Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

How effective are population health surveys for estimating prevalence of chronic conditions compared to anonymised clinical data?

INTRODUCTION

Population health surveys are used to record person-reported outcome measures for chronic health conditions and provide a useful source of data when evaluating potential disease burdens. The reliability of survey-based prevalence estimates for chronic diseases is unclear nonetheless. This study applied methodological triangulation via a data linkage method to validate prevalence of selected chronic conditions (angina, myocardial infarction, heart failure, and asthma).

METHODS

Linked healthcare records were used for a combined cohort of 11,323 adults from the 2013 and 2014 sweeps of the Welsh Health Survey (WHS). The approach utilised consented survey data linked to primary and secondary care electronic health record (EHR) data back to 2002 within the Secure Anonymised Information Linkage (SAIL) Databank.

RESULTS

This descriptive study demonstrates validation of survey and clinical data using data linkage for selected chronic cardiovascular conditions and asthma with varied success. The results indicate that identifying cases for separate cardiovascular conditions was limited without specific medication codes for each condition, but more straightforward for asthma, where there was an extensive list of medications available. For asthma there was better agreement between prevalence estimates based on survey and clinical data as a result.

CONCLUSION

Whilst the results provide external validity for the WHS as an instrument for estimating the burden of chronic disease, they also indicate that a data linkage appproach can be used to produce comparable prevalence estimates using clinical data if a defined condition-specific set of clinical codes are available.

Neurocalcin regulates nighttime sleep and arousal in Drosophila

Sleep-like states in diverse organisms can be separated into distinct stages, each with a characteristic arousal threshold. However, the molecular pathways underlying different sleep stages remain unclear. The fruit fly, Drosophila melanogaster, exhibits consolidated sleep during both day and night, with night sleep associated with higher arousal thresholds compared to day sleep. Here we identify a role for the neuronal calcium sensor protein Neurocalcin (NCA) in promoting sleep during the night but not the day by suppressing nocturnal arousal and hyperactivity. We show that both circadian and light-sensing pathways define the temporal window in which NCA promotes sleep. Furthermore, we find that NCA promotes sleep by suppressing synaptic release from a dispersed wake-promoting neural network and demonstrate that the mushroom bodies, a sleep-regulatory center, are a module within this network. Our results advance the understanding of how sleep stages are genetically defined.

Drosophila TDP-43 dysfunction in glia and muscle cells cause cytological and behavioural phenotypes that characterize ALS and FTLD

Amyotrophic lateral sclerosis (ALS) and frontotemporal lobar degeneration (FTLD) are neurodegenerative disorders that are characterized by cytoplasmic aggregates and nuclear clearance of TAR DNA-binding protein 43 (TDP-43). Studies in Drosophila, zebrafish and mouse demonstrate that the neuronal dysfunction of TDP-43 is causally related to disease formation. However, TDP-43 aggregates are also observed in glia and muscle cells, which are equally affected in ALS and FTLD; yet, it is unclear whether glia- or muscle-specific dysfunction of TDP-43 contributes to pathogenesis. Here, we show that similar to its human homologue, Drosophila TDP-43, Tar DNA-binding protein homologue (TBPH), is expressed in glia and muscle cells. Muscle-specific knockdown of TBPH causes age-related motor abnormalities, whereas muscle-specific gain of function leads to sarcoplasmic aggregates and nuclear TBPH depletion, which is accompanied by behavioural deficits and premature lethality. TBPH dysfunction in glia cells causes age-related motor deficits and premature lethality. In addition, both loss and gain of Drosophila TDP-43 alter mRNA expression levels of the glutamate transporters Excitatory amino acid transporter 1 (EAAT1) and EAAT2. Taken together, our results demonstrate that both loss and gain of TDP-43 function in muscle and glial cells can lead to cytological and behavioural phenotypes in Drosophila that also characterize ALS and FTLD and identify the glutamate transporters EAAT1/2 as potential direct targets of TDP-43 function. These findings suggest that together with neuronal pathology, glial- and muscle-specific TDP-43 dysfunction may directly contribute to the aetiology and progression of TDP-43-related ALS and FTLD.

