Pulling the plug on a pseudomonas outbreak: ancillary equipment as vectors of infection

OBJECTIVES

Outbreaks of infection related to flexible endoscopes are well described. However, flexible endoscopy also requires the use of ancillary equipment such as irrigation plugs. These are potential vectors of infection but are infrequently highlighted in the literature. This paper reports a cystoscopy-associated outbreak of Pseudomonas aeruginosa from contaminated irrigation plugs in a UK tertiary care centre.

METHODS

Laboratory, clinical and decontamination unit records were reviewed, and audits of the decontamination unit were performed. Flexible cystoscopes and irrigation plugs were assessed for contamination. Retrospective and prospective case finding was performed utilizing the microbiology laboratory information management system. Available P. aeruginosa isolates underwent variable nucleotide tandem repeat (VNTR) typing. Confirmed cases were defined as P. aeruginosa infection with an identical VNTR profile to an outbreak strain.

RESULTS

Three strains of P. aeruginosa were isolated from five irrigation plugs but none of the flexible cystoscopes. No acquired resistance mechanisms were detected. Fifteen confirmed infections occurred, including bacteraemia, septic arthritis and urinary tract infection. While failure of decontamination likely occurred because the plugs were not dismantled prior to reprocessing, the manufacturer's reprocessing instructions were also incompatible with standard UK practice. The Medicines and Healthcare Products Regulatory Agency was informed. A field safety notice was issued, and the manufacturer issued updated reprocessing instructions.

CONCLUSIONS

Ancillary equipment can represent an important vector for infection, and should be considered during outbreak investigations. Users should review the manufacturer's instructions for reprocessing ancillary equipment to ensure that they are compatible with available procedures.

In the Name of COVID-19: Is the ECB Fuelling the Climate Crisis?

We offer preliminary evidence drawing on a novel dataset of corporate bonds issued in the European energy sector since January 2020 in combination with the European Central Bank's (ECB) purchases under the Pandemic Emergency Purchase Programme (PEPP) in response to COVID-19. We show that the likelihood of a European energy company bond to be bought as part of the ECB's programme increases with the greenhouse gas (GHG) intensity of the bond issuing firm. We also find weaker evidence that the ECB's PEPP portfolio during the pandemic is likely to become tilted towards companies with anti-climate lobbying activities and companies with less transparent GHG emissions disclosure. Our findings imply that, at later stages of the COVID-19 recovery, an in-depth analysis may be necessary to understand if, and if yes why, the ECB fuelled the climate crisis.

An outbreak of two strains of OXA-48 producing Klebsiella pneumoniae in a teaching hospital

OXA-48 producers can be difficult to detect in clinical specimens due to phenotypic low-level resistance to carbapenems. Additionally, low infection rates make clinical specimens poor sentinels for the presence of OXA-48 producers within a healthcare institution.

We report an outbreak of OXA-48-producing Klebsiella pneumoniae (OXAKp) that was discovered following culture of OXAKp in a urine specimen from a patient with no known risk factors for acquisition. Widespread screening across medical wards in the trust revealed evidence of transmission across several wards. Samples from 60 patients were positive for OXAKp. Five patients had OXAKp clinical infection, four of whom were treated with ceftazidime/avibactam. Variable number tandem repeat analysis of the OXAKp isolates revealed two predominant strain types clustered around two groups of wards.

Infection prevention measures included isolation and cohort nursing of infected and colonized patients, restriction of affected ward areas to new admissions, stringent hand hygiene and use of personal protective equipment. Environmental cleaning of patient areas was carried out using chlorine-releasing disinfectants and hydrogen peroxide vapour. Entire wards were decanted to enable effective cleaning of empty ward areas. The outbreak lasted almost five months and is estimated to have cost around £400 000.

During the course of the outbreak, there were five reported prescription and administration incidents related to confusion between ceftazidime and ceftazidime/avibactam. No patient harm resulted from these incidents and the implementation of brand name prescribing for ceftazidime/avibactam prevented further incidents.

Case management: a critical review of the outcome literature

Case management has been an integral part of psychiatric practice in the United States for over a decade and has generated a large body of literature. The application of case management principles to the care of people suffering from psychiatric disorders is becoming increasingly popular in the United Kingdom and Europe and literature is now beginning to be published. However, no definitive statements about the efficacy of case management have been made due to a range of conceptual and methodological problems. The present paper is a critical review of the case management outcome literature. Reported outcomes are reviewed in the context of study design and service characteristics. The authors conclude that case management practice can have at least some impact on patients' use of services (including marked decrease in in-patient bed days); satisfaction with services; engagement with services; and social networks and relationships when it is delivered as a direct, clinical service with high staff: patient ratios. A set of recommendations are suggested for the future practice and presentation of research into case management.

