluid samples obtained from 30 patients suspected of having ILD or pneumonia were cytocentrifuged and additionally stained with May-Grünwald-Giemsa stain. Two observers differentiated 200 cells in each quadrant as well as in a circular pattern around the center of the cytocentrifuge spot.

RESULTS

Lymphocytes and alveolar macrophages were not randomly distributed on the cytocentrifuge spot. Ten samples of patients with histologically confirmed ILD were selected to test the diagnostic impact using a validated computer program. The predicted diagnosis did not correspond to the histologic diagnosis for one quadrant from 1 of these 10 samples (sarcoidosis instead of idiopathic pulmonary fibrosis), whereas the differential cell counts performed around the center of the cytocentrifuge spot provided the correct diagnosis in all cases.

CONCLUSION

BAL fluid differential cell counts varied between the quadrants of the cytocentrifuge spot. The center of the cytocentrifuge spot appeared to be the most reliable area. Therefore, cell counting is recommended in a circular pattern around the center of the cytocentrifuge spot.

DNA-DNA reassociation studies of Streptococcus constellatus with unusual 16S rRNA sequences

DNA-DNA reassociation studies were performed on previously described 'CI strains', which form an unusual 16S rRNA population within the 'anginosus' group of Streptococcus. The CI strains displayed reassociation values of >70% with the Streptococcus constellatus NCDO 2226T strain, with Tm values <1 degrees C, indicating phylogenetic species identity.

Haemolytic activity of the Streptococcus milleri group' and relationship between haemolysis restricted to human red blood cells and pathogenicity in S. intermedius

A collection of 297 clinically documented 'Streptococcus milleri' strains, identified to the genotype level by 16S rRNA gene hydridisation, was screened for haemolysis of human and animal red blood cells. Forty-nine strains (65%) of the S. intermedius genotype displayed haemolysis restricted to human blood; they were named 'exclusive human haemolytic' (EHH) S. intermedius strains. The 26 remaining S. intermedius strains were named S. intermedius non-EHH strains. Quantitative studies on the haemolysis indicated that intermedilysin was the factor involved. The S. intermedius EHH strains represented the S. intermedius phenotype, whereas the S. intermedius non-EHH strains were phenotypically characteristic of S. constellatus. The complete 16S rRNA sequences of the S. intermedius EHH strains exhibited identity with S. intermedius strains ATCC 27335 (= NCDO 2227, NCTC 11324); the 16S rRNA sequences of the S. intermedius non-EHH strains were identical to S. constellatus strain ATCC 27823 (= NCDO 2226, NCTC 11325) except for positions 228 and 229 that carried an S. intermedius sequence signature. The 16S sequence similarities between the non-EHH strains and the S. constellatus and the S. intermedius type strains were 99.5% and 98.6%, respectively. Hybridisations of the complete 16S rRNA genes with oligonucleotide probes indicated a 16S rRNA homogeneity within the S. intermedius EHH and the non-EHH strains respectively. The S. intermedius EHH strains were isolated most frequently from infection- and abscess-related specimens. The present data emphasise the genetic variability within the S. constellatus species and redefine the S. intermedius species as a homogeneous group at the 16S rRNA level.

Diagnostic value of BAL fluid cellular profile and enzymes in infectious pulmonary disorders

Determination of the cellular profile of bronchoalveolar lavage fluid (BALF), lactate dehydrogenase (LDH) and alkaline phosphatase (ALP) appeared to be useful in monitoring pulmonary damage. The aim of this study was to investigate whether the cellular profile, LDH, its isoenzyme pattern and/or ALP in BALF are useful in the diagnostic work-up of patients with suspected pneumonia. The BALF specimens of 80 patients were studied. Group I consisted of patients with a pulmonary infection (n=33) and group II of patients without signs of a pulmonary infection (n=47). Differentiation between these two groups was based upon the results of microscopy and quantitative cultures. The absolute as well as relative numbers of polymorphonuclear neutrophils (PMNs) was significantly higher in group I compared to group II (p<0.0001). The absolute number of PMNs showed a sensitivity of predicting the correct group of 95.7% and a specificity of 84.8%. The LDH activity in BALF was significantly higher in group I than in group II (p<0.0001). The LDH4/LDH5 ratio in BALF was lower in group I compared to group II (p<0.0001) and appeared to be the best discriminator between the two groups with a sensitivity of 93.6% and a specificity of 93.9%. In conclusion, the number of polymorphonuclear neutrophils as well as the lactate dehydrogenase activity, particularly its isoenzymes, in bronchoalveolar lavage fluid appeared to be of potential practical value to distinguish between infectious and noninfectious pulmonary disorders.