[Diabetic, neuropathic, arteriopathic foot and dressing choice]

The definition for the diabetic foot is infection, ulceration or destruction of deep tissues of the foot associated with neuropathy or peripheral vascular disease in the lower extremity of people with diabetes. Non-diabetic patients may suffer the same risks when neuropathy and arteriopathy are present. Knowing that 85% of amputations are preceded by foot ulcers, prevention is primordial. At the onset of an ulcer, immediate treatment must be undertaken and preferably by an interdisciplinary team. Delayed healing and increased risk of infection are often due to an associated vascular disease. While the array of dressings is expansive there is no «gold standard» treatment or «miracle dressing» described for foot ulcers. The management consists of wound analysis, debridement, woundcare and especially offloading.

Therapeutics and anaesthesia

Many aspects of hypertension care outside pregnancy may be applied in pregnancy, but little information is available on which to base decision-making. It would seem reasonable to continue previous dietary salt restriction and physical activity in women with pre-existing (and controlled) hypertension, encourage a heart-healthy diet in all women with a hypertension disorder of pregnancy, and take patient preference into account when deciding on place of care. Although bed rest has become a key part of obstetric practice and for care of women with a hypertension disorder of pregnancy, in particular, the evidence is lacking to support this practice. This may also increase thromboembolic risk. Antihypertensive treatment is strongly advised for women with severe hypertension. The most common agents are parenteral labetalol, hydralazine, or oral nifedipine capsules. Clinicians should familiarise themselves with multiple agents. Until the role of antihypertensive treatment for non-severe hypertension in pregnancy is clarified by ongoing research, clinicians should explicitly state an individual patient's blood pressure goal, which could reasonably be anywhere between 130/80 and 155/105 mmHg. Labetalol and methyldopa are used most commonly. Breastfeeding should be encouraged. Many risk factors for hypertension (e.g. obesity), as well as hospitalisation and pre-eclampsia, all increase the thromboembolic risk for pregnant women, and care providers should consider thromboprophylaxis in the appropriate setting. Finally, anaesthetists play a critical role in the management of women with a hypertension disorder of pregnancy, and should be involved earlier rather than later in the course of their care.

Influence of CO(2)-HCO(3) Levels and pH on Growth, Succinate Production, and Enzyme Activities of Anaerobiospirillum succiniciproducens

Growth and succinate versus lactate production from glucose by Anaerobiospirillum succiniciproducens was regulated by the level of available carbon dioxide and culture pH. At pH 7.2, the generation time was almost doubled and extensive amounts of lactate were formed in comparison with growth at pH 6.2. The succinate yield and the yield of ATP per mole of glucose were significantly enhanced under excess-CO(2)-HCO(3) growth conditions and suggest that there exists a threshold level of CO(2) for enhanced succinate production in A. succiniciproducens. Glucose was metabolized via the Embden-Meyerhof-Parnas route, and phosphoenolpyruvate carboxykinase levels increased while lactate dehydrogenase and alcohol dehydrogenase levels decreased under excess-CO(2)-HCO(3) growth conditions. Kinetic analysis of succinate and lactate formation in continuous culture indicated that the growth rate-linked production rate coefficient (K) cells was much higher for succinate (7.2 versus 1.0 g/g of cells per h) while the non-growth-rate-related formation rate coefficient (K') was higher for lactate (1.1 versus 0.3 g/g of cells per h). The data indicate that A. succiniciproducens, unlike other succinate-producing anaerobes which also form propionate, can grow rapidly and form high final yields of succinate at pH 6.2 and with excess CO(2)-HCO(3) as a consequence of regulating electron sink metabolism.

Odour emissions from anaerobic piggery ponds. 2: improving estimates of emission rate through recognition of spatial variability

Odour emission rates were measured for seven different anaerobic ponds treating piggery wastes at six to nine discrete locations across the surface of each pond on each sampling occasion over a thirteen month period. Significant variability in emission rates were observed for each pond. Measurement of a number of water quality variables in pond liquor samples collected at the same time and from the same locations as the odour samples indicated that the composition of the pond liquor was also variable. The results indicated that spatial variability was a real phenomenon and could have a significant impact on odour assessment practices. Considerably more odour samples would be required to characterise pond emissions than currently recommended by most practitioners, or regulatory agencies.

