Point of Care Ultrasound Identification and Aspiration of a Neck Lymph Node

The tissue diagnosis and staging of all types of lung cancer is foundational for prognosis and establishing the optimal treatment plan. In order to appropriately stage lung cancer, the highest stage should be established using the 8th edition TNM criteria, where tumor size (T), nodal involvement (N), and metastasis (M) are all taken into account. Establishing a tissue diagnosis may involve the use of CT guided biopsy, navigational bronchoscopy, endobronchial biopsy, EBUS, percutaneous lymph node biopsy and/or excisional biopsy of supraclavicular nodes. It is recommended to proceed with the method that is considered least invasive and provides the highest staging. We present a case of recurrent lung adenocarcinoma diagnosed with real time ultrasound-guided fine needle aspiration of a neck lymph node.

Testing Patterns and Disparities for Alpha-1 Antitrypsin Deficiency

BACKGROUND

Alpha-1 antitrypsin deficiency is an under-recognized genetic cause of chronic lung and liver disease; it remains unclear what the testing frequency and disparities are for alpha-1 antitrypsin deficiency.

METHODS

This is a retrospective cohort study of people with newly diagnosed chronic obstructive pulmonary disease and liver disease identified at the University of Florida between January 1, 2012 and December 31, 2021. We performed incidence and prevalence analysis for alpha-1 antitrypsin (AAT) testing and point-biserial correlation analysis for tobacco use and AAT testing. We evaluated characteristics with AAT testing using adjusted multivariable logistic regression.

RESULTS

Among 75,810 subjects with newly diagnosed chronic obstructive pulmonary disease and liver disease between 2012 and 2021, 4248 (5.6%) were tested for AAT deficiency. All subjects had an AAT level performed, while 1654 (39%) had phenotype testing. Annual incidence of testing increased for subjects with newly diagnosed chronic obstructive pulmonary disease or liver disease from 2.8% and 5.4%, respectively, in 2012 to 4.1% and 11.3%, respectively, in 2021. Adjusted multivariable regression analysis showed factors favoring AAT testing were White race, and concomitant chronic obstructive pulmonary disease and liver disease. Increasing age, non-White race, current tobacco use, and being a male with chronic obstructive pulmonary disease had lower odds of AAT testing.

CONCLUSION

Although slowly improving, testing for AAT deficiency continues to have a low uptake in the clinical setting despite guidelines recommending broader testing. Individuals of White race and those with concomitant chronic obstructive pulmonary disease and liver disease are more likely to be tested, while older subjects, individuals of non-White race, current tobacco use, and men with chronic obstructive pulmonary disease are less favored to be tested.

Impact of a Computerized Clinical Decision Support System to Improve Chronic Obstructive Pulmonary Disease Diagnosis and Testing for Alpha-1 Antitrypsin Deficiency

Rationale: Chronic obstructive pulmonary disease (COPD) and alpha-1 antitrypsin deficiency (AATD) are underrecognized diseases. This is in part due to the underdiagnosis and lack of confirmation of COPD but also from poor adherence to AATD screening recommendations. Objectives: A clinical decision support system (CDSS) to guide primary care providers improves spirometry testing and confirmation of COPD diagnosis in subjects at risk and improves AATD screening in patients with confirmed COPD. Methods: A CDSS was created to be applied to all Veterans attending single-center Veterans Affairs primary care clinics. The CDSS had an algorithmic dialogue with components executed in phases during different clinic visits: screening for COPD risk using the COPD population screening (COPD-PS) questionnaire, spirometry recommendation, and ordering tool for subjects with a prior diagnosis of COPD or subjects considered high risk by the COPD-PS, dialogue to confirm or discard the diagnosis of COPD, and recommendations for AATD screening in subjects with confirmed COPD. The latter was performed by ordering alpha-1 antitrypsin (AAT) serum levels. Each step of the CDSS algorithm approach was recorded and available to be retrieved at a later date for analysis. Results: Over 6 years, a total of 6,235 Veterans >40 years of age completed the CDSS. According to the COPD-PS questionnaire, 962 (18.5%) subjects were identified as high risk for COPD. An additional 579 subjects with a prior diagnosis of COPD also entered the subsequent steps of the CDSS algorithm. Of the high-risk cohort, the CDSS led to an increase in spirometry testing from 24% to 83% and led to a new diagnosis of COPD in 342 (43%). In the prior COPD diagnosis group, spirometry testing increased from 58% to 84%, leading to COPD reconfirmation in only 326 (67%). A total of 489 (68%) subjects with confirmed COPD completed AAT testing prompted by the CDSS, with 23 subjects identified with AATD and one with severe AATD. Conclusions: In the Veterans Affairs system, the use of a clinical decision support system algorithm that incorporates screening for COPD and AATD improves COPD over- and underdiagnosis and screening rates of AATD in a primary care setting.