Investigation of co-infections with pathogens associated with gill disease in Atlantic salmon during an amoebic gill disease outbreak

Gill diseases are a complex and multifactorial challenge for marine farmed Atlantic salmon. Co-infections with putative pathogens are common on farms; however, there is a lack of knowledge in relation to the potential effect co-infections may have on pathology. The objective of this study was to determine the prevalence and potential effects of Neoparamoeba perurans, Desmozoon lepeophtherii, Candidatus Branchiomonas cysticola, Tenacibaculum maritimum and salmon gill poxvirus (SGPV) during a longitudinal study on a marine Atlantic salmon farm. Real-time PCR was used to determine the presence and sequential infection patterns of these pathogens on gill samples collected from stocking until harvest. A number of multilevel models were used to determine the effect of these putative pathogens on gill health (measured as gill histopathology score), while adjusting for the effect of water temperature and time since the last freshwater treatment. Results indicate that between 12 and 16 weeks post-seawater transfer (wpst), colonization of the gills by all pathogens had commenced and by week 16 of marine production each of the pathogens had been detected. D. lepeophtherii and Candidatus B. cysticola were by far the most prevalent of the potential pathogens detected during this study. Detections of T. maritimum were found to be significantly correlated with temperature showing distinct seasonality. Salmon gill poxvirus was found to be highly sporadic and detected in the first sampling point, suggesting a carryover from the freshwater stage of production. Finally, the model results indicated no clear effect between any of the pathogens. Additionally, the models showed that the only variable which had a consistent effect on the histology score was N. perurans.

Protein and chemotherapy profiling of extracellular vesicles harvested from therapeutic induced senescent triple negative breast cancer cells

Triple negative breast cancer (TNBC) is an aggressive subtype with relatively poor clinical outcomes and limited treatment options. Chemotherapy, while killing cancer cells, can result in the generation of highly chemoresistant therapeutic induced senescent (TIS) cells that potentially form stem cell niches resulting in metastases. Intriguingly, senescent cells release significantly more extracellular vesicles (EVs) than non-senescent cells. Our aim was to profile EVs harvested from TIS TNBC cells compared with control cells to identify a potential mechanism by which TIS TNBC cells maintain survival in the face of chemotherapy. TIS was induced and confirmed in Cal51 TNBC cells using the chemotherapeutic paclitaxel (PTX) (Taxol). Mass spectrometry (MS) analysis of EVs harvested from TIS compared with control Cal51 cells was performed using Ingenuity Pathway Analysis and InnateDB programs. We demonstrate that TIS Cal51 cells treated with 75 nM PTX for 7 days became senescent (senescence-associated β-galactosidase (SA-β-Gal) positive, Ki67-negative, increased p21 and p16, G2/M cell cycle arrest) and released significantly more EVs (P=0.0002) and exosomes (P=0.0007) than non-senescent control cells. Moreover, TIS cells displayed an increased expression of the multidrug resistance protein 1/p-glycoprotein. MS analysis demonstrated that EVs derived from senescent Cal51 cells contained 142 proteins with a significant increased fold change compared with control EVs. Key proteins included ATPases, annexins, tubulins, integrins, Rabs and insoluble senescence-associated secretory phenotype (SASP) factors. A fluorescent analogue of PTX (Flutax-2) allowed appreciation of the removal of chemotherapy in EVs from senescent cells. Treatment of TIS cells with the exosome biogenesis inhibitor GW4869 resulted in reduced SA-β-Gal staining (P=0.04). In summary, this study demonstrates that TIS cells release significantly more EVs compared with control cells, containing chemotherapy and key proteins involved in cell proliferation, ATP depletion, apoptosis and the SASP. These findings may partially explain why cancer senescent cells remain viable despite chemotherapeutic challenge.

Effectiveness of a care bundle to reduce surgical site infections in patients having open colorectal surgery

Introduction In 2010 a care bundle was introduced by the Department of Health (DH) to reduce surgical site infections (SSIs) in England. To date, use of the care bundle has not been evaluated despite incorporating interventions with resource implications. The aim of this study was to evaluate the DH SSI care bundle in open colorectal surgery. Methods A prospective cohort design was used at two teaching hospitals in England. The baseline group consisted of 127 consecutive patients having colorectal surgery during a 6-month period while the intervention group comprised 166 patients in the subsequent 6 months. SSI and care bundle compliance data were collected using dedicated surveillance staff. Results Just under a quarter (24%) of the patients in the baseline group developed a SSI compared with just over a quarter (28%) in the care bundle group (p>0.05). However, compliance rates with individual interventions, both before and after the implementation of the bundle, were similar. Interestingly, in only 19% of cases was there compliance with the total care bundle. The single intervention that showed an associated reduction in SSI was preoperative warming (p=0.032). Conclusions The DH care bundle did not reduce SSIs after open colorectal surgery. Despite this, it is not possible to state that the bundle is ineffective as compliance rates before and after bundle implementation were similar. All studies evaluating the effectiveness of care bundles must include data for compliance with interventions both before and after implementation of the care bundle; poor compliance may be one of the reasons for the lower than expected reduction of SSIs.

