Assessment of scoring systems to describe the position of tracheostomy tubes within the airway - the lunar study

BACKGROUND

Malposition of tracheostomy tubes is difficult to detect at the bedside and may contribute to eventual device misplacement. Endoscopic examination can be undertaken via tracheoscopic (T-view) or trans-laryngeal (L-view) approach, offering more precise detail regarding positioning within the airway. The aims of this study were to evaluate inter-rater agreement between bespoke T and L view scoring systems and subsequently whether T-views could predict L-views.

METHODS

Adult intensive care unit patients with percutaneous or surgical tracheostomies were included and paired T and L-views of their tracheostomy tube within the airway were taken on up to four occasions. Images were later scored by five independent raters using bespoke scoring systems. The primary outcome was to determine the T and L view scoring system with the best inter-rater agreement, defined by weighted kappa and intra-class correlation coefficients. The secondary outcome was to assess agreement between T and L-view scoring systems.

RESULTS

Seventy-one T-views and 43 L-views were obtained from a total of 20 patients. Images were scored by five raters, resulting in 355 T-view scores, 215 L-view scores and 215 paired T and L-view scores for comparison. There was good inter-rater agreement (highest T-view k = 0.84, L-view k = 0.72). There was poor agreement between T and L-view scores for each of the paired images (highest k = 0.25) although extreme-to-extreme misclassification rates remained acceptable.

CONCLUSIONS

Whilst our data demonstrated good inter-rater agreement between scoring systems, it is not possible to reliably predict the T-view orientation and position of a tracheostomy tube within the airway from the paired L-view.

CLINICAL TRIAL REGISTRATION

NCT01356719.

Parents with mental illness - a qualitative study of identities and experiences with support services

WHAT IS KNOWN ON THE SUBJECT?: According to estimates more than half of adult mental health service users are parents, but their experiences are largely lacking from research literature. Parental mental illness can often be viewed from a risk perspective. Parents with mental illness and their families have unmet support needs. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Parents with mental illness want acknowledgement that they can be able and responsible. Many parents adopt an expert by experience identity. Fathers can feel their parental role is not recognized and mothers express fears of being judged if they discuss their illness. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Adult mental health services need to recognize and support parental role of service users. Joint care planning and family oriented care should be promoted. Professionals should take advantage of the knowledge of these parents and they could be more actively engaged in service development.

ABSTRACT

Introduction Parental mental illness is often viewed from a risk perspective. Despite this, being a parent can be both valuable and motivating. Research literature lacks the perspective of mothers and fathers, who have experienced mental illness. Aim This study explores how parents with mental illness construct their identities as mothers and fathers and their experiences with health and social care services. Method Three focus groups with 19 participants were conducted in Finland and Scotland. Methods of discourse analysis have been used in to analyse the interview data. Results Adult service users want their parenting role recognized and supported. Parents have knowledge and skills which can be utilized and many have adopted an expert by experience identity. Discussion Being able to see oneself as a 'good' parent can be challenging but important. Parents may require support, but want to be included in the planning of their care. Services could make more use of the knowledge and skills parents and families have, and joint working could lessen parents' anxieties. Implications for practice Mental health practitioners are in a key position in providing more family centred, resource focused care. Service user expertise should be acknowledged in clinical practice.

Detection of clinically relevant pain relief in cats with degenerative joint disease associated pain

Background

Detection of clinically relevant pain relief in cats with degenerative joint disease (DJD) is complicated by a lack of validated outcome measures and a placebo effect.

Hypothesis/Objectives

To evaluate a novel approach for detection of pain relief in cats with DJD.

Animals

Fifty‐eight client‐owned cats.

Methods

Prospective, double‐masked, placebo‐controlled, stratified, randomized, clinical study. Enrolled cats were 6–21 years of age, with owner‐observed mobility impairment, evidence of pain in at least 2 joints during orthopedic examination, and overlapping radiographic evidence of DJD, and underwent a 2‐week baseline period, 3‐week treatment period with placebo or meloxicam, and 3‐week masked washout period. Outcome measures were evaluated at days 0, 15, 36, and 57.

