Chronic pain treatment with pregabalin in end stage respiratory failure patients awaiting lung transplantation on ambulatory veno-venous extra corporeal membrane oxygenator support; a series of nine cases

Background

End-stage respiratory failure is non-treatable with mechanical ventilation and can be treated with veno-venous extracorporeal membrane oxygenators (VV-ECMO). It can also be used as a bridge to lung transplantation or recovery of lung function. This patient group can suffer from chronic pain, which is further exacerbated by painful procedures required as part of treatment. Pregabalin is licensed for chronic neuropathic pain and generalized anxiety disorder. Thus far, it has not been tried in routine analgesia protocols for pain relief of patients on VV-ECMO.

Case Series

We included nine patients aged 17-54 years on VV-ECMO awaiting lung transplantation. Exclusion criteria were acute kidney injury and chronic kidney disease. All patients had morphine patient-control analgesia. In addition, pregabalin 50 mg twice daily was initiated in all patients with dose escalation as required. Pain scores and quality of sleep were evaluated daily. All patients experienced significant pain relief, demonstrated by reduced pain scores after treatment commencement. The mean visual analogue scale score was reduced significantly from 6 ± 2 to 3 ± 1. A significant increase in good-quality sleep duration was recorded from 5 ± 1.7 hours per day before to 8 ± 2.1 hours per day after pregabalin treatment. All patients except for two reported reduced anxiety levels of at least 2 ± 1 scale improvement (p <0.05).

Conclusions

Pregabalin is an efficient analgesic with accompanying anxiolytic effects in this group of patients with unique characteristics such as high analgesia requirements and exacerbated psychological and emotional stress. HIPPOKRATIA 2023, 27 (1):22-24.

A Comparison of the Performance of SARS-CoV-2 Antibody Assays in Healthcare Workers with COVID-19

Aims Since its emergence, significant interest surrounds the use of SARS-CoV-2 serological tests as an alternative or as an adjunct to molecular testing. However, given the speed of this pandemic, paralleled with the pressure to develop and provide serological tests in an expediated manner, not every assay has undergone the rigorous evaluation that is usually associated with medical diagnostic assays. We aimed to examine the performance of several commercially available SARS-CoV-2 IgG antibody assays among participants with confirmed COVID-19 disease and negative controls. Methods Serum taken between day 17 and day 40 post onset of symptoms from 41 healthcare workers with RT-PCR confirmed COVID-19 disease, and pre-pandemic serum from 20 negative controls, were tested for the presence of SARS-CoV-2 IgG using 7 different assays including point-of-care (POC) and laboratory-based assays. Results Assay performance varied. The lab-based Abbott diagnostics SARS-CoV-2 IgG assay proved to be the assay with the best positive and negative predictive value, and overall accuracy. The POC Nal von Minden GmbH and Biozek assays also performed well. Conclusion Our research demonstrates the variations in performance of several commercially available SARS-CoV-2 antibody assays. These findings identify the limitations of some serological tests for SARS-CoV-2. This information will help inform test selection and may have particular relevance to providers operating beyond accredited laboratories.

Standardisierter Computer-basiert-organisierter Report des EEG (SCORE) – Eine strukturierende Form der EEG-Befundung

Eine 2013 von der „International Federation of Clinical Neurophysiology“ gegründete Taskforce hat eine international konsensfähige EEG-Terminologie entwickelt. Im Folgenden soll das Resultat – die 2. Version des Standardized Computer-based Organized Reporting of EEG (SCORE) - vorgestellt werden. Die Terminologie wurde im Rahmen eines Softwarepaketes (SCORE-EEG) in der klinischen Praxis an über 12.000 EEGs getestet. Die Auswahl der Begriffe ist kontextabhängig: die initiale Auswahl bestimmt, welche weiteren Auswahlmöglichkeiten zur Verfügung stehen. Im Verlauf wird automatisch ein Befund erstellt und dessen Einzelmerkmale in eine Datenbank eingespeist. SCORE verfügt über Module spezifisch für die Befundung epileptischer Anfälle, sowie charakteristischer neonataler und intensivmedizinische EEG-Merkmale. SCORE ist nicht nur ein nützliches Werkzeug im ambulanten, klinischen und wissenschaftlichen Setting, es erleichtert auch Qualitätssicherung, Datenaustausch und die EEG-Aus und Weiterbildung.