Veterinary and human biobanking practices: enhancing molecular sample integrity

Animal models have historically informed veterinary and human pathophysiology. Next-generation genomic sequencing and molecular analyses using analytes derived from tissue require integrative approaches to determine macroanalyte integrity as well as morphology for imaging algorithms that can extend translational applications. The field of biospecimen science and biobanking will play critical roles in tissue sample collection and processing to ensure the integrity of macromolecules, aid experimental design, and provide more accurate and reproducible downstream genomic data. Herein, we employ animal experiments to combine protein expression analysis by microscopy with RNA integrity number and quantitative measures of morphologic changes of autolysis. These analyses can be used to predict the effect of preanalytic variables and provide the basis for standardized methods in tissue sample collection and processing. We also discuss the application of digital imaging with quantitative RNA and tissue-based protein measurements to show that genomic methods augment traditional in vivo imaging to support biospecimen science. To make these observations, we have established a time course experiment of murine kidney tissues that predicts conventional measures of RNA integrity by RIN analysis and provides reliable and accurate measures of biospecimen integrity and fitness, in particular for time points less than 3 hours post-tissue resection.

The physical health of the seriously mentally ill: an overview of the literature

Despite the wealth of literature which attests to the relationship between serious mental illness (SMI) and physical ill health, the provision of optimum physical health care for mental health service users remains a challenge. In England the Department of Health has identified the evident health inequalities for people with SMI as a priority area for health improvement, publishing numerous policy directives aimed at addressing these inequalities. However, this is a highly complex process and little is known about why the rhetoric of holistic health care has proved unattainable thus far. In this paper we present an informed commentary of the contemporary literature with the aim of offering a more comprehensive understanding of the health inequalities faced by people with SMI. We searched relevant databases for publications related to: the causes of poor physical health among the mentally ill, strategies to address these health needs and the impact which professional education, culture and services structure has on this facet of service delivery. This enabled us to identify potential strategies that can be adopted by health care practitioners wishing to improve the health of this vulnerable group, and by educationalists to advance professionals' knowledge of this important and ostensibly neglected area.

"It's a hidden issue": exploring the experiences of women with HIV-associated neurocognitive challenges using a disability framework

PURPOSE

To use the World Health Organization's International Classification of Functioning, Disability and Health (ICF) to explore the experiences of women living with self-identified HIV-associated neurocognitive challenges.

METHOD

This interpretive, qualitative study involved key informant interviews with 16 women with self-identified HIV-associated neurocognitive challenges. Data were collected through 60-90 min, in-depth, semi-structured interviews. Thematic analysis was performed using an inductive approach. Theoretical analysis then used the ICF to reconceptualize the data using a disability lens.

RESULTS

Participants perceived impairments (e.g. memory loss, difficulty multi-tasking) and participation restrictions (e.g. parenting, work roles) resulting from their neurocognitive challenges as having a larger impact on their daily lives than activity limitations (e.g. difficulty with chores). Participants held contrasting views about parenting: women with children drew strength from parenting whereas women without children worried that parenting could compromise their health. Participation in work and volunteering roles was viewed as integral to managing neurocognitive challenges and health overall.

CONCLUSIONS

Conceptualizing neurocognitive challenges through a disability lens focuses attention on how impairments interact with other realities in these women's lives. This exploratory study reveals the need for future research exploring perceptions among people living with HIV-associated neurocognitive challenges with attention to aging and among other vulnerable groups.