Augmentation Therapy Modulates Systemic Inflammation in Individuals with Alpha-1 Antitrypsin Deficiency and Chronic Obstructive Pulmonary Disease

Background

Alpha-1 antitrypsin (AAT) deficiency is a genetic disorder that leads to chronic obstructive pulmonary disease (COPD) and lower circulating levels of AAT, which is a protease inhibitor with potent anti-inflammatory effects. In order to better understand the presence of systemic inflammation in AAT-deficient individuals with COPD, we investigatedthe plasma levels of C-reactive protein (CRP).

Methods

AAT-deficient individuals and a matched cohort with a normal AAT genotype were recruited from the Alpha-1 Foundation DNA and Tissue Bank. AAT genotypes were determined by a combination of a Taqman-based assay. AAT and CRP levels were determined by nephelometry. Comparisons were determined by unpaired t-test and standard Pearson's correlation.

Results

Our study included 40 control participants and 742 AAT-deficient participants, of which 498 received augmentation therapy. In the AAT-deficient participants, the plasma AAT was 20.2±11.6µM and 4.5±1.3µM (P<0.0001) with and without augmentation therapy, respectively, and the CRP was 0.32±0.53mg/dL and 0.69±1.97mg/dL (P=0.0169), respectively. There was a negative correlation between the percentage predicted of forced expiratory volume in 1 second and CRP in the group not receiving augmentation therapy (r=-0.2528, P<0.05), and there was no correlation in participants receiving augmentation therapy.

Conclusion

Compared to healthy individuals, AAT-deficient individuals with COPD have higher levels of circulating CRP, suggesting increased systemic inflammation. However, AAT-deficient individuals receiving augmentation therapy had lower plasma CRP levels compared to those who are not.

Outcomes and Survival Following Lung Transplantation in Non-Cystic Fibrosis Bronchiectasis

Disease-specific outcomes in patients with non-cystic fibrosis bronchiectasis following lung transplantation are not well described.

We performed a retrospective analysis to describe outcomes in these patients. Patients with non-cystic fibrosis bronchiectasis who have undergone lung transplantation in the USA were identified using the Organ Procurement and Transplant Network database. Survival data were analysed for the post-lung allocation score period with Kaplan–Meier curves, and a log-rank test was conducted to compare survival data among an age-, sex- and activation date-matched non-cystic fibrosis bronchiectasis cohort.

721 patients with non-cystic fibrosis bronchiectasis were listed for lung transplantation between March 1992 and September 2019. 407 patients received lung transplantation with a median age at listing of 47 years. The Kaplan–Meier survival analysis for lung transplantation recipient non-cystic fibrosis bronchiectasis patients during the post-lung allocation score period at 1, 5 and 10 years was 87%, 53% and 16%, respectively. The median survival time post-lung transplantation is 6.0 years (interquartile range: 2.3–11.9 years), which is similar to an age- and sex-matched cohort (p=0.86).

This retrospective analysis demonstrates that median survival after lung transplantation in non-cystic fibrosis bronchiectasis was similar to other lung transplantation recipients over the study period. We suggest that the development of specific criteria for lung transplantation in non-cystic fibrosis bronchiectasis may improve patient selection and benefit a larger group of patients with this therapy.

A retrospective analysis using UNOS data showed that median survival post-LT for patients with non-CF bronchiectasis is 6.0 years, which is similar to an age- and sex-matched cohorthttps://bit.ly/3eSv95p

Clinical outcomes and survival following lung transplantation in patients with Alpha-1 antitrypsin deficiency

OBJECTIVE

The primary intention of our study is to describe disease-specific outcomes in patients with alpha-1 antitrypsin deficiency (AATD) following lung transplantation (LT).

METHODS

We reviewed the Organ Procurement and Transplant Network database to identify AATD patients who have undergone LT in the United States.