The Complete Genome Sequence of Methanobrevibacter sp. AbM4

Methanobrevibacter sp. AbM4 was originally isolated from the abomasal contents of a sheep and was chosen as a representative of the Methanobrevibacter wolinii clade for genome sequencing. The AbM4 genome is smaller than that of the rumen methanogen M. ruminantium M1 (2.0 Mb versus 2.93 Mb), encodes fewer open reading frames (ORFs) (1,671 versus 2,217) and has a lower G+C percentage (29% versus 33%). Overall, the composition of the AbM4 genome is very similar to that of M1 suggesting that the methanogenesis pathway and central metabolism of these strains are highly similar, and both organisms are likely to be amenable to inhibition by small molecule inhibitors and vaccine-based methane mitigation technologies targeting these conserved features. The main differences compared to M1 are that AbM4 has a complete coenzyme M biosynthesis pathway and does not contain a prophage or non-ribosomal peptide synthase genes. However, AbM4 has a large CRISPR region and several type I and type II restriction-modification system components. Unusually, DNA-directed RNA polymerase B' and B'' subunits of AbM4 are joined, a feature only previously observed in some thermophilic archaea. AbM4 has a much reduced complement of genes encoding adhesin-like proteins which suggests it occupies a ruminal niche different from that of M1.

An overview of pharmacology and acute pain: part one

This two-part article, the fourth in a series on pain, explores the four main divisions of pharmacology: pharmacodynamics--what the medicine does to the body; pharmacokinetics--what the body does to the medicine; pharmacoeconomics--the cost and benefit ratio compared to other treatments; and pharmacovigilance--a medicine's safety profile. Part two, which will published next week, will explore the main categories of analgesic medicines.

An overview of pharmacology and acute pain: part two

This article explores the role of medicines in the management of acute pain. The main categories of analgesic drugs are outlined and the different routes of administration are explored. The characteristics and precautions associated with the different classes of medicines are also highlighted.

Solution doping of microstructured polymer optical fibres

Solution doping of microstructured polymer optical fibres [mPOF] is demonstrated, a technique which allows dopants to be introduced after polymerisation through the microstructure. Controlled diffusion is used to disperse the dopant uniformly across the fibre core, and the final concentration can be systematically varied by appropriate choice of conditions. We use this technique to produce a fibre doped with Rhodamine 6G and characterize its loss and fluorescence behavior.

Clinical care of patients with epidural infusions

Opioids and local anaesthetics are the two main agents used in epidural analgesia. The procedure has many potential side-effects, including hypotension, pruritus, urinary retention, headache and respiratory depression.

Cost associated with the treatment of influenza in a managed care setting

OBJECTIVE

The purpose of this study was to assess the costs and treatments associated with influenza patients with and without secondary viral or bacterial infections in a managed care setting.

METHODS

Patients with influenza diagnoses (ICD-9 = 487) were identified in the PharMetrics database between January 1, 1997 and June 30, 1998. Patients were placed into 3 cohorts: influenza only (INF), influenza plus a secondary bacterial respiratory infection (BRI), and influenza plus a secondary viral respiratory infection (VRI). The index date was defined as the date of the first occurrence of an influenza diagnosis during the study period. Medical claims were assessed from the index date to the end of the influenza episode, which was defined as the date of the last claim for influenza followed by a 90-day "clean period" during which no influenza-related charges occurred.

RESULTS

A total of 18,000 patients met the inclusion criteria. The mean age was 29 years, and 54% were female. Approximately 93% of patients were placed in the INF cohort, and 3% each in the BRI and VRI groups. The BRI cohort had the highest mean total cost ($5593* SD = 10,939), compared with the VRI cohort ($847 SD = 1782) and INF cohort ($602 SD = 2813) (P less than.0001 vs INF; P less than.0001 vs VRI). This total cost disparity was primarily driven by differences in inpatient costs: BRI ($3509, SD = 9474); VRI ($208, SD = 1327); INF ($138, SD = 2145). Patients in the BRI cohort averaged 0.5 hospitalizations per patient vs 0.06 in the VRI cohort and 0.03 in the INF cohort.

CONCLUSIONS

Subjects in the BRI cohort were significantly more costly and had an increased risk of hospitalization as compared with subjects in the VRI or INF cohorts. Early intervention with antiviral agents and/or antibiotics, where appropriate, could result in significant cost savings for managed care organizations.

Systematic review of ondansetron for the prevention and treatment of postoperative nausea and vomiting in adults

OBJECTIVES

To determine the efficacy and safety of ondansetron for the prevention and treatment of postoperative nausea and vomiting (PONV) in adults.

DESIGN

Systematic review of published double-blind randomised controlled trials.

DATA SOURCES

Twenty seven trials from 1990 to July 1998 retrieved from a systematic literature search (Medline, Cinahl, Embase, Cochrane Library, reference lists, hand searching of anaesthetic journals, & provided manufacturer information); restricted to English language.

MAIN OUTCOME MEASURES

Estimation of efficacy (incidence of complete absence of nausea or other outcome measure as defined by the authors) at 24 hours.