Odour emissions from anaerobic piggery ponds. 1. Results of a three season, 14-month survey

Odour emission rates were measured for seven different anaerobic ponds treating piggery wastes at six to nine discrete locations across the surface of each pond on each sampling occasion over a 14-month period. Emission rate values varied between ponds, between seasons for the same pond and even for the same pond on different days of a sampling week. Average seasonal emission rates ranged from 7.9 to 46.5OU/m(2)s, while average emission rates ranged from 16.0 to 29.0OU/m(2)s. Factors potentially responsible for the variability in emission rates were investigated, including air and pond liquor temperatures, time of day of sample collection, season and the impact of a prolonged drought.

Combined therapeutic use of AdGFPFasL and small molecule inhibitors of ceramide metabolism in prostate and head and neck cancers: a status report

As of January 2005, there were 1020 gene therapy clinical trials ongoing worldwide with 675 or 66.2% devoted to cancer gene therapy. The majority are occurring in the US and Europe (http://www.wiley.co.uk/genetherapy/clinical/). At the present time, to our knowledge there are no trials that employ gene delivery of Fas Ligand (FasL). As an important note, and in contrast to somatic cell therapy trials, there are no reported deaths due to therapeutic vector administration in any cancer gene therapy trial. That said, from our studies and from the published literature, the issue of gene delivery remains the major obstacle to successfully employing gene therapy for cancer treatment. Numerous laboratories are studying this with many different approaches. My co-workers and I have focused on the delivery issue by using various approaches that address tumor targeting and transgene expression. In addition, we are focusing on enhancing tumor cell killing via the bystander effect and through use of small molecules to enhance bystander activity.

Sentinel node biopsy should be supplemented by axillary sampling in patients with small breast cancers

Axillary clearance provides important prognostic information but is associated with significant morbidity. Sentinel node biopsy can provide staging .141 patients with node negative early breast cancers-tumour size less than 1.5 cm measured clinically or by imaging had guided axillary sampling (sentinel lymph node biopsy in combination with axillary sampling). Four node axillary sampling improved the detection rate of axillary node metastases by 13.6% as compared to blue dye sentinel node biopsy alone. Positive sampled nodes strongly indicated the likelihood of further metastatic being revealed by axillary dissection (67%). Negative sampled nodes in combination with a positive sentinel node biopsy were associated with a much lower rate of further nodal involvement in the axillary clearance (8%).

p53 tumor suppressor protein regulates the levels of huntingtin gene expression

The p53 protein is a transcription factor that integrates various cellular stress signals. The accumulation of the mutant huntingtin protein with an expanded polyglutamine tract plays a central role in the pathology of human Huntington's disease. We found that the huntingtin gene contains multiple putative p53-responsive elements and p53 binds to these elements both in vivo and in vitro. p53 activation in cultured human cells, either by a temperature-sensitive mutant p53 protein or by gamma-irradiation (gamma-irradiation), increases huntingtin mRNA and protein expression. Similarly, murine huntingtin also contains multiple putative p53-responsive elements and its expression is induced by p53 activation in cultured cells. Moreover, gamma-irradiation, which activates p53, increases huntingtin gene expression in the striatum and cortex of mouse brain, the major pathological sites for Huntington's disease, in p53+/+ but not the isogenic p53-/- mice. These results demonstrate that p53 protein can regulate huntingtin expression at transcriptional level, and suggest that a p53 stress response could be a modulator of the process of Huntington's disease.

Bisphosphonate infusions: patient preference, safety and clinic use

GOALS OF WORK

We set out to assess the preference of patients with common cancers involving bone receiving intravenous bisphosphonate therapy for either pamidronate (P) or zoledronic acid (Z) and their preference for the location of the infusion (clinic or home). We also aimed to monitor these patients' renal safety, and to compare their time in clinic to receive P and Z infusions.