RESULTS

Two thousand two hundred and thirteen patients with AATD underwent LT between March 1992 and September 2019. A total of 1556 patients received LT with a median age at listing was 51 years. The median time spent on the LT waitlist was 263 days. The median ischemic time was 4.75 h. The Kaplan-Meier survival analysis following LT for AATD patients at 1-, 5-, and 10 years was 82%, 56%, and 34%, at 1-, 5-, and 10 years, respectively. The median survival time post-LT is 6.4 years (Interquartile range 5.6-6.8 years). The post-LT survival was significantly better in double LT compared to single LT (Median 7.7 vs 4.4 years, p < 0.001). Increasing age, presence of CMV mismatch, reintubation prior to discharge, and requiring treatment for rejection within one year of transplantation did impact post-LT mortality.

CONCLUSION

The median survival after LT in AATD is 6.4 years and is similar to other lung diseases. When compared to usual COPD LT, AATD patients have increased post-LT mortality due to infections and liver disease. Recipients of a double lung transplant had a favorable outcome compared to single lung transplant.

Smoking-related diffuse cystic lung disease

Smoking tobacco is associated with an array of pulmonary symptoms and diseases. We describe a case of a woman with a spontaneous pneumothorax and diffuse cystic lung disease due to smoking. The presence of diffuse cystic changes in a woman is suggestive of lymphangioleiomyomatosis (LAM); however, her vascular endothelial growth factor-D was normal and surgical lung biopsy and pathology had notable absence of LAM cells and presence of intra-alveolar pigment laden macrophages and intraluminal mucostasis. Smoking-related diffuse cystic lung disease can mimic LAM and is a novel entity with only four other cases reported.

Abstract P5-09-06: Underdiagnosis of HBOC in breast cancer patients: Are genetic testing guidelines a tool or an obstacle?

Background: Pathogenic genetic variants are estimated to occur in 10-15% of all breast cancer patients, with BRCA 1/2 accounting for 40-50% of pathogenic/likely pathogenic (P/LP) variants. However, it is estimated that &lt;30% of breast cancer patients harboring a BRCA 1/2 variant have been identified, with the percentage being much less for ˜20 other breast cancer associated genes. Reasons for this are multifactorial and include complicated and restrictive testing guidelines developed at a time when the cost of testing was high and guidelines for management were limited. Today, cost has plummeted and there are definitive management guidelines for a broader range of genes. We created a community based Registry to determine the incidence of P/LP variants in breast cancer patients who meet and who do not meet the NCCN 2017 genetic testing criteria.

Methods: An IRB-approved multicenter prospective registry was initiated with 20 community and academic sites experienced incancer genetic testing and counseling.

Eligibility criteria included patients with a breast cancer diagnosis who had not been previously tested. Consecutive patients aged 18-90 were consented and underwent an 80 gene panel test (Invitae –Multi-Cancer Panel). The non-inferiority study was powered to detect a difference in P/LP variant rate of 4 percentage points with statistical significance (p&lt;0.05, Fisher's exact test).

HIPAA compliant electronic case report forms collected information on patient diagnosis, test results, and physician recommendations made after test results were received.

Results: Over 1000 patients were enrolled and data from 910 subjects analyzed to date. 50.4% met NCCN criteria and 49.5% did not. Median age for the enrolled patients is 60.5 and ranged from 22-93. 56.0% of patients were recently diagnosed with breast cancer. 10.9% of patients had a history of a prior non breast cancer. Overall, 8.9% of patients had a pathogenicvariant. 9.6% of patients who met NCCN criteria with test results had a P/LP variant. 8.2% of patients who did not meet criteria had a P/LP variant. The difference of positive cases among the two groups is not statistically significant (P = 0.49)

4.9% of patients had pathogenic variants if only an 11 gene standard breast cancer panel was considered.

The spectrum of mutated genes varied between the two groups, with some overlap.

Conclusions:

There was no statistically significant difference in the number of pathogenic/likely pathogenic variants between those patients who met and those who did not meet NCCN guidelines. Expanded panel testing yields more medically actionable P/LP variants than testing BRCA 1/2 alone or breast cancer panels with 11 genes. This study demonstrates that there will be a significant number of patients with P/LP variants are missed if NCCN guidelines are required for genetic testing. Current NCCN guidelines for the genetic testing of breast cancer patients are an obstacle to identifying patients with P/LP variants and should be removed.