Results

Both groups significantly improved after the treatment period (day 36) on client‐specific outcome measures (CSOM) and feline musculoskeletal pain index (FMPI) (P < .0001 for both); there was no difference between the groups on CSOM or FMPI score improvement. After the masked washout period, more cats that received meloxicam during the treatment period had a clinically relevant decrease in CSOM score (P = .048) and FMPI score (P = .021) than cats that received placebo.

Conclusions and Clinical Importance

Using both a client‐specific and a general clinical metrology instrument, owners of cats with DJD were able to detect evident recurrence of clinical signs after withdrawal of active medication than after withdrawal of placebo, and that this study design might be a novel and useful way to circumvent the placebo effect and detect the efficacy of pain‐relieving medications.

Elucigene FH20 and LIPOchip for the diagnosis of familial hypercholesterolaemia: a systematic review and economic evaluation

BACKGROUND

Familial hypercholesterolemia (FH) is an autosomal dominant genetic condition causing a high risk of coronary heart disease. The prevalence of this disease is about 1 in 500 in the UK, affecting about 120,000 people across the whole of the UK. Current guidelines recommend DNA testing, however, these guidelines are poorly implemented, therefore 102,000 or 85% of this group remain undiagnosed.

OBJECTIVES

To assess the diagnostic accuracy, effect on patient outcomes and cost-effectiveness of Elucigene FH20 and LIPOchip for the diagnosis of FH.

DATA SOURCES

Electronic databases including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, BIOSIS, Science Citation Index, Conference Proceedings Citation Index - Science and Cochrane Controlled Trials Register were searched until January 2011.

REVIEW METHODS

A systematic review of the literature on diagnostic accuracy was carried out according to standard methods. An economic model was constructed to assess the cost-effectiveness of alternative diagnostic strategies for the confirmation of clinically diagnosed FH in index cases and for the identification and subsequent testing of first-, second- and possibly third-degree biological relatives of the index case. Twelve strategies were evaluated linking diagnostic accuracy to treatment outcomes and hence quality-adjusted life-years (QALYs). Deterministic and probabilistic sensitivity analyses were undertaken to investigate model and parameter uncertainty.

RESULTS

Fifteen studies were included for diagnostic accuracy; three reported Elucigene FH20, five reported LIPOchip, four reported low-density lipoprotein cholesterol (LDL-C) tests and three reported an age- and gender-specific LDL-C test against a reference standard of comprehensive genetic analysis (CGA). Sensitivity ranged from 44% to 52% for Elucigene FH20 and from 33.3% to 94.5% for various versions of LIPOchip in detecting FH-causing mutations in patients with a clinical diagnosis of FH. For LIPOchip version 10 (designed to detect 189 UK specific mutations), sensitivity would be 78.5% (based on single-centre data - Progenika, personal communication). For all other Elucigene FH20 or LIPOchip studies (apart from one LIPOchip study), specificity could not be calculated as no false-positive results could be derived from the given data. The LDL-C test was generally reported to be highly sensitive but with low specificity. For age- and gender-specific LDL-C cut-offs for cascade testing, sensitivity ranged from 68% to 96%. One UK-based study reported sensitivity of 91% and specificity of 93%. For the cost-effectiveness review, only one study reporting cost-effectiveness of any one of the comparators for this assessment was identified. Pre-screen strategies such as Elucigene FH20 followed by CGA were not cost-effective and were dominated by the single more comprehensive tests (e.g. CGA). Of the non-dominated strategies, Elucigene FH20, LIPOchip platform (Spain) and CGA were all cost-effective with associated incremental cost-effectiveness ratios (ICERs) relative to LDL-C of dominance (test is less costly and more effective), £871 and £1030 per QALY gained respectively. CGA generates the greatest QALY gain and, although other tests have lower ICERs relative to LDL-C, this is at the expense of QALY loss compared with the CGA test. Probabilistic sensitivity analysis shows that CGA is associated with an almost 100% probability of cost-effectiveness at the conventional value of willingness to pay of £20,000 per QALY gain.

LIMITATIONS

There was much uncertainty regarding the diagnostic accuracy of the included tests, with wide variation in sensitivity across reported studies. A lack of published information for the most recent version of LIPOchip created additional uncertainty, especially in relation to the chip's ability to detect copy number changes. For the economic modelling, we aimed to choose the best studies for the base-case sensitivity of the tests; however, a number of informed choices based on clinical expert opinion had to be made in the absence of published studies for a number of other parameters in the modelling. This adds some uncertainty to our results, although it is unlikely that these would be sufficient in magnitude to alter our main results and conclusions.