PATIENTS AND METHODS

Enrolled in the study were 184 patients, and all received initial infusions of Z (so any first infusion reactions did not confound preferences for P). For their second and third infusions, patients were randomized to receive Z then P or P then Z, and questioned on their preferences. For up to 1 year they continued on Z infusions every 3-4 weeks, while their renal safety was monitored. Where practical, later infusions were given at home (rather than in the clinic) and patients questioned on their preferred infusion location. In a convenience subset of 43 patients, clinic use for Z and P infusions was also measured by timing infusions and other procedures.

MAIN RESULTS

Of 144 patients who received a third infusion, 138 responded to questions on bisphosphonate preference, and of these 138, 92% (127) preferred Z to P, because shorter infusions caused less disruption to their day. Only 12% of eligible patients (16/138) received home infusions, but 13/14 questioned preferred this location. Among 184 patients, 19 episodes of renal impairment were noted, mostly owing to disease progression (e.g. obstructive uropathy), with none linked to Z therapy. The mean clinic time taken to receive Z and any concomitant therapy was about half that for P (78 vs 161 min).

CONCLUSIONS

Cancer patients prefer shorter bisphosphonate infusions-and at home, where practical. Regular Z 4 mg infusions appear to be safe in these patients, with routine monitoring of serum creatinine. Using Z rather than P could save busy cancer centres time and improve patient satisfaction.

Causes of sediment toxicity to Mytilus galloprovincialis in San Francisco Bay, California

Since the San Francisco Regional Monitoring Program (RMP) sampling began, elutriate samples prepared with sediment from the Grizzly Bay monitoring station have been consistently toxic to bivalve larvae (Mytilus galloprovincialis). An investigation into the cause of toxicity was initiated with a Phase I Toxicity Identification Evaluation (TIE) using bivalve embryos. TIE results and chemical analyses of elutriate samples suggested that divalent metals were responsible for the observed toxicity. Following the initial characterization of trace metals as toxicants, additional TIEs were performed on elutriates prepared from three additional Grizzly Bay samples collected between 1997 and 2001. Additional TIEs included ethylenediamine tetraacetic acid (EDTA) treatments in a sediment-water interface (SWI) exposure system, and the use of a cation exchange column with serial elution of sample fractions with hydrochloric acid of increasing normality. EDTA significantly reduced toxicity in overlying water in the SWI system. The cation exchange column reduced both toxicity and concentrations of trace metals, and serial elution of the column added back both toxicity and specific metals contained in individual acid fractions. Chemical analyses of three elutriate samples demonstrated copper concentrations were within the range toxic to bivalves. Results of Phase I TIEs, additional Phase II treatments, SWI exposures, and metals analyses indicate the potential for metal toxicity in sediments from this estuarine site. When combined with the results of standard TIE methods, a solid-phase cation extraction and elution approach identified copper as the most probable cause of toxicity.

A novel mammalian receptor for the evolutionarily conserved type II GnRH

Mammalian gonadotropin-releasing hormone (GnRH I: pGlu-His-Trp-Ser-Tyr-Gly-Leu-Arg-Pro-Gly-NH2) stimulates pituitary gonadotropin secretion, which in turn stimulates the gonads. Whereas a hypothalamic form of GnRH of variable structure (designated type I) had been shown to regulate reproduction through a cognate type I receptor, it has recently become evident that most vertebrates have one or two other forms of GnRH. One of these, designated type II GnRH (GnRH II: pGlu-His-Ser-His-Gly-Trp-Tyr-Pro-Gly-NH2), is conserved from fish to man and is widely distributed in the brain, suggesting important neuromodulatory functions such as regulating K+ channels and stimulating sexual arousal. We now report the cloning of a type II GnRH receptor from marmoset cDNA. The receptor has only 41% identity with the type I receptor and, unlike the type I receptor, has a carboxyl-terminal tail. The receptor is highly selective for GnRH II. As with the type I receptor, it couples to G(alpha)q/11 and also activates extracellular signal-regulated kinase (ERK1/2) but differs in activating p38 mitogen activated protein (MAP) kinase. The type II receptor is more widely distributed than the type I receptor and is expressed throughout the brain, including areas associated with sexual arousal, and in diverse non-neural and reproductive tissues, suggesting a variety of functions. Surprisingly, the type II receptor is expressed in the majority of gonadotropes. The presence of two GnRH receptors in gonadotropes, together with the differences in their signaling, suggests different roles in gonadotrope functioning.