Universal BC Genetic Testing RegistryNCCN Criteria (910 patients analyzed)#/% who have P/LP variants#/% who do not have P/LP variantsPatients who meet guidelines44/459 (9.6%)415/459 (90.4%)Patients who do not meet guidelines37/451 (8.2%)414/451 (91.8%)

Citation Format: Beitsch P, Whitworth P, Baron P, Rosen B, Compagnoni G, Simmons R, Smith LA, Holmes D, Brown E, Gold L, Clark P, Coomer C, Grady I, Barbosa K, Riley L, Kinney M, Lyons S, MacDonald H, Kahn S, Ruiz A, Patel R, Curcio L, Esplin E, Yang S. Underdiagnosis of HBOC in breast cancer patients: Are genetic testing guidelines a tool or an obstacle? [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-09-06.

Abstract P5-09-03: Expanded panel testing superior to BRCA1/2 and breast cancer panel in patients with breast cancer

Background: The testing of hereditary breast and ovarian cancer (HBOC) patients for BRCA1/2 only was established years ago to identify patients with clinically actionable variants and limit the economic burden. However, the cost of genetic testing has plummeted, and the number of breast cancer-risk genes with management guidelines has expanded. We created a community-based registry to test all breast cancer patients. A primary objective of this registry included accruing and comparing patients who did and did not meet NCCN guidelines and determining if providing all breast cancer patients with comprehensive multi-gene panel testing yields additional clinical value than testing BRCA1/2 alone.

Methods: An IRB-approved multicenter prospective registry was initiated with 20 community-based and academic breast sites, selected to insure geographic and ethnic diversity. Consecutive patients ages 18-90 with current or prior breast cancer were offered testing with an 80-gene panel (Invitae, San Francisco, CA). HIPAA-compliant case report forms collected patient diagnosis, test results, and physician recommendations made after test results.

Results: Over 1,000 patients were enrolled and data on 911 have been analyzed to date. Median age of patients is 60.5 (range 22 to 93). 56.0% were recently diagnosed with breast cancer. Of these patients, 50.54% met NCCN criteria, and 49.5% did not. 10.9% had history of a prior non-breast cancer. The pathogenic/likely pathogenic (P/LP) variant rate for patients on a comprehensive 80-gene panel was 8.9%. When restricted to a guidelines-based 11-gene breast cancer panel (BRCA1/2, ATM, CDH1, CHEK2, NBN, NF1, PTEN, STK11, TP53, PALB2), 4.9% had P/LP variants; when limited to BRCA1/2, 1.6% had P/LP variants. Of all patients with P/LP findings, 93% had variants in cancer-risk genes with established management recommendations (Table 1) and 80% had germline variants conferring eligibility for precision medicine-based cancer treatments, such as PARP inhibitors, through actively enrolling clinical trials.

Conclusions: This study demonstrates that comprehensive panel testing of breast cancer patients provides a higher yield of clinically actionable P/LP variants than BRCA1/2 testing alone. Limited panels may miss clinically relevant P/LP variants, leaving risk for preventable cancers undiscovered and unnecessarily restricting patients' treatment options. These results also suggest that variants in tumor suppressor genes, not previously thought related to breast cancer, may contribute to its etiology. A comprehensive panel strategy reveals untapped clinical utility and can impact breast cancer patient care by informing implementation of precision medicine treatment interventions and guiding long-term medical management and surveillance for patients and their family members.

 PatientsVariantsWith breast cancer management guidelines (including variants ATM*, BRCA1*, BRCA2*, CHEK2*, NBN*, NF1, PALB2*, TP53*)45 (56%)46 (55%)With cancer guidelines and clinical management implications (including variants BARD1*, FH, MITF, MSH6*, MUTYH*, PTCH1, RAD50*, RAD51C*, RAD51D*, RB1, RET, VHL)31 (38%)33 (39%)Evidence of actionability accruing (including variants BLM, DIS3L2, RECQL4)5 (6%)5 (6%)Totals8184*P/LP variants in these genes confer potential clinical trial eligibility, e.g. NCT02401347.

Citation Format: Beitsch P, Whitworth P, Baron P, Rosen B, Compagnoni G, Simmons R, Smith LA, Holmes D, Brown E, Gold L, Clark P, Coomer C, Grady I, Barbosa K, Riley L, Kinney M, Lyons S, MacDonald H, Kahn S, Ruiz A, Patel R, Curcio L, Esplin E, Yang S, Michalski S. Expanded panel testing superior to BRCA1/2 and breast cancer panel in patients with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-09-03.