RESULTS

Seven double-blind randomised controlled trials with 1,623 patients studied intravenous ondansetron 1 mg, 4 mg, or 8 mg for the treatment of postoperative nausea and vomiting (PONV). Four mg, compared with metoclopramide 10 mg, produced higher patient satisfaction scores and an increased incidence of freedom from nausea at 24 hours. Further studies are required to compare the safety, efficacy and dose response with other anti-emetics at 24 hours. Twenty double-blind randomised controlled trials with 4,364 patients studied intravenous and oral administration of ondansetron 1 mg, 4 mg, and 8 mg for the prevention of postoperative nausea and vomiting. There appears to be no significant difference between droperidol (0.625 mg, 1 mg or 1.25 mg) i.v. and ondansetron 4 mg in efficacy and incidence of side effects. Compared with metoclopramide, ondansetron produced less nausea but the incidence of vomiting was the same at 24 hours.

CONCLUSIONS

Further PONV could be prevented with ondansetron 4 mg compared with placebo and metoclopramide 10 mg. Further studies are required to compare ondansetron with other anti-emetics for the treatment of PONV. For prophylaxis of PONV ondansetron 4 mg appears to be equal to low dose droperidol in efficacy and the incidence of side effects, and superior to metoclopramide. Ondansetron should perhaps be limited to second line treatment in view of patient satisfaction, efficacy and cost when compared with droperidol.

Nocturnal asthma: effect of salmeterol on quality of life and clinical outcomes

OBJECTIVE

To evaluate the effect of salmeterol on asthma-specific quality of life in patients experiencing significant nocturnal symptoms.

DESIGN

Randomized, double-blind, placebo-controlled, multicenter clinical trial.

SETTING

Allergy/respiratory care clinics.

PATIENTS

Nonsmokers > or = 12 years of age with nocturnal asthma symptoms on at least 6 of 14 days during screening and > or = 15% decrease in peak expiratory flow (PEF) from baseline on nocturnal awakening at least once during screening.

INTERVENTIONS

Salmeterol, 42 microg, or placebo twice daily. Patients were allowed to continue theophylline, inhaled corticosteroids, and "as-needed" albuterol.

MEASUREMENTS AND RESULTS

Outcome measures included Asthma Quality of Life Questionnaire (AQLQ) global and individual domain scores, FEV1, PEF, nighttime awakenings, asthma symptoms, and supplemental albuterol use. Mean change from baseline for the global and domain AQLQ scores was significantly greater (p < or = 0.005) with salmeterol compared with placebo. At week 12, salmeterol significantly (p < 0.001 compared with placebo) increased mean change from baseline in FEV1, morning and evening PEF, percentage of symptom-free days, percentage of nights with no awakenings due to asthma, and the percentage of days and nights with no supplemental albuterol use. Significant improvements in PEF were observed after treatment with salmeterol regardless of concomitant treatment with theophylline (p < 0.05).

CONCLUSIONS

These results provide evidence that validates the role of salmeterol in improving quality of life in patients with moderate persistent asthma who exhibited nocturnal asthma symptoms and supports the efficacy of salmeterol compared with that of placebo (ie, "as-needed" albuterol).

Vowel change in Australian English

The dynamic nature of vowel systems has recently been investigated in several English dialects confirming that phonetic disruptions often have systemic consequences and suggesting that change follows predictable patterns of movement. The present paper examines the nature of vowel change in Australian English by comparing two sets of data from different subjects at each end of a 25-year interval. A series of multivariate analyses of variance reveals significant acoustic differences between the two sets of data providing strong evidence for systemic effects. The analysis also indicates the presence of chain and parallel shifts within vowel classes as well as a close correspondence between monophthong and diphthong movement in phonetic space. The observed monophthong/diphthong relationships suggests that change in one class of vowels impacts on the other in a parallel fashion in this dialect of English.

Immune Effector Mechanisms in Parasitic Infections

edited by F.Y. Liew and K. Vickerman, Philosophical Transactions of the Royal Society of London Series B, Vol. 352, No. 1359, 1997. pp 1293-1394, ISSN 0962-8436.

Efficacy, safety, and impact on quality of life of salmeterol in patients with moderate persistent asthma

OBJECTIVE

To evaluate the efficacy, safety, and impact on asthma-specific quality of life of salmeterol, a highly selective, long-acting beta 2-agonist, compared with that of placebo (i.e., "as-needed" albuterol).

STUDY DESIGN

Randomized, double-blind, placebo-controlled, parallel-group, multicenter study.