CONCLUSIONS

As targeted tests designed to detect a limited number of genetic mutations, Elucigene FH20 and LIPOchip cannot detect all cases of FH, in contrast with CGA. CGA is therefore the most effective test in terms of sensitivity and QALY gain, and is also highly cost-effective with an associated ICER of £1030 per QALY gain relative to current practice (LDL-C). Other tests such as Elucigene FH20 and LIPOchip are also cost-effective; however, because of inferior sensitivity compared with CGA, these tests offer cost savings but at the expense of large QALY losses compared with CGA. Further prospective multicentred studies are required to evaluate the diagnostic accuracy of new and emerging tests for FH with the LDL-C test in patients with a clinical diagnosis based on the Simon Broome criteria. Such studies should verify both test-positive and -negative results against a reference standard of CGA and should include a full economic evaluation.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The changing pattern of referral in acute kidney injury

BACKGROUND

Acute kidney injury (AKI) is not only managed by nephrologists, but also by several other subspecialists. The referral rate to nephrologists and the factors influencing it are unknown.

AIMS

To determine the referral rate, factors affecting referral and outcomes across the spectrum of AKI in a population based study.

METHODS

We identified all patients with serum creatinine concentrations ≥150 µmol/l (male) or ≥130 µmol/l (female) over a 6-month period. AKI was defined according to the RIFLE classification (risk, injury, failure, loss, end stage renal disease [ESRD]). Clinical information and outcomes were obtained from each patient's case records.

RESULTS

A total of 562 patients were identified as having AKI (incidence 2147 per million population/year [pmp/y]). One hundred and sixty-four patients (29%) were referred to nephrologists-referral rate 627 pmp/y. Forty-nine percent of patients whose serum creatinine rose to >300 µmol/l were referred compared with 22% in our previous study of 1997. Forty-eight patients required renal replacement therapy-incidence 184 pmp/y in comparison to 50 pmp/y in our previous study of 1997. Patients had higher odds of referral if they were male, of younger age and were in the F category of the RIFLE classification. Patients had lower odds of referral if they had multiple co-morbid conditions or if they were managed in a hospital without a nephrology service.

CONCLUSION

There has been a significant rise in the referral rate of patients with AKI to nephrologists but even during our period of study only one-third of such patients were being referred. With rising incidence and increased awareness, the referral rate will certainly rise putting a significant burden on the nephrology services.

Aluminium intoxication in renal disease

Aluminium intoxication in renal failure occurred over weeks or months when dialysis fluid or parenteral solutions were heavily contaminated and over many years when the main source was oral administration of aluminium-containing phosphate binders. Encephalopathy was common during subacute intoxication but in slow aluminium poisoning the main brunt was borne by the bones. However, in both tempos of intoxication several organs or systems were involved. Encephalopathy was usually accompanied by bone disease, bone disease by parathyroid suppression and both by anaemia. The heart and the lymphocytes are probably damaged by aluminium overload. Among the many questions left unanswered 15 years after the incrimination of aluminium as the cause of this multi-system illness are: (1) does low level aluminium overload in renal failure cause gradual deterioration in cerebral function? And, if so, (2) does it resemble Alzheimer's disease or a slow-onset version of dialysis encephalopathy? The evidence we review suggests that the answer to (1) is 'yes' and to (2) 'probably the latter'.

An interesting byproduct of screening: assessing the effect of HRT on arterial calcification in the female breast

Arterial calcification in the female breast (BAC) is a common but unreported finding on breast screening mammograms. Accumulating evidence suggests that BAC may have importance as a marker for generalised vascular disease. In this study, we have assessed the influence of HRT usage on the prevalence of BAC in 4400 women undergoing mammography for breast cancer screening. Significantly increased levels of breast arterial calcification were observed in women who had never used HRT compared with a group of women presently using HRT.