Detection of non-infectious conditions mimicking pneumonia in the intensive care setting: usefulness of bronchoalveolar fluid cytology

The present study investigated the usefulness of bronchoalveolar (BAL) fluid cytology in the identification of non-infectious pulmonary conditions in patients hospitalized in the intensive care unit (ICU) and suspected of pneumonia. A total of 182 BAL fluid samples obtained during a 27-month period from 130 ICU patients with suspected pneumonia were quantitatively cultured and investigated for opportunistic pathogens. Cytocentrifuged preparations stained with the May-Grünwald Giemsa and Perls's methods were reviewed. A non-infectious aetiology was considered when cultures yielded micro-organisms in quantities < 10(3) colony-forming units (CFU) per ml, in the absence of any other pathogen and in conjunction with one or more of the following cytological findings: > 20% haemosiderin macrophages, > 10% lymphocytes, the presence of activated lymphocytes, plasma cells, > 5% eosinophils, a preponderance of foamy macrophages, reactive type II pneumocytes or malignant cells. Patients' clinical records were reviewed to identify a clinical diagnosis for these episodes. In thirty-five (19.2%) BAL fluid samples from 26 patients, the cytological findings pointed to a non-infectious origin. An alternative diagnosis was ascertained in 20 of 26 patients. Diagnoses included: drug-induced pneumonitis (n = 7), aspiration of gastric contents (n = 2), pulmonary emboli (n = 3), adult respiratory distress syndrome (n = 4), lung contusion (n = 1), cardiogenic pulmonary oedema (n = 1), and carcinomatous lymphangitis (n = 2). The BAL fluid cytological findings were readily discernable and proved to be useful in the diagnostic work-up of samples obtained from ICU patients with suspected pneumonia.

BAL fluid cytology in the assessment of infectious lung disease

The need for rapid laboratory results has marked the application of bronchoalveolar lavage (BAL) fluid cytology as a valuable tool in the assessment of infectious lung conditions. The techniques of BAL fluid processing presented here can be performed in a microbiological laboratory. The diagnostic value of BAL fluid cytology for the prediction of ventilator-associated pneumonia is discussed.

Does the cellular bronchoalveolar lavage fluid profile reflect the severity of sarcoidosis?

The aim of this study was to assess whether the cellular bronchoalveolar lavage fluid (BALF) profile, particularly the number of polymorphonuclear neutrophils (PMNs), is associated with disease severity of sarcoidosis and its usefulness in determining remission. Twenty-six nonsmoking outpatients with sarcoidosis were included in this study. The patients were divided into two subgroups according to the absolute number of PMNs in BALF: < or =0.2x10(4) cells x mL(-1) (group 1; n = 15) and >0.2x10(4) cells x mL(-1) (group 2; n = 11). The radiographic stage, high-resolution computed tomography (HRCT) findings, 67Ga lung uptake as well as lung function tests differed significantly between group 1 and 2. Follow-up revealed that 14 (93.3%) patients of group 1 compared to four (36.4%) of group 2 recovered spontaneously without the help of corticosteroids. In contrast, no differences were found in the number of lymphocytes in BALF nor in the serum angiotensin converting enzyme (sACE) level between both groups. The number of PMNs, the transfer factor of the lungs for carbon monoxide (TL,CO), the forced expiratory volume in one second (FEV1) and one of the HRCT subscores discriminated between patients with different disease progression. Of these parameters the PMNs appeared to be the only one which differentiated patients who demonstrated remission and those who deteriorated. In conclusion, these results indicate that the number of polymorphonuclear neutrophils in bronchoalveolar lavage fluid distinguish between sarcoidosis patients who demonstrated remission and those having a more severe course of the disease. Whether polymorphonuclear neutrophils may be considered as markers of disease activity and/or prognosis in sarcoidosis needs further investigation.