PATIENTS AND METHODS

Five hundred thirty-eight nonsmoking symptomatic patients 12 years of age and older meeting American Thoracic Society asthma criteria were enrolled at 55 outpatient clinics; 443 patients completed the study. Patients were randomly assigned to treatment with either salmeterol aerosol 42 micrograms twice daily or placebo (as-needed albuterol) for 12 weeks. We assessed changes in quality of life using the Asthma Quality of Life Questionnaire (AQLQ). Efficacy measurements included daily peak expiratory flow (PEF) rate, daytime and nighttime asthma symptoms, results of pulmonary function tests, and supplemental albuterol use. Patients recorded their PEF rate, supplemental albuterol use, and asthma-related symptoms daily. Pulmonary function tests and AQLQ assessments were performed at baseline and after 4, 8, and 12 weeks of treatment. Safety measurements included vital signs, physical examination, and reports of clinical adverse events at baseline and after 4, 8, and 12 weeks of treatment.

RESULTS

Mean changes from baseline in AQLQ global and domain scores were significantly greater in the salmeterol group compared with the placebo group (P < 0.001). Patients treated with salmeterol also had significant improvements in mean PEF rates, supplemental albuterol use, asthma symptom scores, and forced expiratory volume in 1 second compared with those given placebo. Both salmeterol and placebo were well tolerated and were not associated with any clinically significant changes in vital signs or physical examination findings.

CONCLUSIONS

Salmeterol 42 micrograms twice daily resulted in significantly greater improvements in asthma-specific quality of life, pulmonary function, and asthma symptoms compared with placebo (as-needed albuterol) in patients with moderate persistent asthma.

Efficacy, safety, and effects on quality of life of salmeterol versus albuterol in patients with mild to moderate persistent asthma

BACKGROUND

Salmeterol xinafoate is a long-acting, highly selective, beta2-adrenergic agonist that produces bronchodilation and clinically significant improvement in pulmonary function for up to 12 hours in patients with asthma.

OBJECTIVE

To evaluate the impact on asthma-specific quality of life, efficacy, and safety of salmeterol versus albuterol in adult patients with mild-to-moderate persistent asthma.

METHODS

A randomized, double-blind, double-dummy, parallel-group, multicenter study was conducted in 539 adult asthma patients over 12 weeks. Patients were randomized to receive either salmeterol 42 microg via metered-dose inhaler twice daily or albuterol 180 microg four times daily. Upon entry into the study, 46% of patients were being treated with an inhaled corticosteroid and were allowed to continue treatment throughout the study. Pulmonary function and asthma symptoms were monitored daily, and patients completed the Asthma Quality of Life Questionnaire (AQLQ) at baseline and after 4, 8, and 12 weeks of treatment.

RESULTS

Treatment with salmeterol twice daily produced significantly greater improvements from baseline in all quality of life domain ("Activity Limitation," "Asthma Symptoms," "Emotional Function," "Environmental Exposure") scores and in the global AQLQ score at 12 weeks (P < or = .038) compared with albuterol treatment four times daily. Pulmonary function and asthma symptoms were also significantly improved with salmeterol compared with albuterol.

CONCLUSIONS

Salmeterol 42 microg administered twice daily is significantly more effective than albuterol 180 microg four times daily for improving asthma-specific quality of life, controlling asthma symptoms, and improving pulmonary function in patients with mild-to-moderate persistent asthma. Furthermore, those improvements were maintained over a 12-week period.

Ondansetron prevents postoperative emesis in male outpatients. S3A-379 Study Group

STUDY OBJECTIVES

To determine (1) the efficacy and safety of ondansetron in the prevention of postoperative nausea and vomiting (PONV) in male outpatients; (2) prognostic factors for PONV in male outpatients; and (3) patients' perceptions of the debilitating effects of PONV in the ambulatory surgery setting.

DESIGN

Prospective, randomized, stratified, double-blind study.

SETTING

Multicenter-24 medical centers.

PATIENTS

468 ASA physical status I and II males at least 12 years of age scheduled for general anesthesia.

INTERVENTIONS

All patients received intravenous ondansetron 4 mg or placebo prior to undergoing general balanced (opioid) anesthesia.

MEASUREMENTS AND MAIN RESULTS

In the postanesthesia care unit (PACU), the number of emetic episodes, vital signs, adverse events, and nausea assessments were recorded by a blinded observer. After discharge, and until the end of the 24-hour study period, patients completed a diary that collected emetic episodes, adverse events, nausea, and pharmacoeconomic data. There were no differences in patient demographics or safety profiles between groups. The number of patients with no emesis and no nausea during the 24-hour study period was significantly greater (p < 0.05) with ondansetron 4 mg compared with placebo. Prognostic factors for an increased likelihood of developing PONV in males included a history of motion sickness or previous PONV, patients undergoing nonorthopedic procedures, and surgeries lasting longer than one hour. Finally, 38% of patients experiencing PONV perceived PONV to be as, or more debilitating than, the aftereffects of surgery itself.

CONCLUSIONS

Ondansetron 4 mg was more effective than placebo in preventing PONV in male outpatients. Males at potential risk for developing PONV include: (1) those with a history of motion sickness and/or PONV; (2) patients undergoing nonorthopedic procedures; and (3) procedures lasting longer than one hour. Such patients may benefit from receipt of a prophylactic antiemetic. Postoperative nausea and vomiting has a debilitating effect that can be differentiated by patients from the effects of surgery itself.