Creation of a new transgene cloning site near the right ITR of Ad5 results in reduced enhancer interference with tissue-specific and regulatable promoters

Tissue-specific transgene expression is a valuable research tool and is of great importance in delivering toxic gene products with adenovirus vectors to tumors. Limiting cytotoxic gene expression to the target cells is highly desirable. While a number of successful applications of tissue- and tumor-specific gene expression using Ad vectors has been reported, cloning of some promoters into Ad vectors resulted in modulation or loss of tissue specificity. This phenomenon is likely the result of the interaction of E1A enhancer (and possibly other Ad sequences) with the promoter cloned in the E1 region. We have compared performance parameters of prostate-specific and tet-regulatable promoters in plasmids containing the terminal repeat sequences of Ad5 with or without the E1A enhancer. Subsequently, adenoviral vectors were constructed containing identical expression units either in the E1 region or near the right ITR, and tested in several cell lines. Here, we report that promoters placed near the right ITR of Ad5 retain higher selectivity and lower background expression in both plasmid and adenovirus vectors. We confirm that the E1A enhancer can interfere with the desired activity of nearby promoters, and describe an alternative transgene insertion site for construction of Ad vectors.

Development of the Handicap Assessment and Resource Tool (HART)

An important determinant of whether people can live in community settings is the absence of significant handicap. People with considerable disabilities can live without handicap if they have adequate supports. Handicap, rather than disability, limits peoples' residence options. Disability assessment tools are commonly used to guide where people can live--these assess neither the resources available nor the personal-care handicap present. The Handicap Assessment and Resource Tool (HART) was designed to provide information about the personal-care issues (clothing, hygiene, nutrition, mobility, safety, residence and supports) relevant to choice of residence. The HART was tested by occupational therapists who are frequently expected to provide recommendations regarding disabled clients' residence options. It is a client-centred tool that addresses key occupational performance components of personal care. Pilot testing in hospital and community settings shows the HART is a comprehensive and practical tool that is acceptable to users and clients.

Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports

OBJECTIVE

To receive and collate reports of death or major complications of transfusion of blood or components.

DESIGN

Haematologists were invited confidentially to report deaths and major complications after blood transfusion during October 1996 to September 1998.

SETTING

Hospitals in United Kingdom and Ireland.

SUBJECTS

Patients who died or experienced serious complications, as defined below, associated with transfusion of red cells, platelets, fresh frozen plasma, or cryoprecipitate.

MAIN OUTCOME MEASURES

Death, "wrong" blood transfused to patient, acute and delayed transfusion reactions, transfusion related acute lung injury, transfusion associated graft versus host disease, post-transfusion purpura, and infection transmitted by transfusion. Circumstances relating to these cases and relative frequency of complications.

RESULTS

Over 24 months, 366 cases were reported, of which 191 (52%) were "wrong blood to patient" episodes. Analysis of these revealed multiple errors of identification, often beginning when blood was collected from the blood bank. There were 22 deaths from all causes, including three from ABO incompatibility. There were 12 infections: four bacterial (one fatal), seven viral, and one fatal case of malaria. During the second 12 months, 164/424 hospitals (39%) submitted a "nil to report" return.

CONCLUSIONS

Transfusion is now extremely safe, but vigilance is needed to ensure correct identification of blood and patient. Staff education should include awareness of ABO incompatibility and bacterial contamination as causes of life threatening reactions to blood.