Relationship between enzymatic markers of pulmonary cell damage and cellular profile: a study in bronchoalveolar lavage fluid

It has been suggested that alterations in bronchoalveolar lavage fluid (BALF) reflect pathologic changes in the lung. Cytoplasmatic enzymes such as lactate dehydrogenase (LDH), alkaline phosphatase (ALP), and LDH isoenzymes are recognized indicators of cell damage or death. The aim of this study was to determine whether there is a relation between the enzyme activity and the cell types present in BALF. Therefore, BALF samples obtained from patients with various pulmonary disorders were studied. Out of these samples a group with mainly polymorphonuclear neutrophils (PMNs; n = 15; Group I) and another with mainly alveolar macrophages (AMs; n = 10; Group II) were selected. Additionally, the value of analysis of lysed cells in BALF for assessment of LDH-isoenzyme patterns was examined. The cell-free fraction of BALF of Group II showed lower LDH and ALP activity compared to Group I. The LDH-isoenzyme pattern also differed, with the LDH3/LDH5 ratios being lower in all BALF samples with predominantly PMNs than in BALF samples with predominantly AMs. Lysis of the cells present in the BALF samples by sonication prior to LDH-isoenzyme analysis provided no additional information beyond that found by analysis of the cell-free BALF. In conclusion, determination of enzyme activity appears to be useful in monitoring pulmonary inflammation.

A nucleotide-specific polymerase chain reaction assay to differentiate rabies virus biotypes in South Africa

Antigenic and nucleotide sequence analyses have shown that two distinct biotypes of rabies virus are circulating in South Africa. One of these typically infects members of the family Canidae, while the other comprises a heterogeneous group of apparently indigenous viruses, infecting members of the Viverridae family. In recent times, it has become evident that a considerable amount of cross-infection may occur and the manifestation of viverrid rabies in non-viverrid animals in particular appears to have become more commonplace. Consequently, the need to rapidly distinguish between rabies virus biotypes has become increasingly important in efforts to monitor the epidemiology of rabies in the southern African region. In this study, a nested polymerase chain reaction (PCR) assay was developed to distinguish between these two groups of rabies viruses. Consensus oligonucleotides were used to amplify the cytoplasmic domain of the rabies virus glycoprotein and the adjacent intergenic region. The resultant amplicon was subsequently used as template in second round heminested PCR in the presence of type-specific primers, thereby successfully generating amplicons of characteristic size for each biotype.

Pulmonary infiltration associated with myelodysplasia

Four case histories are reported in which the initial signs and symptoms were those of pulmonary infiltration and in which subsequently a diagnosis of myelodysplasia was made. The analysis of bronchoalveolar lavage fluid--demonstrating predominantly neutrophils and lymphocytes, and, occasionally blast cells as well as plasma cells--indicated that the pulmonary infiltration was related to the myelodysplastic process. As no other causes of pulmonary infiltration could be found, it seems that a pulmonary infiltrate can be the presenting symptom of a myelodysplastic syndrome. Although pleuropulmonary infiltrates most often are caused by infections, these cases illustrate that myelodysplasia related infiltrates should also be considered.

BAL fluid LDH activity and LDH isoenzyme pattern in lipoid pneumonia caused by an intravenous injection of lamp oil

A 30 year old man developed lipoid pneumonia after an injection of lamp oil. In addition to "foamy" alveolar macrophages, bronchoalveolar lavage (BAL) fluid analysis showed an increased number of neutrophils. Moreover, lactate dehydrogenase (LDH) and alkaline phosphatase activities were elevated. The increase seen in LDH activity both in serum and BAL fluid was accompanied by shifts in the isoenzyme pattern in similar directions for both fluids. These findings suggest a pulmonary source for the temporary serum as well as BAL fluid LDH increase. This case indicates the usefulness of bronchoalveolar lavage fluid analysis as a probe to detect pulmonary injury caused by a pneumotoxicant and, probably, to monitor recovery or deterioration.