Prevention of group B streptococcal colonization and bacteremia in neonatal mice with topical vaginal inhibitors

Pregnant Swiss-Webster mice were vaginally inoculated with 10(5) virulent and avirulent serotype III Streptococcus agalactiae and treated 4 days later with topical vaginal inhibitor solutions. Preparations containing lipoteichoic acid (LTA) or glycerophosphate (GP), the repeating linear backbone of LTA, significantly reduced neonatal colonization and bacteremia by the virulent isolate and colonization by the avirulent strain. Similar results were obtained if bacteria were preincubated with LTA or GP at 37 degrees C for 30 min before vaginal inoculation. Human serum albumin (HSA), a known inhibitor of binding of LTA to human fetal epithelial cells, also resulted in reduction in colonization and bacteremia of neonatal mice. However, maternal treatment with a combination of HSA (2%) and GP (1%) completely prevented neonatal colonization and bacteremia without altering the normal aerobic bacterial vaginal flora. These results provide impetus to the development of an alternative means of preventing neonatal group B streptococcal infections in humans without requiring maternal immunization or chemoprophylaxis.

Ondansetron: a cost-effective advance in anti-emetic therapy

A cost-effectiveness analysis is one form of full economic evaluation where drug acquisition costs and the costs that are incurred as a result of using a particular treatment are assessed together with clinical efficacy. This paper reviews two such studies. One of the studies was a prospective randomised cost-effectiveness study which compared ondansetron (8 mg i.v. 0, 4 and 8 h following chemotherapy) with metoclopramide (3 mg/kg i.v. followed by an infusion of 0.5 mg/kg/h for 8 h) over the first 24 h following chemotherapy in hospitalised patients receiving highly emetogenic chemotherapy. This study showed that the cost per successfully treated patient (defined in this study as having < or = 1 emetic episode and no adverse events) for these 2 treatments were approximately equal: ondansetron pounds 95 and metoclopramide pounds 92. The second study was an economic evaluation based on data collected over a 5-day period following cyclophosphamide-based chemotherapy given on an outpatient basis for the treatment of breast cancer. Patients received an intravenous dose of 16 mg dexamethasone with either 8 mg ondansetron or 60 mg metoclopramide intravenously before chemotherapy followed by oral dosing with 8 mg ondansetron or 20 mg metoclopramide 3 times daily for 5 days. The costs per successfully treated patient (defined in this study as no vomiting or retching episodes and no anti-emetic-related adverse events during the 5-day period) were comparable: ondansetron pounds 184 and metoclopramide pounds 160. A recent study has established that ondansetron (8 mg) given orally twice daily is as effective as the same dose given 3 times a day. A sensitivity analysis using the cost of an ondansetron twice daily regimen showed that ondansetron is more cost-effective than metoclopramide (pounds 133 vs. pounds 160). These cost effectiveness studies have shown that ondansetron is at least as cost-effective as metoclopramide and simplified ondansetron dosing schedules render ondansetron more cost-effective. These full economic evaluations illustrate that drug acquisition costs can be a misleading guide to the economic impact of antiemetics.

Prevention of Escherichia coli K1 bacteremia in newborn mice by using topical vaginal carbohydrates

Pregnant Swiss-Webster mice were vaginally inoculated with 5 x 10(4) Escherichia coli K1 strain LH (O75:K1:H3) or C94 (O7:K1:H-). Inhibitor solutions were applied vaginally before delivery and the incidence of bacteremia and surface colonization determined in neonates at 3 days of age. E. coli K1 strain LH resulted in bacteremia in 77% and colonization in 74% of control newborn mice. After topical maternal vaginal D-mannose treatment, bacteremia and colonization were present in 25% of neonates. Topical vaginal application of subinhibitory concentration of gentamicin reduced bacteremia to 23% of neonates. Topical methyl-alpha-D-mannoside and p-nitrophenyl-D-mannoside, however, prevented bacteremia in 100% of newborn mice. A neonatal meningitis strain of E. coli K1 (C94) caused bacteremia in 100% of neonates and was also completely inhibited by methyl-alpha-D-mannoside. This technique of vaginal treatment before delivery may have applicability to human mothers and their infants.

Identification of a high-virulence clone of serotype III Streptococcus agalactiae by growth characteristics at 40 degrees C

A high-virulence clone of serotype III Streptococcus agalactiae causing invasive neonatal disease was previously identified by multilocus enzyme electrophoresis. A simple procedure involving growth at 40 degrees C distinguished all isolates classified in this high-virulence clone from other serotype III isolates, which are more frequently associated with asymptomatically colonized infants, as well as the other serotypes of group B streptococci. The high-virulence clone failed to grow at 40 degrees C in FMC, a chemically defined medium, in contrast to the other organisms, which grew readily.