Glucolipsin A and B, two new glucokinase activators produced by Streptomyces purpurogeniscleroticus and Nocardia vaccinii

During the screening of the natural products for their ability to increase the activity of glucokinase by relieving inhibition by long chain fatty acyl CoA esters (FAC), two novel compounds, glucolipsin A (1) and B (2) were isolated from the butanol extracts of Streptomyces purpurogeniscleroticus WC71634 and Nocardia vaccinii WC65712, respectively. The structures of these two compounds were established by spectroscopic methods and chemical degradation. Glucolipsin A (1) and B (2) relieved the inhibition of glucokinase by FAC with RC50 values of 5.4 and 4.6 microM.

Laser-induced fluorescence (LIF) recognition of the structural composition of porcine heart valves

Reconstruction and replacement of heart valves with grafts fro pig tissue is a common procedure. However, bioprosthetic valves wear out in a shorter time span than mechanical valves. Bioprosthetic valve structure may contribute to degenerative changes that lead to valve failure. There is, at present, no method to examine the structure of a tissue valve prior to implant. Laser-induced fluorescence (LIF) of natural fluorophores is an elegant method developed for the detection of tumors, dermal lesions and atherosclerosis. We have studied LIF as a potential diagnostic technique for analysis of valvular tissue. Using excimer laser excitation, we examined natural fluorescence recorded from porcine aortic, mitral and pulmonary valves. All three valve outflow surface tissue layers are less fluorescent at 390-450 nm than the inflow layers. Immunohistochemical analysis of collagen I and elastin content in inflow and outflow surface layers of all three valves correlated well with LIF intensities and dI/d lambda values at selected wavelengths. In conclusion, the differences observed in emitted LIF from valve surface layers are found to correlate well with diversity in the structural protein content. The LIF spectroscopic measurements may provide an appropriate tool for examination of tissue valve structure prior to use for implantation.

1-Methoxy-agroclavine from Penicillium sp. WC75209, a novel inhibitor of the Lck tyrosine kinase

A high-throughput screen was developed and implemented to identify inhibitors of the Lck tyrosine kinase. This report describes the identification of a specific inhibitor of this enzyme from the solid fermentation culture of the Penicillium sp., WC75209. The active compound was isolated and structurally characterized as 1-methoxy-5R, 10S-agroclavine, a new member of the ergot alkaloid family.

Malaria surveillance in New York City: 1991-1996

BACKGROUND

The transmission of malaria has increased in recent years in many countries where it was once eradicated or under control, and malaria remains a major cause of morbidity and mortality throughout the developing world. Imported cases of malaria have been increasing in New York City and throughout the United States during the past decade. The New York City Department of Health has modified its malaria surveillance program in order to improve the assessment of diagnosis and treatment of malaria in New York City residents and to provide appropriate advice to health professionals who treat these patients.

OBJECTIVES

To describe the epidemiologic and clinical characteristics of laboratory-confirmed cases of malaria diagnosed in New York City residents from January 1, 1991, through December 31, 1996.

METHODS

The retrospective study of case reports was carried out by the Malaria Surveillance Program of the Bureau of Communicable Diseases, New York City Department of Health, New York City, NY. It included the laboratory diagnosis of malaria and the species involved, and included also descriptive epidemiologic information of patients with malaria (age, sex, race/ethnicity, date and place of onset of illness, travel history, immigration status, previous history of malaria, history of blood transfusion, drugs used for treatment or prophylaxis), as well as a record of clinical complications of the infection (thrombocytopenia, hemolysis, anemia, cerebral malaria, renal failure, respiratory distress syndrome, fatal outcome).

RESULTS

Malaria was diagnosed in 988 residents of New York City during the 5-year period from January 1, 1991, through December 31, 1995. The largest number of cases, 254 (26%), occurred in 1996, with the majority of these cases (76%) observed between the months of May and October. Sixty-four percent (627) of these cases were males. The age range of cases was from newborn (first day of life) to 83 years (median, 31 years). Of the 962 cases of whom the racial/ethnic identity was known, 580 (59%) were black/non-Hispanic and 255 (26%) were Asian/Pacific Islander. Travel outside of the United States was reported by 958 patients, the majority to Africa (569/958, 59%). Only 139 patients (14%) claimed the use of malaria prophylaxis during travel. Plasmodium falciparum was identified in 505 (51%) and P. vivax in 356 (36%) of the cases. Clinical complications included hemolysis with severe anemia, thrombocytopenia, cerebral malaria, renal failure, and respiratory distress syndrome. All four fatal cases involved infections with P. falciparum, either alone or in combination with another plasmodia species.