Oral arginine attenuates the growth hormone response to resistance exercise

This study investigated the combined effect of resistance exercise and arginine ingestion on spontaneous growth hormone (GH) release. Eight healthy male subjects were studied randomly on four separate occasions [placebo, arginine (Arg), placebo + exercise (Ex), arginine + exercise (Arg+Ex)]. Subjects had blood sampled every 10 min for 3.5 h. After baseline sampling (30 min), subjects ingested a 7-g dose of arginine or placebo (blinded, randomly assigned). On the exercise days, the subject performed 3 sets of 9 exercises, 10 repetitions at 80% one repetition maximum. Resting GH concentrations were similar on each study day. Integrated GH area under the curve was significantly higher on the Ex day (508.7 ± 169.6 min·ng/ml; P < 0.05) than on any of the other study days. Arg+Ex (260.5 ± 76.8 min·ng/ml) resulted in a greater response than the placebo day but not significantly greater than the Arg day. The GH half-life and half duration were not influenced by the stimulus administered. The GH secretory burst mass was larger, but not significantly, on the Arg, Ex, and Arg+Ex day than the placebo day. Endogenous GH production rate (Ex > Arg+Ex > Arg > placebo) was greater on the Ex and Arg+Ex day than on the placebo day ( P < 0.05) but there were no differences between the Ex and Arg+Ex day. Oral arginine alone (7 g) stimulated GH release, but a greater GH response was seen with exercise alone. The combined effect of arginine before exercise attenuates the GH response. Autonegative feedback possibly causes a refractory period such that when the two stimuli are presented there will be suppression of the somatotrope.

Alkaptonuric ochronosis: a case report

Alkaptonuric ochronosis is a rare autosomal recessive metabolic disorder resulting in a deficiency of homogentisic acid oxidase (alkaptonuria). Ultimately, this enzyme deficiency enables homogentisic acid to accumulate, become polymerized, and be systemically deposited within various tissues of the body (ochronosis). As the disease progresses, tissue deposition of polymerized homogentisic acid eventually will lead to the progressive degeneration of all affected body systems. There is no definitive cure for alkaptonuric ochronosis, and treatment is aimed at controlling and ameliorating symptoms. Multiple systemic complications occur as a result of alkaptonuric ochronosis. In the skeletal system, cervical, thoracic and lumbosacral degenerative disk disease develops, as do widespread arthritic changes in peripheral and weight-bearing joints. In the respiratory system, dyspnea can develop owing to limited chest excursion as a result of stiffening of cartilage in the chest wall. In the cardiovascular system, coronary and valvular calcification frequently occurs. In the genitourinary system, calculi formation and urine discoloration are chief manifestations. This case report describes a 63-year-old man with alkaptonuric ochronosis who sustained a stress fracture of the left femoral neck, necessitating surgical repair, which was done without complications. An overview of alkaptonuric ochronosis is presented, and anesthetic implications are discussed.

Topology of electronic charge density and energetics of planar faults in fcc metals

Using ab initio calculations we have studied the energetics and the evolution of the electronic charge density with shear in three fcc metals exhibiting different deformation properties, aluminum, silver, and iridium. The charge redistribution described by the change in character of specific charge density critical points (cps), is ascertained from the values of the charge density, rho(0), and its three principal curvatures, rho( parallel parallel), rho(hh), and rho(vv), respectively. The change in character of cps correlates with the energetics. For all three metals, rho(hh) vanishes near the unstable stacking configuration. The symmetry or asymmetry of the charge redistribution, measured by rho(hh)/rho(vv), may be an important factor determining stacking fault energies.

Immigrant nurses' experience of racism

PURPOSE

To document and describe the experiences of immigrant nurses of colour who have filed grievances concerning their employers' discriminatory practices; and to solicit their views of existing policies and recommendations for equity in professional life.

DESIGN AND METHODS

In this descriptive, exploratory study nine immigrant nurses of colour in Ontario, Canada, were interviewed between 1997 and 1998. Data were collected through face-to-face interviews and in focus groups. The discourse theory and methods of van Dijk and Essed were used to analyse the qualitative data.

FINDINGS

Recurring themes were: (a) being marginalized and acknowledging and naming the racist experiences; (b) experiencing physical stress and emotional pain; (c) strategizing to cope and survive; (d) recommending policy changes.

CONCLUSIONS

All nurses interviewed had experienced reprisals as a result of complaining or filing grievances and unfairness was encountered in the redress process itself. Participants recommended policy initiatives to ensure equity and fair practices in the nursing profession.

Evaluation of a PCR/DNA probe colorimetric membrane assay for identification of Campylobacter spp. in human stool specimens

DNA was extracted from 50 human stool specimens using the QIAamp DNA stool minikit. PCR amplification was followed by post-PCR hybridization to DNA probes specific for the Campylobacter genus, Campylobacter jejuni, and Campylobacter coli in a colorimetric membrane assay. Thirty-two of 38 culture-positive specimens were PCR/DNA probe positive for C. jejuni. The assay is rapid and simple and can be applied to stool specimens for the detection of Campylobacter.