Adherence of group B streptococci to buccal epithelial cells in neonates with different gestational ages

Adherence of group B streptococci to buccal epithelial cells was determined in 81 neonates with different gestational ages. There was a significant curvilinear increase in adherence in premature neonates with decreasing gestational ages. Amniotic fluid did not inhibit attachment of group B streptococci to epithelial cells. Increased adherence of group B streptococci to premature neonates may explain, in part, the increased susceptibility of these infants to disease from this organism.

Ticarcillin/clavulanic acid combination. Treatment of bacterial infections in hospitalized children

Eighteen patients 2 months to 11 years of age with culture proven bacterial infections were treated with parenteral ticarcillin/clavulanic acid in a noncomparative study. Seven patients had pneumonia, two had tracheobronchitis, three had soft tissue abscess, two had periorbital cellulitis, three had urinary tract infection and one had purulent bursitis. Four of the 18 were bacteremic. Organisms treated included Staphylococcus aureus (6), Pseudomonas aeruginosa (5), Haemophilus influenzae (2), Branhamella catarrhalis (2), Escherichia coli (1), Streptococcus pneumoniae (1), Klebsiella pneumoniae (1), Streptococcus pyogenes (1) and Serratia marcescens (1). Thirteen of 15 (87%) organisms tested were beta-lactamase positive. Therapy was given intravenously in six doses per day at 310 mg/kg. Duration of treatment ranged from 5 to 28 (mean 11) days, with an average time of 4 days to clinical improvement. Seventeen patients (94%) were clinically cured. One patient with recurrent aspiration pneumonia due to mixed infection with multiple gram-negative enteric bacilli failed therapy. Adverse effects were minimal and transient. Notably, mild to moderate thrombocytosis occurred in four (22%) patients that resolved uneventfully. We conclude that ticarcillin/clavulanic acid is safe and effective therapy for serious infections in hospitalized children.

Molecular cloning of cDNA corresponding to mRNA species whose steady state levels in the thyroid are enhanced by thyrotropin. Homology of one of these sequences with ferritin H

A lambda gt11 cDNA library was constructed using poly(A)+ mRNA from thyrotropin (TSH)-stimulated Fisher rat thyroid (FRTL5) cells. The library was screened for nonthyroglobulin cDNA sequences by differential plaque filter hybridization using single-stranded cDNA probes synthesized from mRNA prepared from quiescent and TSH-stimulated FRTL5 cells. Thyroglobulin cDNA-containing recombinants in the library were avoided by prehybridizing the TSH probe to excess thyroglobulin cDNA. Of 48,000 clones screened, 60 were chosen as representing mRNA species whose abundance was increased in TSH-stimulated versus quiescent cultures. Southern blot analysis of 9 clones confirmed that the TSH-cDNA probe hybridized to a greater extent to the cDNA inserts than did the control probe. cDNA insert sizes varied between 0.3 kilobase (kb) and 1.0 kb. Northern slot blot analysis using as probes the cDNA of four of these clones (FC4, FC26, FC29, and FC43) demonstrated that TSH stimulation of FRTL5 cells increased the steady state levels of the respective mRNA species by 4-12-fold. For all 4 clones, increases in mRNA levels were apparent within approximately 1 h and were maximal after 14-18 h of TSH stimulation. Determination of the partial nucleotide sequence of these 4 clones confirmed that none was thyroglobulin, thyroid peroxidase, or any other gene previously reported to be stimulated by TSH. Three of the clones bore no homology to any known nucleotide sequence, but FC26 was 85% homologous with human ferritin H. Northern blot analysis using the FC26 cDNA insert as a probe confirmed hybridization to an mRNA species of 1 kb, the known size of ferritin H mRNA. In summary, using the technique of differential plaque filter hybridization, we have identified 4 new genes whose mRNA levels are increased by TSH stimulation of thyroid cells. One of these genes is homologous to human ferritin H.

IGF-I increases c-fos expression in FRTL5 rat thyroid cells by activating the c-fos promoter

We studied the effect of IGF-1 on c-fos mRNA expression in FRTL5 rat thyroid cells. IFG-1, or calf serum, transiently increased c-fos mRNA levels in quiescent FRTL5 cells, with the latter being more potent. This increase was prevented by actinomycin D. FRTL5 cells were stably transfected with the c-fos promoter linked upstream to the reporter gene chloramphenicol acetyl transferase (CAT). Calf serum and IGF-1 increased c-fos promoter activity in a prolonged manner, and to an equal degree. Our data indicate that IGF-1, as well as additional factor(s) in serum, increase c-fos mRNA levels, at least in part, by activation of the c-fos promoter.