Primary antiphospholipid syndrome associated Liebman-Sachs endocarditis leading to diffuse alveolar hemorrhage: A case report

A 26 year old female presented for recurrent blood tinged sputum during the previous year with development of frank hemoptysis three days prior to admission. Diffuse alveolar hemorrhage (DAH) was confirmed with serial lavages. The patient had no history of autoimmune disease, vascular thrombosis or pregnancy morbidity including miscarriages or pre-eclampsia. High dose steroids were initiated along with noninvasive ventilatory support. Transthoracic echocardiogram showed severe mitral regurgitation and a vegetation on the mitral valve; transesophageal echocardiogram determined the lesion highly suggestive of Libman-Sachs endocarditis. Blood cultures were negative. Immunological evaluation established the patient was negative for: anti-nuclear antibody, anti-double-stranded DNA antibody, rheumatoid factor, anti-smith antibody, anti-cyclic citrullinated peptide, anti-neutrophil cytoplasmic antibodies, anti-glomerular basement membrane antibodies. Further evaluation revealed elevated levels of anticardiolipin immunoglobulin G and anti-beta 2 glycoprotein immunoglobulin G which continued to increase for months after hospitalization. She was diagnosed with DAH secondary to acute mitral regurgitation caused by Libman-Sachs endocarditis in the presence of primary antiphospholipid antibody syndrome.

DAH is an important disease to understand given its high mortality rate. Few case reports relating the presence of Libman-Sachs endocarditis induced by antiphospholipid antibody syndrome leading to DAH have been published. Unique here is the absence of rheumatologic markers thus supporting a diagnosis of primary antiphospholipid antibody syndrome (APS). This patient had no findings associated with rheumatological disorders potentially making this diagnosis easily overlooked. This case further illustrates the importance of evaluating patients with APS presenting with DAH as there are multiple etiologies that lead to this pathology thus different treatment avenues are to be considered during management.

Pulmonary Lymphangitic Carcinomatosis From Renal Cell Carcinoma

Lymphangitic carcinomatosis, the presence of tumor within the pulmonary lymphatics, occurs in the setting of malignant tumors and is associated with a poor prognosis. Here we describe a case of lymphangitic carcinomatosis in the setting of renal cell carcinoma and review the radiological manifestations of this disease.

Prevalence of cervical cancer and associated mortality in Grenada, 2000-2010

Objective To assess cervical cancer prevalence and associated mortality in Grenada, West Indies during 2000-2010. Methods Records of visits to hospital and clinical facilities were obtained from the histopathology laboratory of the Grenada General Hospital. Records were de-identified and electronically compiled. Cervical cancer prevalence was assessed via cross-sectional analysis of this secondary data. Of a total 12 012 records, 2 527 were selected for analysis using sampling without replacement. Cases were matched to corresponding patient data from death registries, where possible, and used to calculate associated mortality rates. Results The observed prevalence of cervical cancer was 52.4 per 100 000 women (ages 15 and above). The highest rates of cervical cancer occurred in the 35-44 age group, with the second highest among 45-64-year-olds. A total of 65 deaths were attributable to cervical cancer during 2000-2010, more than 50% of which were among women > 65 years old. The observed mortality rate was 16.7 per 100 000, almost twice the rate estimated by WHO for the region. Conclusions This study demonstrates the need for a comprehensive cervical cancer-screening program in Grenada. Results should contribute to informing future studies on how to appropriately generate and execute public health policy for education, screening, prevention, and control of cervical cancer in Grenada.

Abstract P2-06-04: Impact of genomic testing on chemotherapy utilization

Genomic testing for breast cancer has become a common practice. The two main tests at our institution are Oncotype DX® and MammaPrint®. Each test has unique features and criteria. We sought to compare the practice pattern between these tests and compare them to patients who did not undergo any genomic testing.

Methods: This is a retrospective review of all breast cancer patients between May 2008 and August 2011. Data was primarily thorough our tumor registry database. In some cases individual charts were also reviewed. Results: We analyzed 1093 breast cancers in 1064 patients. The average age was 62. The stage at diagnosis was 19% DCIS, 41% stage I, 24% stage II, 11% stage III and 5% stage IV. Of the 1093 cancers, 70 (6%) had an Oncotype test performed, 180 (16%) had a MammaPrint test done, 4 (0.4%) had both test, and 839 (77%) had no genomic test performed. Patients with an Oncotype test were more likely to be stage I than those with a MammaPrint (66% vs 48%). Additionally, patients who had a MammaPrint test more often received chemotherapy when compared to either the Oncotype test or no genomic testing.