The sensitivity of the assessment process in screening mammography

A follow-up of 3143 women from four screening centres, who were assessed after screening mammography, showed that 371 had breast cancer diagnosed at that assessment and 62 developed a breast cancer in the following 6 years. Of these, 32 were judged to be false-negatives at assessment, with 23 of the 32 at the site originally suspected. The results show that the assessment process is not infallible and that the scale of the problem only becomes clear when an exhaustive search is made for missed cancers.

Environmental cues and gene expression in Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans

Microorganisms typically adapt to environmental cues by turning on and off the expression of virulence genes which, in turn, allows for optimal growth and survival within different environmental niches. This adaptation strategy includes sensing and responding to changes in nutrients, pH, temperature, oxygen tension, redox potential, microbial flora, and osmolarity. For a bacterium to adhere to, penetrate, replicate in, and colonize host cells, it is critical that virulence genes are expressed during certain periods of the infection process. Thus, throughout the different stages of an infection, different sets of virulence factors are turned on and off in response to different environmental signals, allowing the bacterium to effectively adapt to its varying niche. In this review, we focus on the regulation of virulence gene expression in two pathogens which have been implicated as major etiological agents in adult and juvenile periodontal diseases: Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans. Understanding the mechanisms of virulence gene expression in response to the local environment of the host will provide crucial information in the development of effective treatments targeted at eradication of these periodontal disease pathogens.

Evaluation of local invasion by oesophageal carcinoma--a prospective study of prone computed tomography scanning

The aim of this study was to assess the value of prone computed tomography compared with the traditional supine position, in the assessment of invasion of adjacent mediastinal structures by oesophageal cancer. A prospective, single blind case-case comparative study of signs of local tumour invasion was conducted. Sixty nine consecutive patients undergoing computed tomography for preoperative staging of oesophageal carcinoma were studied. Computed tomography scanning of the thorax was performed in the standard supine followed by prone position; in 39 patients the computed tomography findings were correlated with the surgical findings. Four established radiological signs used to assess mediastinal invasion were scored in each case. Based on the radiological scoring system, there was a significant down staging in the probability of aortic invasion in 12 of the 69 cases (p<0.05). A similar improvement in accuracy was seen in the cases undergoing surgery; of the 38 cases who did not have aortic invasion at operation, 10 cases were scored as high for aortic invasion on the supine scans compared with only three on the prone position (p<0.05). Prone scanning was not of significant additional value in the assessment of major airway or pericardial invasion. Modification of the computed tomography protocol to include scanning in the prone position will improve the accuracy of the preoperative staging of patients with oesophageal malignancy and reduce the chance of overstaging disease. Especially in centres where endoscopic ultrasound is not available, our modification may reduce the chance of denying patients potentially curative operations.

Characterization and expression of HmuR, a TonB-dependent hemoglobin receptor of Porphyromonas gingivalis

The gram-negative pathogen Porphyromonas gingivalis requires hemin for growth. Hemoglobin bound to haptoglobin and hemin complexed to hemopexin can be used as heme sources, indicating that P. gingivalis must have a means to remove the hemin from these host iron-binding proteins. However, the specific mechanisms utilized by P. gingivalis for the extraction of heme from heme-binding proteins and for iron transport are poorly understood. In this study we have determined that a newly identified TonB-dependent hemoglobin-hemin receptor (HmuR) is involved in hemoglobin binding and utilization in P. gingivalis A7436. HmuR shares amino acid homology with TonB-dependent outer membrane receptors of gram-negative bacteria involved in the acquisition of iron from hemin and hemoglobin, including HemR of Yersinia enterocolitica, ShuA of Shigella dysenteriae, HpuB of Neisseria gonorrhoeae and N. meningitidis, HmbR of N. meningitidis, HgbA of Haemophilus ducreyi, and HgpB of H. influenzae. Southern blot analysis confirmed the presence of the hmuR gene and revealed genetic variability in the carboxy terminus of hmuR in P. gingivalis strains 33277, 381, W50, and 53977. We also identified directly upstream of the hmuR gene a gene which we designated hmuY. Upstream of the hmuY start codon, a region with homology to the Fur binding consensus sequence was identified. Reverse transcription-PCR analysis revealed that hmuR and hmuY were cotranscribed and that transcription was negatively regulated by iron. Inactivation of hmuR resulted in a decreased ability of P. gingivalis to bind hemoglobin and to grow with hemoglobin or hemin as sole iron sources. Escherichia coli cells expressing recombinant HmuR were shown to bind hemoglobin and hemin. Furthermore, purified recombinant HmuR was demonstrated to bind hemoglobin. Taken together, these results indicate that HmuR serves as the major TonB-dependent outer membrane receptor involved in the utilization of both hemin and hemoglobin in P. gingivalis.