Evaluation of methods for detection of toxins in specimens of feces submitted for diagnosis of Clostridium difficile-associated diarrhea

Clostridium difficile is the principal pathogen associated with hospital-acquired acute diarrheal disease. We have evaluated the performances of six approaches for diagnosis of C. difficile-associated diarrhea (CDAD). Consecutive stool specimens (n = 200) from 133 patients were examined by cytotoxin assay, by culture of C. difficile on cycloserine-cefoxitin-fructose agar, and by toxin detection using four rapid immunoassay systems (Oxoid Toxin A test, ImmunoCard Toxin A test, TechLab Tox A/B II test, and Premier Toxins A&B test). A diagnosis of CDAD was established for 35 (27%) patients (representing 29% of specimens). The adjusted sensitivity and specificity of the methods were, respectively, 98 and 99% for the cytotoxin assay, 54 and 99% for ImmunoCard, 50 and 98% for Oxoid, 79 and 98% for TechLab, 80 and 98% for Premier, and 57 and 100% for culture. The TechLab and Premier assays are acceptable tests for diagnosis of CDAD but are not equivalent to the cytotoxin assay.

Psychosocial impact of the lipodystrophy syndrome in HIV infection

Lipodystrophy is a poorly understood condition associated with antiretroviral therapy in HIV infection. The symptoms may include some combination of central fat accumulation, peripheral fat depletion, and metabolic disturbance. A qualitative survey of 33 HIV-infected heterosexual women and gay men with lipodystrophy assessed psychosocial impact and effect on quality of life. Dominant themes included erosion of self-image and self-esteem, problems in social and sexual relations, threats to locus of control, forced HIV disclosure, and demoralization and depression. Another theme was clinicians' minimization of the importance of lipodystrophy. Further research is required to fully understand the psychosocial impact of lipodystrophy and to develop strategies that help individuals cope.

Anhydride modified cantharidin analogues: synthesis, inhibition of protein phosphatases 1 and 2A and anticancer activity

Two series of anhydride modified cantharidin analogues were synthesised and screened for their phosphatase inhibition (PP1 and PP2A) and cytotoxicity in various cancer cell lines (Ovarian A2780, ADDP; Osteosarcoma 143B; and Colon HCT116 and HT29). One series was synthesised by a novel, high yielding one-pot hydrogenation-ring-opening-esterification procedure, the other by acid catalysed acetal formation. Analogues 5-7 and 9 displayed moderate PP2A selectivity (ca. 5- to 20-fold) and inhibition typically in the low microM range (comparable, in some cases to cantharidin). The anticancer activity of these analogues varied with the cell line under study; however, many of them showed selective cytotoxicity for the colon tumour cell lines.

How do general practitioners select antidepressants for depressed elderly people?

This study aimed to identify factors predicting general practitioner's (GPs) choice of which antidepressant to prescribe for depression in the elderly, using a postal questionnaire survey based on three clinical case vignettes. The main outcome measure was the GP's primary reason for selection of an antidepressant. GPs prescribing SSRIs gave 'few side effects' and 'safer in overdose' as the most important reasons for choosing the antidepressant. Older GPs were more likely to use unmodified tricyclics, and selected drugs based on their knowledge and experience in use of the drug. Cost was rarely a primary consideration. Educational programmes should address the reluctance by some GPs to use new or unfamiliar medications and highlight issues relating to side-effects and drug safety.

Mechanism of relaxations to dendroaspis natriuretic peptide in canine coronary arteries

Experiments were designed to determine mechanisms by which Dendroaspis natriuretic peptide (DNP) causes relaxations in coronary arteries. Rings of canine left circumflex artery with and without endothelium were suspended in organ chambers filled with Krebs-Ringer bicarbonate solution (37 degrees C, bubbled with 95% O2/5% CO2). Concentration-response curves to DNP (10(-10) to 3 x 10(-7) M) were obtained in arteries contracted with prostaglandin (PGF(2alpha), 2 x 10(-6) M), either in the absence or the presence of C-ANP (10(-6) M) to inhibit natriuretic clearance receptors; indomethacin to inhibit cyclooxygenase (INDO, 10(-5) M), N(G)-monomethyl-L-arginine to inhibit production of nitric oxide (L-NMMA; 10(-4) M), HS-142-1 to inhibit particulate guanylate cyclase (10(-5) M); 1H-[1,2,4]oxadiazolo-[4,3-alpha]quinoxalin-1-one to inhibit soluble guanylate cyclase (ODQ; 10(-5) M), or tetraethylammonium to inhibit potassium channels (TEA; 10(-3) or 10(-2) M). Relaxations to DNP were greater in rings with than in those without endothelium. C-ANP significantly attenuated relaxations to DNP only in rings with endothelium. HS-146-1 but not INDO, L-NMMA, ODQ, and TEA significantly reduced relaxations to DNP in rings with and without endothelium contracted with PGF(2alpha). These results suggest that the endothelium augments inhibitory effects of DNP and that natriuretic clearance receptors mediate this component of the response to DNP in canine coronary arteries. In addition, relaxations to DNP in canine arterial smooth muscle involve activation of particulate guanylate cyclase but not hyperpolarization.