Rotary ultrasonic machining of CFRP composites: a study on power consumption

Carbon fiber reinforced plastic (CFRP) composites are very difficult to machine. A large number of holes need to be drilled in CFRP for many applications. Therefore, it is important to develop cost-effective drilling processes. CFRP has been drilled by rotary ultrasonic machining (RUM) successfully. The literature has reports about the effects of input variables on output variables (including cutting force, torque, surface roughness, tool wear, and workpiece delamination) in RUM of CFRP. However, there are no reports on power consumption in RUM of CFRP. This paper reports the first study on power consumption in RUM of CFRP. It reports an experimental investigation on effects of input variables (ultrasonic power, tool rotation speed, feedrate, and type of CFRP) on power consumption of each component (including ultrasonic power supply, spindle motor, coolant pump, and air compressor) and the entire RUM system.

Protective factors relating to decreased risks of adolescent suicidal behaviour

BACKGROUND

Suicide has been identified as one of the three leading causes of death in adolescents and young adults. No previous study in China has tested the association between protective factors and urban adolescents' suicidal behaviours. In this study we tested the hypothesis that suicidal behaviours would be associated with multiple protective factors.

METHODS

A stratified random of 9015 students from 100 junior middle schools in Beijing, Hangzhou, Wuhan and Urumqi completed the Chinese version of Global School-Based Student Health Survey.

RESULTS

Overall, 17.4% of students had seriously considered attempting suicide, and 8.1% had made a specific plan to attempt suicide during the 12 months preceding the survey. The students in Wuhan (18.7%) and Urumqi (20.8%) cities were significantly more likely than students in Beijing (14.4%) and Hangzhou (14.4%) to have suicidal ideation (chi2 = 45.9, P < 0.001). Female students were significantly more likely than male students to have suicidal ideation and have made suicide attempts [odds ratio (OR) = 1.4, P < 0.001]. Results indicated that the rates of suicidal ideation and suicide attempts increased with age (OR = 1.44, P < 0.001). Multivariate logistic regression models showed that suicide risk tended to decrease significantly when 'days of missed classes or school without permission were less than one', and when students thought students in their school were kind and helpful most of the time or always', 'parents or guardians checked to see if homework was done most of the time or always', 'parents or guardians understood their problems and worries most of the time or always' and 'parents or guardians really know what they are doing with their free time most of the time or always'.

CONCLUSIONS

Adolescent suicide behaviour should be a serious problem. Measures can be taken to prevent suicide by observing the factors significantly linked to suicidal behaviour. Steps can then be taken to identify adolescents who have serious suicidal ideation so that intervention can be taken to reduce the suicidal rate.

Antimicrobial resistance of Escherichia coli strains causing community-acquired urinary tract infections among insured and uninsured populations in a large urban center

We assessed the susceptibility of Escherichia coli strains causing communityacquired urinary tract infection (UTI) in a large urban center in Brazil, comparing two different populations (patients with health insurance vs. uninsured). 581 nonduplicate strains of E. coli were isolated. The prevalence of antimicrobial resistance was greater than 20% for ampicillin (51%), trimethoprim-sulfamethoxazole (43%), tetracycline (41%) and chloramphenicol (22%). Overall, 12% of the E. coli isolates were resistant to ciprofloxacin. Resistance prevalences to most antimicrobials were similar in the two study populations. Our data provide much needed information on the prevalence of antimicrobial resistance among E. coli causing communityacquired UTI in Brazil. Antimicrobial resistance among strains of E. coli causing community-acquired UTIs was relatively high, particularly resistance to ciprofloxacin.

Prevalence of vaginal colonization by drug-resistant Candida species in college-age women with previous exposure to over-the-counter azole antifungals

We enrolled 382 college-age women in a cross-sectional survey to investigate the relationship between use of over-the-counter (OTC) azole-based antifungal drugs and vaginal colonization by drug-resistant Candida. This study showed no correlation (P=.506) between previous OTC exposure and colonization of drug-resistant Candida in vaginal flora. However, a small number of resistant Candida species isolates were obtained from women with a history of multiple exposures to OTC antifungals; given the widespread use of these products, this may be an emerging concern.