Transposition of the endogenous insertion sequence element IS1126 modulates gingipain expression in Porphyromonas gingivalis

We have previously reported on a Tn4351-generated mutant of Porphyromonas gingivalis (MSM-3) which expresses enhanced arginine-specific proteinase activity and does not utilize hemin or hemoglobin for growth (C. A. Genco et al., Infect. Immun. 63:2459-2466, 1995). In the process of characterizing the genetic lesion in P. gingivalis MSM-3, we have determined that the endogenous P. gingivalis insertion sequence element IS1126 is capable of transposition within P. gingivalis. We have also determined that IS1126 transposition modulates the transcription of the genes encoding the lysine-specific proteinase, gingipain K (kgp) and the arginine-specific proteinase, gingipain R2 (rgpB). Sequence analysis of P. gingivalis MSM-3 revealed that Tn4351 had inserted 60 bp upstream of the P. gingivalis endogenous IS element IS1126. Furthermore, P. gingivalis MSM-3 exhibited two additional copies of IS1126 compared to the parental strain A7436. Examination of the first additional IS1126 element, IS1126(1), indicated that it has inserted into the putative promoter region of the P. gingivalis kgp gene. Analysis of total RNA extracted from P. gingivalis MSM-3 demonstrated no detectable kgp transcript; likewise, P. gingivalis MSM-3 was devoid of lysine-specific proteinase activity. The increased arginine-specific proteinase activity exhibited by P. gingivalis MSM-3 was demonstrated to correlate with an increase in the rgpA and rgpB transcripts. The second additional IS1126 element, IS1126(2), was found to have inserted upstream of a newly identified gene, hmuR, which exhibits homology to a number of TonB-dependent genes involved in hemin and iron acquisition. Analysis of total RNA from P. gingivalis MSM-3 demonstrated that hmuR is transcribed, indicating that the insertion of IS1126 had not produced a polar effect on hmuR transcription. The hemin-hemoglobin defect in P. gingivalis MSM-3 is proposed to result from the inactivation of Kgp, which has recently been demonstrated to function in hemoglobin binding. Taken together, the results presented here demonstrate that the introduction of Tn4351 into the P. gingivalis chromosome has resulted in two previously undocumented phenomena in P. gingivalis: (i) the transposition of the endogenous insertion sequence element IS1126 and (ii) the modulation of gingipain transcription and translation as a result of IS1126 transposition.

Improving the visibility of radio-opaque markers in mammography

Owing to the high mean film optical densities used in breast screening mammography, and the very high maximum optical densities that can be obtained using modern mammographic film, it is often found that for larger exposures the nominally radio-opaque markers used to identify views, left and right etc., cannot be seen using a normal illuminator. A simple solution to this problem is to back the radio-opaque markers with a thin metal filter chosen to keep the marker information visible over a wide range of exposures. A convenient material for this is copper foil in the form of self-adhesive tape. The improvement in marker contrast produced by this modification is illustrated using point optical density measurements on marked test films produced at the extremes of the mammographic exposure range.

Energy model for contrast detection: spatiotemporal characteristics of threshold vision

A model for contrast detection of spatiotemporal stimuli is proposed which consists of a spatiotemporal linear filter, an energy device and a threshold device. Assuming the existence of independent intrinsic noise, the probability of stimulus detection was approximated by a Weibull function of the response energy. With this assumption, the stimulus energy is a constant at fixed detection probability. This energy model for contrast detection satisfactorily accounted for the elliptical threshold contours of line pairs at stimulus separations within the range 2-30 min and at stimulus onset asynchronies within the range 20-140 ms. The threshold contour at a large stimulus onset asynchrony (300 ms) was in the form of a rounded square. This finding was explained by assuming that the probability of seeing the line pair was determined by the joint probability that at least one stimulus had been detected. With the energy model, the temporal and spatial autocorrelation functions of the response to a flashed line were evaluated. The autocorrelation functions thus determined were used to predict the temporal contrast sensitivity function to a flickering line stimulus and the spatial contrast sensitivity function to flashed gratings, which were in agreement with the experimental data. The data obtained were fitted adequately by an impulse response approximated by a spatiotemporal Gabor-like function.