Amphotericin B dosage for disseminated candidiasis in premature infants

Amphotericin B (Amp-B) serum concentrations were determined in five infants with disseminated candidiasis. All patients had positive blood cultures for Candida and one patient had Candida albicans meningitis. Amp-B sterilized the blood and the cerebrospinal fluid within four to nine days. Total doses of Amp-B varied from 11.6-62.3 mg. There was no laboratory or clinical evidence of renal toxicity. Two infants died of causes unrelated to disseminated candidiasis. Disseminated candidiasis in premature infants was treated successfully with 0.5 mg/kg doses of Amp-B, but further studies with more evaluable cases are needed to confirm the correct dose.

Lack of toxicity of oral and intrapulmonary group B streptococcal lipoteichoic acid

Lipoteichoic acid (LTA) was prepared from type III group B streptococci and administered by topical oral application or intravenous or intratracheal injection in weanling and adult white New Zealand rabbits. Tritiated [3H]LTA in tissues and body fluids was measured by scintillation spectrometry. Five minutes to 120 h after intravenous injection of 10 mg (17 x 10(6) dpm) of [3H]LTA, none was present in blood. Combined urine and fecal excretion peaked at 24 h and decreased over 5 days. There was no effect on collagen-induced platelet aggregation. [3H]LTA concentrations were greatest in colon, bone, stomach, and skin 1 day after intravenous injection. After a 5-mg oral dose (8.5 x 10(6) dpm) in an adult animal, fecal excretion peaked at 24 h and decreased after 4 days. No systemic absorption was noted. No [3H]LTA was found in any of seven tissues examined at autopsy 3 days after 1 to 5 mg/kg oral doses in weanling animals with normal or traumatized buccal mucosa. No effect was noted on platelet aggregation or serum complement, there was no increase in the incidence of nephrocalcinosis and the buccal mucosa remained histologically normal. Intratracheal injection of 0.5 to 2.5 mg/kg of LTA resulted in no tachypnea or alteration in blood gases. All animals remained healthy after LTA administration. The absence of toxicity and absorption in animals suggests that studies could be performed in humans to evaluate the safety and efficacy of oral LTA.

Nocardia asteroides brain abscess following mastoidectomy

Nocardia asteroides brain abscess occurred after mastoidectomy and tympanoplasty in a previously healthy 10-year-old boy. Combined surgical excision and trimethoprim/sulfamethoxazole therapy resulted in significant improvement.

Candida albicans adherence in newborn infants

Adherence of Candida albicans to buccal epithelial cells from full-term infants was significantly lower than adherence to epithelial cells from premature infants and healthy school-age children, until the full-term infants reached 5 days of age. Adherence in premature infants (gestational age 28-39 weeks) at birth was more than twice that of term infants and remained unchanged during the first week of life. Differences in Candida adherence in premature and term newborns may be due to developmental, salivary, receptor site or other unknown factors.

Adherence of Candida albicans to buccal epithelial cells in children and adults

Adherence of Candida albicans to BEC was determined in 20 children with oral candidiasis, 20 with oral colonization with C. albicans, and 40 uninfected controls not receiving antibiotics. Mean adherence was 15.3 +/- 0.08 yeast/cell in controls and significantly increased to 16.2 +/- 0.5 in colonized children (p less than 0.001) and 19.3 +/- 0.8 in children with oral candidiasis (p less than 0.001). Adherence was the same in normal adults and children, suggesting a stable cell receptor system that is not age dependent. Adherence was also tested daily in 15 initially noncolonized, previously healthy children receiving antibiotics. Normally adherent background bacteria decreased significantly (p less than 0.004) on the first day of narrow- or broad-spectrum antibiotic therapy. C. albicans adherence increased significantly (p less than 0.004) on the second day. Oral colonization with C. albicans occurred on the third day of therapy. None of the children developed oral candidiasis over 3 to 9 days of observation. Healthy control children showed no change in adherence when tested daily for 1 week. Increased fungal adherence to BEC during antibiotic therapy may explain, in part, the increased incidence of Candida colonization in patients receiving antibiotics. Persistence of organisms may then permit disease to develop.