Hepatitis C in injecting drug-using women during and after pregnancy

BACKGROUND

A high proportion of female injecting drug users (IDU) have evidence of hepatitis C virus (HCV) infection. We undertook a prospective study of patients attending a clinic for pregnant IDU to determine the impact of pregnancy on the course of HCV infection and whether pregnancy is affected by HCV infection.

METHODS

One hundred and thirty-one IDU were recruited and followed up with liver function tests, HCV serology and HCV-RNA tests.

RESULTS

Of 131 patients, 125 had HCV antibodies (anti-HCV positive) at delivery, and of these 62% were HCV-RNA positive. The anti-HCV-negative women were younger and had a shorter duration of drug use than the anti-HCV-positive women. There were no differences between viraemic and non-viraemic women with respect to age, ethnicity, duration of injecting drug use, methadone maintenance dose, hepatitis B exposure or reported high-risk behaviour. Alanine aminotransferase (ALT) levels were higher and the proportion with ALT > 55 IU/L higher in viraemic women. Viraemia persisted in all 55 women who were viraemic at term. Eleven had an ALT flare post-partum that was unrelated to viral load and was clinically unsuspected. Four had concurrent elevated gamma-glutamyltranspeptidase and were considered to be drinking alcohol at hazardous levels. Four of 23 women who were HCV-RNA negative at term became positive during follow up.

CONCLUSIONS

Pregnancy does not adversely affect the course of hepatitis C. A modest rebound in ALT levels, but not HCV-RNA, occurs after delivery in some viraemic women. This supports the theory that immune mechanisms rather than direct viral cytopathology are involved in hepatocyte injury during HCV infection. Hepatitis C infection did not influence pregnancy complications and outcomes.

Mechanical distention modulates alveolar epithelial cell phenotypic expression by transcriptional regulation

The development of a normal pulmonary alveolar epithelium, essential for gas exchange, is critical for the successful adaptation to extrauterine life. From observations of natural and experimental developmental abnormalities, it has been hypothesized that mechanical factors may play a role in regulating differentiation of the pulmonary alveolar epithelium. To test this hypothesis directly, we have investigated the in vitro effects of mechanical distention on the expression of specific markers for the type I and type II cell phenotypes. Fetal rat lung (18-d) explants were mechanically distended in culture for 18 h. Mechanical distention caused an increase in RTI 40 messenger RNA (mRNA), a marker of the type I cell phenotype, of 10.6 times (n = 3, P < 0.05) that of undistended controls. In contrast, mechanical distention resulted in a decrease in mRNA content of two markers of the type II cell phenotype, surfactant protein (SP)-B and SP-C. SP-B was reduced to 10 +/- 9% (n = 3, P < 0.005) and of SP-C to 12 +/- 7% (n = 3, P < 0.0001) of undistended controls. Mechanical distention had no effect on content of mRNA for SP-A or 18S ribosomal RNA. Examined by nuclear run-on assays, mechanical distention caused changes in transcriptional rates of RTI 40, SP-B, and SP-C. These data show that mechanical distention stimulates expression of a type I cell marker and inhibits expression of markers for the type II phenotype; these effects occur at least in part at the transcriptional level. These studies support the hypothesis that mechanical distention of fetal lung tissue stimulates expression of the type I cell phenotype and inhibits expression of the type II phenotype.

Localization of a candidate surfactant convertase to type II cells, macrophages, and surfactant subfractions

Pulmonary surfactant exists in the alveolus in several distinct subtypes that differ in their morphology, composition, and surface activity. Experiments by others have implicated a serine hydrolase in the production of the inactive small vesicular subtype of surfactant (N. J. Gross and R. M. Schultz. Biochim. Biophys. Acta 1044: 222-230, 1990). Our laboratory recently identified this enzyme in the rat as the serine carboxylesterase ES-2 [F. Barr, H. Clark, and S. Hawgood. Am. J. Physiol. 274 (Lung Cell. Mol. Physiol. 18): L404-L410, 1998]. In the present study, we determined the cellular sites of expression of ES-2 in rat lung using a digoxygenin-labeled ES-2 riboprobe. ES-2 mRNA was localized to type II cells and alveolar macrophages but not to Clara cells. Using a specific ES-2 antibody, we determined the protein distribution of ES-2 in the lung by immunohistochemistry, and it was found to be consistent with the sites of mRNA expression. Most of the ES-2 in rat bronchoalveolar lavage is in the surfactant-depleted supernatant, but ES-2 was also consistently localized to the small vesicular surfactant subfraction presumed to form as a consequence of conversion activity. These results are consistent with a role for endogenous lung ES-2 in surfactant metabolism.