Women with normal mammography describing symptoms at screening

A retrospective study from May 1989 to June 1995 identified 4327 women with symptoms and normal mammography, from a total population of 139,852. The women with symptoms were divided into two groups: those who had been recalled for assessment, because of potentially significant symptoms, and those who had not. Out of 448 women recalled for assessment with significant symptoms, 8 malignancies were detected and 8 benign biopsies were performed. Review of the remaining 3879 women with symptoms showed that 4 had developed interval cancers in the same breast as the symptoms described at the previous screening attendance. No cancer was detected at subsequent screening examinations. This review shows that breast cancer is so uncommon in women attending for screening with symptoms that a policy of only recalling women with significant symptoms is justifiable.

Assessing the economic value of antihypertensive medications

OBJECTIVE

To assess the economic value of antihypertensive medications by comparing the likelihood of coronary heart disease and stroke events and subsequent event treatment costs.

STUDY DESIGN

Duration of blood pressure reduction was used to profile event risk reduction of three antihypertensive medications.

METHODS

We used clinical data to determine the duration of blood pressure reduction achieved with use of two angiotensin converting enzyme inhibitors and one angiotensin II receptor antagonist. We then used trough-to-peak ratios to calculate the reduction in risk of coronary heart disease and stroke events associated with each medication.

RESULTS

Across a number of different event treatment cost and population size estimates, the economic value of different medications can be assessed.

CONCLUSION

Our method for assessing the economic value of antihypertensive medications can be applied to other drug classes and can be further refined by integrating patient population and other risk-related data.

Descriptive terms for mammographic abnormalities: observer variation in application. The Northern Region Breast Screening Radiology Audit Group

In an attempt to standardize descriptive terms of mammographic appearances, observer variation was studied in an analysis of mammograms showing either opacities or microcalcification. The results are presented for 80 examples of each which were assessed by two teams of four radiologists. The observer variation was so great that the Audit Group has abandoned the attempt to classify the radiological observations by the use of these descriptive terms.

Case report: mobile fatty globules in benign cystic teratoma of the mediastinum

Benign cystic teratoma is a well recognized cause of an anterior mediastinal mass. The presence of fat, found in approximately half the cases, suggests the diagnosis. We report a new feature, which consists of components of the tumour drifting upwards (anteriorly) during the course of a computed tomography examination. The appearance is compared with a popular light fitting.

Malnutrition in hospitalized pediatric patients. Current prevalence

OBJECTIVE

To document the current prevalence of protein-energy malnutrition compared with that reported from the same institution in 1976.

DESIGN

All inpatients of this tertiary-care facility were assessed by anthropometric, laboratory, and clinical nutrition assessment methods in a 1-day cross-sectional survey. The comparison study from 1976 was also a 1-day cross-sectional survey.

SETTING

A tertiary-care facility in Boston, Mass.

PATIENTS

The entire inpatient population was assessed on a single weekday in September 1992.

MAIN OUTCOME MEASURES

Prevalence of acute and chronic malnutrition as judged by anthropometric and laboratory data. Data on demographics, admission classification, underlying disease, route of nutrition, and global nutritional status were also assessed.

RESULTS

The prevalence of acute protein-energy malnutrition (weight for height) based on the Waterlow criteria was as follows: severe, 1.3%; moderate, 5.8%; mild, 17.4%; and none, 75.5%. The prevalence of chronic protein-energy malnutrition (height for age) was as follows: severe, 5.1%; moderate, 7.7%; mild, 14.5%; and none, 72.8%. Although the prevalence of acute and chronic protein-energy malnutrition was significantly less in 1992 than in 1976 (P = .03 and P < .001, respectively), the numbers are still alarmingly high. Children younger than 2 years and older than 18 years and those with chronic medical conditions had a higher prevalence of protein-energy malnutrition. Twenty-four percent of patients had a serum albumin level less than 30 g/L, 34.8% had a total lymphocyte count less than 1.5 x 10(9)/L, and 24.9% had a hemoglobin concentration less than 105 g/L. One fourth of all patients were obese (> 120% weight for height), with the greatest prevalence in children aged 2 to 18 years.