Variation in water relations characteristics of terminal shoots of Port-Orford-cedar (Chamaecyparis lawsoniana) seedlings

We measured water relations attributes of the terminal shoots of 3-year-old Port-Orford-cedar (Chamaecyparis lawsoniana (A. Murr.) Parl.) seedlings that represented its geographic range. Pressure-volume curves were developed and osmotic potentials at full (psi(sf)) and zero turgor (psi(sz)), relative water content at zero turgor, and an index of tissue elasticity (IE) were calculated for 38 families during early, mid- and late summer at an inland nursery, and for 12 of these families during mid- and late summer at a coastal nursery. Compared with other conifer species, psi(sz) was high (-1.4 to -1.5 MPa) and declined in seedlings at both nurseries as the season progressed. Both IE and osmotic amplitude (psi(sf)-psi(sz)) increased during the season. Osmotic potential at zero turgor was lower and osmotic amplitude greater in seedlings at the inland nursery than at the coastal nursery. Correlations of water relations attributes with geographic location of the seed sources were weak and usually not significant. High elevation southern sources exhibited smaller differences in psi(sz) between nurseries than low elevation northern sources. The small differences in water relations attributes among sources and between nurseries suggest that some may be of marginal physiological importance; however, sources that produced larger seedlings appeared to be less desiccation tolerant. We conclude that, when moving genotypes during reforestation, decisions based on patterns in tree size and timing of growth will account for these small differences in water relations.

Molecular epidemiology: focus on infection

Molecular biology techniques have become increasingly integrated into the practice of infectious disease epidemiology. The term "molecular epidemiology" routinely appears in the titles of articles that use molecular strain-typing ("fingerprinting") techniques-regardless of whether there is any epidemiologic application. What distinguishes molecular epidemiology is both the "molecular," the use of the techniques of molecular biology, and the "epidemiology," the study of the distribution and determinants of disease occurrence in human populations. The authors review various definitions of molecular epidemiology. They then comment on the range of molecular techniques available and present some examples of the benefits and challenges of applying these techniques to infectious agents and their affected host using tuberculosis and urinary tract infection as examples. They close with some thoughts about training future epidemiologists to best take advantage of the new opportunities that arise from integrating epidemiologic methods with modern molecular biology.

Long-term outcomes of stereotactic breast biopsies

Stereotactic core needle biopsies (SCNBs) are accurate and relatively convenient for the patient; however, the long-term follow-up of benign results has not been reported. All patients between 1993 and 1998 undergoing SCNB at a community-based hospital were entered into a registry. Follow-up was obtained by a retrospective analysis of the charts. Biopsies were performed on 865 lesions. One hundred thirty-one (15%) were malignant, 42 (5%) were suspicious for malignancy, 687 (79%) were benign, and five (1%) were lobular carcinoma in situ. Of the 42 patients with suspicious findings 38 underwent biopsy. Ten were malignant and 28 benign. Of the 687 patients with benign pathology, 377 had follow-up available with a mean length of 1.7 years. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of SCNB for benign lesions in our study are all 100 per cent. Eight lesions were worrisome and await final analysis. Of 687 patients with benign lesions 310 were lost to follow-up. This study suggests that patients with a benign diagnosis should be returned to routine mammography. These data also extend the reported follow-up to 1.7 years and establish an acceptable level of accuracy for SCNB. The lost patients remind us that follow-up is essential despite a benign diagnosis.

Cross-sensitivity reaction between tacrolimus and macrolide antibiotics

A patient with an allergy to a macrolide antibiotic was given tacrolimus and developed a sudden cutaneous reaction.

A parallel intraphagosomal survival strategy shared by mycobacterium tuberculosis and Salmonella enterica

Mycobacterium tuberculosis and Salmonella enterica cause very different diseases and are only distantly related. However, growth within macrophages is crucial for virulence in both of these intracellular pathogens. Here, we demonstrate that in spite of the phylogenetic distance, M. tuberculosis and Salmonella employ a parallel survival strategy for growth within macrophage phagosomes. Previous studies established that the Salmonella mgtC gene is required for growth within macrophages and for virulence in vivo. M. tuberculosis contains an open reading frame exhibiting 38% amino acid identity with the Salmonella MgtC protein. Upon inactivation of mgtC, the resulting M. tuberculosis mutant was attenuated for virulence in cultured human macrophages and impaired for growth in the lungs and spleens of mice. Replication of the mgtC mutant was inhibited in vitro by a combination of low magnesium and mildly acidic pH suggesting that the M. tuberculosis-containing phagosome has these characteristics. The similar phenotypes displayed by the mgtC mutants of M. tuberculosis and Salmonella suggest that the ability to acquire magnesium is essential for virulence in intracellular pathogens that proliferate within macrophage phagosomes.