Prevention of group B streptococcal colonization with topically applied lipoteichoic acid in a maternal-newborn mouse model

An animal model of maternal-newborn transmission of group B streptococci (GBS) was developed. Pregnant Swiss-Webster mice were colonized by applying 10(8) GBS to the oral cavity, vagina, and nipples daily for 3 days before delivery. Lipoteichoic acid (LTA) from type III GBS or phosphate buffered saline was applied topically to the oral cavity, perineum or nape of newborn mice. Cultures of newborn mice at 3 days of age revealed 35 of 75 (47%) controls and 0 of 79 animals given 2 doses of LTA (2 mg/ml) were positive for GBS at one or more sites. One to two% of control and LTA-treated mice remained culture positive at 7 days of age. None developed GBS disease and no obvious toxicity was noted. This is the first in vivo evidence that colonization with GBS can be prevented by interfering with their adherence to epithelial surfaces. LTA also prevented colonization by 60,000 GBS in the oral cavity of 1-day-old newborn mice. A minimum concentration of 0.5 mg LTA/ml was required and similar dose response curves were obtained in preventing maternal-newborn transmission or oral newborn colonization. LTA from type III GBS also protected against types Ia and II. Only 6 of 15 (40%) vaginally colonized, nonpregnant mice became noncolonized 3 days after LTA treatment. Topically applied lipoteichoic acid from group B streptococci may be a useful method of preventing GBS colonization and/or disease in human infants at birth if it is nontoxic. The method avoids the problems associated with antibiotic prophylaxis and vaccine development.

Metastatic endophthalmitis: a complication of meningococcal meningitis

A 13-month-old child with Neisseria meningitidis developed bilateral metastatic endophthalmitis. Treatment with systemic and periocular injections of penicillin G and steroids resulted in resolution of the meningitis and the endophthalmitis. This case should alert the pediatrician to the possibility of binding endophthalmitis in a patient with meningitis and ocular abnormalities.

Rifampin prophylaxis for contacts of Haemophilus influenzae type b disease

Rifampin prophylaxis (20 mg/kg once daily for four days) was used in close contacts of children with Haemophilus influenzae type b (HIB) disease. Two hours after a dose, the concentration of rifampin in serum and saliva exceeded the minimum bactericidal concentrations of organisms obtained from four of the carriers. In both a randomized prospective and an open study, nasopharyngeal carriage was eradicated in 37 (95%) of 39 contacts. No cases of serious H influenzae disease occurred in four to six months of follow-up. At the dose and treatment schedule used, rifampin was safe and effective for eradication of HIB carriage.

Pneumocystis pneumonia in hospitals: outbreaks or improved recognition?

A presumed outbreak of Pneumocystis carinii pneumonitis occurred at a large teaching hospital. The diagnosis was made by lung biopsy or at autopsy in seven patients over a 22 1/2-year period and only by percutaneous lung aspirate in seven patients over a 2 1/2-year period. Apparent outbreaks may be related to both an increase in the number of cases of disease and improved diagnostic methods.

Gallium 67 scanning for the diagnosis of infection in children

Gallium 67 scintigraphy was studied prospectively in 26 children with clinically suspected abscesses. Scan interpretation agreed with the clinical outcome in 21 patients (81%). The true-negative rate was 71% and the true-positive rate was 92%. False-positive scans were related to bleeding and bone infarcts. False-negative scans were related to neutropenia (less than 500 neutrophils/cu mm) and to lesions smaller than 1 cm. Gallium scanning is a safe and reliable method of diagnosis of infection in children, except for patients with neutropenia or whose lesions are smaller than 1 cm. Two-hour scans may be useful in some patients, particularly those with osteomyelitis.

Comparison of pentamidine isethionate and trimethoprim-sulfamethoxazole in the treatment of Pneumocystis carinii pneumonia

Fifty patients with P. carinii pneumonitis were randomized to receive either pentamidine isethionate or trimethoprim-sulfamethoxazole therapy. Those not responding favorably to the first drug after three or more days of therapy were changed to the alternate drug. Of the 26 patients initially treated with TMP-SMZ, 20 recovered (0.77)-17 after TMP-SMZ alone and three of nine who were crossed over to pentamidine. Of the 24 patients initially treated with pentamidine, 18 recovered (0.75)-14 of 15 who received only pentamidine and four of nine who were crossed over to TMP-SMZ. Abnormal values for blood urea nitrogen, creatinine, or glucose; inflammation at injection sites; or combination of these effects occurred in 14 of the 15 patients treated with pentamidine alone. Only one of the 17 patients treated with TMP-SMZ alone developed any of these abnormalities. This study shows that TMP-SMZ is as effective as pentamidine in the treatment of PCP, and that it offers the advantages of minimal adverse effects, oral administration, and ready availability.

Polymicrobial infective endocarditis: an increasing clinical entity

Polymicrobial endocarditis was very uncommon until ten years ago. However, since that time, at least 21 cases were reported, and 10 patients with this mixed infection were seen at our hospital. All, except one of these infections, occurred in patients who had undergone heart surgery or abused intravenous drugs. Although, generally clinically indistinguishable from mono-microbial endocarditis, these mixed infections carried a very high mortality rate (greater than 30 per cent), and an unusually large number of the patients (greater than 50 per cent) needed heart surgery either to control the infection or to repair cardiac defects resulting from the infection. The prognosis depended on the species rather than the number of organisms isolated and on aggressive antimicrobial and surgical therapy.