CONCLUSIONS

Acute and chronic protein-energy malnutrition remains common in hospitalized pediatric patients in the United States. Important risk factors may be underlying chronic disease, periods of normally rapid growth, and recognized need for nutrition intervention.

Characterization of a Tn4351-generated hemin uptake mutant of Porphyromonas gingivalis: evidence for the coordinate regulation of virulence factors by hemin

The ability of Porphyromonas gingivalis to acquire iron in the iron-limited environment of the host is crucial to the colonization of this organism. We report here on the isolation and characterization of a transpositional insertion mutant of P. gingivalis A7436 (designated MSM-3) which is defective in the utilization and transport of hemin. P. gingivalis MSM-3 was selected on the basis of its nonpigmented phenotype on anaerobic blood agar following mutagenesis with the Bacteroides fragilis transposon Tn4351. P. gingivalis MSM-3 grew poorly when supplied with hemin as a sole source of iron; however, growth was observed with hemoglobin or inorganic iron. P. gingivalis MSM-3 grown in either hemin-replete or hemin-depleted conditions bound and transported less [14C]hemin or [59Fe]hemin than did the parent strain. At 4 h, P. gingivalis MSM-3 grown in hemin-replete conditions transported only 10,000 pmol of hemin per mg of protein, or 14% of the amount transported by P. gingivalis A7436. Unlike P. gingivalis A7436, hemin binding and transport by P. gingivalis MSM-3 were not tightly regulated by hemin or iron. Examination of P. gingivalis MSM-3 cultures by electron microscopy revealed an overproduction of membrane vesicles, and determination of the dry weight of purified vesicles indicated that P. gingivalis MSM-3 produced twice as much membrane vesicles as did strain A7436. Extracellular vesicles isolated from P. gingivalis MSM-3 also were found to express increased hemolytic and trypsin-like protease activities compared with the parent strain. When inoculated into subcutaneous chambers implanted in mice, P. gingivalis MSM-3 was highly infectious and more invasive than the parent strain, as indicated by secondary lesion formation and death. Taken together, these results indicate that the decreased transport of hemin by P. gingivalis MSM-3 results in the increased expression of several virulence factors which may be coordinately regulated by hemin.

Modulation of the cytokine and acute-phase response to major surgery by recombinant interleukin-2

Major surgery suppresses host immune reactivity through alterations in monocyte and T cell-derived cytokine, eicosanoid and acute-phase protein release. Recombinant interleukin (IL) 2 augments T lymphocyte and monocyte activity in vitro. Eighteen patients, with localized colorectal cancer, were randomized to receive either recombinant IL-2 or placebo for 3 days by subcutaneous injection before surgery. Serum levels of IL-1 beta, IL-6, tumour necrosis factor alpha, soluble IL-2 receptor, C-reactive protein (CRP) and albumin were measured, and T lymphocyte surface expression of HLA-DR and CD25 and neutrophil phagocytosis were determined, before and for 21 days after surgery. Significant augmentation of IL-6, CRP and soluble IL-2 receptor production, enhanced expression of activation markers and increased neutrophil activity were found. Recombinant IL-2 may have a role in ameliorating the immunosuppression found after major surgery.

Technical report: prone scanning in the CT assessment of oesophageal carcinoma

The use of scanning in the prone position is described in the computed tomographic staging of oesophageal carcinoma. Examples are provided to illustrate how this technique may be of assistance in assessing local tumour invasion.