Tobacco use by youth: a surveillance report from the Global Youth Tobacco Survey project

The Global Youth Tobacco Survey (GYTS) project was developed by the World Health Organization and the US Centers for Disease Control and Prevention to track tobacco use among youth in countries across the world, using a common methodology and core questionnaire. The GYTS is school based and employs a two-stage sample design to produce representative data on smoking among students aged 13-15 years. The first stage consists of a probabilistic selection of schools, and the second consists of a random selection of classes from the participating schools. All students in the selected classes are eligible for the survey. In 1999, the GYTS was conducted in 13 countries and is currently in progress in over 30 countries. This report describes data from 12 countries: Barbados, China, Costa Rica, Fiji, Jordan, Poland, the Russian Federation (Moscow), South Africa, Sri Lanka, Ukraine (Kiev), Venezuela, and Zimbabwe. The findings show that tobacco use in the surveyed age group ranged from a high of 33% to a low of 10%. While the majority of current smokers wanted to stop smoking, very few were able to attend a cessation programme. In most countries the majority of young people reported seeing advertisements for cigarettes in media outlets, but anti-tobacco advertising was rare. The majority of young people reported being taught in school about the dangers of smoking. Environmental tobacco smoke exposure was very high in all countries. These results show that the GYTS surveillance system is enhancing the capacity of countries to design, implement, and evaluate tobacco prevention and control programmes.

noxR3, a novel gene from Mycobacterium tuberculosis, protects Salmonella typhimurium from nitrosative and oxidative stress

Reactive oxygen intermediates (ROI) and reactive nitrogen intermediates (RNI) produced by activated macrophages participate in host defense against the facultative intracellular pathogens Mycobacterium tuberculosis and Salmonella typhimurium. To survive within macrophages, such pathogens may have evolved ROI and RNI resistance mechanisms. ROI resistance pathways have been intensively studied. Much less is known about the mechanisms of resistance to RNI. To identify possible RNI resistance genes in M. tuberculosis, a mycobacterial library was expressed in S. typhimurium and subjected to selection by exposure to the NO donor S-nitrosoglutathione (GSNO) in concentrations sufficient to kill the vast majority of nontransformed salmonellae. Among the rare surviving recombinants was a clone expressing noxR3, a novel and previously anonymous M. tuberculosis gene predicted to encode a small, basic protein. Expression of noxR3 protected S. typhimurium not only from GSNO and acidified nitrite but also from H2O2. noxR3 is the third gene cloned from M. tuberculosis that has been shown to protect heterologous cells from both RNI and ROI. This suggests diversity in the repertoire of mechanisms that help pathogens resist the oxidative and nitrosative defenses of the host.

Clinical presentation of tuberculosis in culture-positive children. Pediatric Tuberculosis Consortium

BACKGROUND

Because tuberculosis (TB) in children implies recent infection, children serve as sentinels for disease transmission within a community. Despite the significance of diagnosing tuberculosis in children, most cases are diagnosed on clinical evidence rather than laboratory findings.

METHODS

We analyzed the demographic and clinical presentation of 156 children with culture proven tuberculosis using Epi-Info Version 6.

RESULTS

Although the clinical characteristics of this population were generally consistent with those seen in previous studies, several unexpected results were observed. Boys were overrepresented in the group of very young children (72% < 1 year). Many of the children had coexisting diseases not known to predispose to TB (37%). Cavitation, usually observed in older children, was seen in four children < or = 1 year of age. Few children were homeless or HIV-infected, but many (42%) lived in female-headed households. Of the adult contacts at risk for TB, many (49%) were recent immigrants to the US. Overall 34% of the population was either foreign born or the children of recent immigrants.

CONCLUSIONS

This series of 156 culture-positive children provides an understanding of the risk factors and clinical presentation of pediatric tuberculosis. The data emphasize the impact of the child's environment on the risk for tuberculosis.