Optimization of sacral ventral root stimulation following SCI: two case reports with six-month follow-up

Sacral ventral root stimulation in conjunction with sacral dorsal rhizotomy has been effective in promoting voiding in individuals with upper-motor-neuron spinal cord injury. We report on two patients who had variable voiding responses to stimulation during the first six months after electrode implantation. We used videourodynamic records and daily voiding records to characterize their voiding difficulties. Different methods were used to improve voiding, including seating adjustments and changes in stimulation parameters. The first patient was unable to empty his bladder on a regular basis with stimulation using 24 pulses per sec stimulating frequency for the first two months after implantation. Voiding was substantially improved by using 35 pulses per sec. At the end of six months, he is regularly emptying his bladder with stimulation and is on an every-second-day bowel program. However, his bowel program has been irregular. The second patient had very good voiding when stimulation was applied in bed, but he had poor voiding with high residual volumes when sitting in his wheelchair. Voiding was improved when he used a wheelchair cushion that was cut out in the back or lifted his buttocks off the chair. These procedures appeared to reduce perineal pressures. This patient has bowel care on alternate days and his bowel care time has been reduced following implantation of the device. Neither of the patients experienced an erection with the device. Both patients feel positive about their implant experience.

Dragmacidins: new protein phosphatase inhibitors from a southern australian deep-water marine sponge, spongosorites sp

A Spongosorites sp. collected during trawling operations off the southern coast of Australia returned the new alkaloid dragmacidin E (3), the structure of which was secured by detailed spectroscopic analysis. Dragmacidin E (3), and its co-metabolite dragmacidin D (1) have been identified as potent inhibitors of serine-threonine protein phosphatases.

Developmental regulation of protein phosphatase types 1 and 2A in post-hatch chicken brain

The activity and subcellular distribution of protein phosphatases 1 and 2A were measured in chicken forebrain and cerebellum during post-hatch development. At all post-hatch ages, a large proportion of PP1 and PP2A was membrane bound and these enzymes were less active than their cytosolic counterparts. The protein concentration of PP1 in the membranes increased 40% between 2 and 14 days and a further 60% between 14 days and adult, whereas the PP1 enzyme activity in the membranes progressively decreased. In contrast to PP1, the protein concentration of PP2A remained constant in all fractions during post-hatch development, and the enzyme activity of PP2A did not change except for a decrease in the membrane-bound activity between 2 and 14 days. These results show that the subcellular distribution and activity of PP1 is selectively regulated during post-hatch development and that membrane association and inactivation of PP1 are independent events.

Transmission of hepatitis C virus to infants of human immunodeficiency virus-negative intravenous drug-using mothers: rate of infection and assessment of risk factors for transmission

The risk of perinatal transmission of hepatitis C virus (HCV) from a cohort of 95 human immunodeficiency virus (HIV)-negative intravenous drug users (IVDU) is described, 89 of whom were positive for antibodies to HCV (anti-HCV). Infection, defined as the presence of HCV RNA in a serum sample collected from an infant at any time during follow-up, was detected in six of 63 (9.5%) infants born to HCV antibody-positive viraemic mothers. No mother who was HCV RNA negative at delivery transmitted HCV to her infant. Hepatitis C virus antibodies became undetectable in uninfected infants by 15 months, but persisted in all HCV-infected infants throughout follow-up. An abnormal alanine aminotransferase (ALT) level was observed on at least one occasion in all HCV-infected infants and in six occasions in uninfected infants. Two of the six HCV-infected infants became HCV RNA negative during follow-up by 27 and 29 months. Both of these infants had a large ALT elevation (mean peak ALT 398U l-1) at around 12 months of age. Analysis of a range of potential risk factors revealed that maternal HCV RNA load was important in predicting transmission, but suggested that other factors play a role in perinatal transmission from mother to child. No difference was found between mothers who transmitted HCV to their infants and those who did not for HCV genotype, duration of drug use, duration of methadone use, methadone dose, history of alcohol abuse, past hepatitis B virus (HBV) infection, mode of delivery, maternal and gestational age, birth weight and incidence of breast-feeding. Mothers who transmitted HCV to their infants had a longer duration between membrane rupture and delivery than the mothers who did not transmit (P = 0.03). HCV RNA was not detected in breast milk and colostrum samples from 38 viraemic mothers, including two who transmitted HCV to their infant.

Does a teaching programme improve general practitioners' management of depression in the elderly?