Correlation of serum cytokine and acute phase reactant levels with alterations in weight and serum albumin in patients receiving immunotherapy with recombinant IL-2

Recombinant IL-2 (rIL-2) has been used alone or in combination with other chemotherapeutic agents to enhance host defences against cancer. Prolonged administration of high doses, required for clinical efficacy, may precipitate serious dose-limiting toxicity. rIL-2-induced 'vascular leak syndrome' leads to hypotension, renal insufficiency, respiratory disturbances and other organ dysfunctions. Serial measurements of serum cytokines and the acute phase protein C-reactive protein (CRP) were performed on nine patients who received high-dose i.v. continuous therapy with rIL-2. The influence of these immunological parameters upon alterations in patients' weight and serum albumin, as indicators of toxicity, was assessed. All patients experienced weight increases during the cycle (3-11% of total body weight). The serum levels of tumour necrosis factor (TNF-alpha) and CRP were highly predictive of alterations in patients' weight (both P < 0.001), while no correlation was found with IL-6 and weight change. Serum albumin fell linearly throughout the infusion cycle, but this showed no correlation with variations in serum levels of IL-6, TNF-alpha, or CRP. The complement components C3 and C4 were significantly reduced at the end of the infusion, suggesting a possible role for this cascade system in mediating these clinical changes. The strong association between serum TNF-alpha and weight change, not previously documented, further supports the hypothesis that TNF-alpha is a key mediator in the pathogenesis of the 'vascular leak syndrome'.

Behavioral Intensive Care Unit (BICU): a new concept in the management of acute agitated behavior in elderly demented patients

Intensive care units were developed in response to the perceived need for increased monitoring in critically ill medical patients. The same principle applies to elderly patients with severe agitated behaviors. These patients can be served by the Geriatric Behavioral Intensive Care Unit (BICU). The uniqueness of the program results from the application of a behavioral and environmental approach to the treatment of agitated behavior. The underlying strategy in the treatment process is to enhance the patient's ability to adapt to his or her home environment. Preliminary results have been encouraging, showing positive outcomes in diverse areas such as low level of institutional placement, patient quality of life, and caregiver symptoms of burden and depression.

Pleuropulmonary abnormalities in primary Sjögren's syndrome

Sixteen patients with primary Sjögren's syndrome (1 degree SS) who complained of dyspnea were investigated with high resolution computerized tomography of the thorax, bronchoalveolar lavage, and transbronchial biopsy. Six patients had evidence of interstitial fibrosis, 5 had a peribronchiolar lymphocytic infiltration and 3 had pleural thickening. We conclude that significant pulmonary disease is not uncommon in patients with 1 degree SS.

Craniofacial form in class III cases

Lateral skull cephalograms from 50 patients who subsequently had surgical correction of their Class III malocclusion were analysed using a complete linkage cluster analysis based on skull shape. Five subgroups were identified and are described. All subjects had a degree of mandibular prognathism while only 14 per cent had maxillary retrognathism. An increased lower face height was found in 58 per cent.

Reactivity of anti-CD15 monoclonal antibody PM-81 with breast cancer and elimination of breast cancer cells from human bone marrow by PM-81 and immunomagnetic beads

The CD15 carbohydrate antigen, lacto-N-fucopentaose III is expressed on a variety of human cancer cells including acute myeloid leukemia, small cell carcinoma of the lung, and colorectal carcinomas. We have found that cells from breast cancer cell lines and patient-derived tissue are strongly CD15 positive, as seen by binding to the PM-81 monoclonal antibody. In this report we show that monoclonal antibody PM-81 and immunomagnetic beads can remove breast cancer cells from bone marrow and thus be used as "purging" agents for autologous bone marrow transplantation. PM-81 and immunomagnetic beads removed up to 3 log of SK-BR-3 and MCF7 breast carcinoma cell line cells while minimally affecting normal hematopoietic progenitor cells. This technique may be useful for purging marrow for autologous bone marrow transplantation in breast cancer.

Low incidence of asymptomatic brain metastases in patients with renal cell carcinoma

Brain metastases from renal cell carcinoma are uncommon. The present study was undertaken to determine the value of routine computerized tomographic (CT) scanning of the brain in patients with renal cell carcinoma. A review of 106 patients with renal cell carcinoma who had undergone CT scan of the brain revealed brain metastases in only 13.2 percent. Brain metastases were accompanied by central nervous system (CNS) symptoms in 78.6 percent of patients, with headaches constituting the most common presenting symptom (64.3%). Brain metastases were detected in only 3.3 percent of patients who had no CNS symptoms at the time of evaluation. It is concluded that CT scanning of the brain should be performed routinely only for those patients who report CNS symptoms at the time of evaluation.