CONCLUSIONS

Imported cases of malaria occur frequently in New York City and may be associated with serious complications. Health care providers should consider this diagnosis in patients who have recently travelled or arrived from abroad, presenting with headache, fever, and other constitutional symptoms. There are many missed opportunities for the use of malaria prophylaxis, and physicians should familiarize themselves with current recommendations for malaria prophylaxis for travel to areas of the world where people are at risk for the transmission of malaria.

Accidental exposures to blood and body fluids among health care workers in dental teaching clinics: a prospective study

The authors evaluated accidental exposures to blood and body fluids reported to a hotline or to health officials at four dental teaching clinics. The authors used a standard questionnaire to solicit and record data regarding each exposure. During a 63-month period, 428 parenteral exposures to blood or body fluids were documented. Dental students and dental assistants had the highest rates of exposure. Syringe needle injuries were the most common type of exposure, while giving injections, cleaning instruments after procedures and drilling were the activities most frequently associated with exposures.

Nicardipine versus nitroprusside for controlled hypotension during spinal surgery in adolescents

Nicardipine or nitroprusside was used to induce controlled hypotension in healthy adolescents with idiopathic scoliosis undergoing spinal fusion. Twenty patients were randomly assigned to the nitroprusside (N) or nicardipine (C) group. All patients received a standardized anesthetic. A target mean arterial blood pressure (MAP) of 60 mm Hg was achieved by varying the vasoactive infusions only. Moderate hemodilution (PCV = 25) and intraoperative blood salvage were used in all cases. Hemodynamic variables, blood loss, occurrence of reflex tachycardia, and reversibility of the hypotensive state were compared between the two groups. Significant differences were observed between the two groups in the amount of blood loss and reversibility of the hypotensive state. Group C had less blood loss (761 +/- 199 mL) than Group N (1297.5 +/- 264, P < or = .05). Time to restoration of baseline MAP was longer with Group C (26.8 +/- 4.0 min) than Group N (7.3 +/- 1.1 min, P < or = 0.001). Both drugs rapidly achieved a stable, controlled hypotensive state and an acceptable operating field. There was no statistically significant difference between groups with respect to the amount of crystalloid administered or urine output. These results suggest that nicardipine is a safe, effective drug for controlled hypotension in this population and that it may offer the significant advantage of reduced blood loss in these patients.

Uncoupling of stem cell inhibition from monocyte chemoattraction in MIP-1alpha by mutagenesis of the proteoglycan binding site

We have studied the role of proteoglycans in the function of Macrophage Inflammatory Protein-1 alpha (MIP-1alpha), a member of the proteoglycan binding chemokine family. Sequence and peptide analysis has identified a basic region within MIP-1alpha which appears to be the major determinant of proteoglycan binding and we have now produced a mutant of MIP-1alpha lacking the basic charges on two of the amino acids within this proteoglycan binding site. This mutant (Hep Mut) appears to have lost the ability to bind to proteoglycans. Bioassay of Hep Mut indicates that it has retained stem cell inhibitory properties but has a compromised activity as a monocyte chemoattractant, thus suggesting uncoupling of these two properties of MIP-1alpha. Receptor studies have indicated that the inactivity of Hep Mut on human monocytes correlates with its inability to bind to CCR1, a cloned human MIP-1alpha receptor. In addition, studies using proteoglycan deficient cells transfected with CCR1 have indicated that the proteoglycan binding site in MIP-1alpha is a site that is also involved in the docking of MIP-1alpha to the monocyte receptor. The site for interaction with the stem cell receptor must therefore be distinct, suggesting that MIP-1alpha utilizes different receptors for these two different biological processes.