General Practitioners have a central role to play in the management of depression in their older patients. However, studies suggest that GPs tend to underdiagnose and undermanage depression in this age group. Continuing Medical Education is an important part of helping GPs keep up to date and improve their practice. We set out to see what effect a half a day postgraduate training course had on the views and knowledge of a group of local GPs on the management of depression in the elderly. Twenty-one general practitioners attended the course and of these fifteen completed a questionnaire with clinical vignettes before and six weeks after the course. Analysis of the questionnaire and vignette data showed significant improvements in a number of areas: in particular, GPs' knowledge about antidepressant treatment increased, as did their preference for cognitive behavioural therapy out of a range of psychological treatments. This study indicates that a teaching package on depression in the elderly can improve general practitioner's management knowledge. It also suggests that old age psychiatrists can play an important part in the education of their GP colleagues. Nevertheless, further studies are needed to ensure that educational programmes make an effective impact on the underdiagnosis and undertreatment of depression in the elderly.

Management of depression in the elderly by general practitioners: referral for psychological treatments

This study investigates referrals for psychological therapies in general practitioners (GPs) from five catchment areas. The results show that 93 per cent of GPs would consider referring elderly patients for psychological help but only 44 per cent had done so and one in three GPs were unfamiliar with the psychological therapies available. When GPs were asked to select a psychological treatment for depression, 60 per cent chose counselling compared to 21 per cent who chose cognitive-behavioural therapy (CBT). Female GPs particularly favoured counselling. Experience in psychiatry was associated with selection of CBT. The results show that GP training and further education should emphasize psychological therapies. This should make referrals more appropriate and improve patient care.

Evaluation of a cognitive-behavioural intervention for pregnant injecting drug users at risk of HIV infection

Pregnant injecting drug users were randomly assigned to: (i) individually receive a six-session cognitive-behavioural intervention in addition to their usual methadone maintenance treatment (intervention condition (I) (n = 40)); or (ii) their usual methadone maintenance treatment only (control condition (C) (n = 40)). There was no change in drug use per se in either group after the intervention. However, at 9-month follow-up the I group had significantly reduced some HIV risk-taking behaviours (in particular injecting risk behaviours). The I group reduced the needle risk associated both with "typical" use (drug use in the month before interview) and "binge" use (drug use in the month nominated as the heaviest month of drug use in the previous 6 months). The intervention had no effect on sexual risk behaviours. The finding of reduced injecting risk behaviour following the six-session intervention suggests that such an intervention may be of benefit for individuals persisting with injecting risk behaviours despite methadone maintenance treatment and the availability of sterile injection equipment.

Semiextended position of intramedullary nailing of the proximal tibia

Over a 24 month period, 30 patients with proximal tibia fractures who were reviewed consecutively were treated by nonreamed, statically locked, intramedullary nailing. There were 16 open, 13 segmental, and 7 comminuted fractures (Winquist III, IV). The average distance from the fracture to the proximal locking screws was 24 mm (range, 0-65 mm). All procedures were performed while the patient's affected leg was on a radiolucent table without traction. The last 25 fractures were nailed using a partial (2/3) medial parapatellar incision while the leg was semiextended. This approach allowed the patella to be subluxed laterally availing the trochlear groove for use as a conduit for nail placement. Using only 15 degrees knee flexion eliminated the extension force of the quadriceps on the proximal fragment, which otherwise would have tended to cause anterior angulation at the fracture site. In the first 5 patients, the average anterior angulation was 8 degrees (range, 5 degrees-15 degrees). Of the 25 patients who were treated while in the semiextended position, none had more than 5 degrees anterior angulation and 19 had no anterior angulation. Fractures of 3 of the 25 patients had greater than 5 degrees angulation in the coronal plane, 2 of which were nailed in the semiextended position. This technique greatly facilitates intramedullary nailing of proximal tibia fractures.

Care of central venous catheters for total parenteral nutrition

This report summarizes data obtained via a mailed questionnaire from 129 Department of Veterans Affairs (VA) hospitals regarding current practices in the care of central venous catheters (CVCs) used for total parenteral nutrition (TPN). The size of VA hospitals' acute medical-surgical beds ranged from 14 to 1320 (median 168) beds. Over 6000 patients annually received CVCs for TPN. Hospitals reported using triple-lumen catheters most frequently as their CVC for TPN (80.3%). A povidone-iodine scrub was used to prepare the skin for CVC insertion by 72.6% of reporting hospitals. Sixty percent of hospitals used transparent polyurethane dressings. Care of CVCs varied among hospitals. Catheter-related infection and sepsis rates were within the national average, although < 50% of responding hospitals provided data on these outcomes. The results of this survey point to the need for a national standardized database relative to patients receiving TPN via a CVC.