Clinical

A surface immunofluorescence assay (SIFA) using live spirochetes was analyzed and compared with Western blot (WB), fluorescent treponemal antibody absorption (FTA-ABS), microhemagglutination (MHA-TP), and Treponema pallidum immobilization (TPI) assays for detecting serum antibodies to T. pallidum in patients with syphilis, in disease controls, and in healthy subjects. SIFA and WB were 99% sensitive (99 of 100 positive specimens) and specific (140 of 140 negative specimens); FTA-ABS showed a sensitivity and a specificity of 90 and 89% (90 of 100 positive and 125 of 140 negative specimens), respectively. MHA-TP showed a sensitivity of 84% (84 of 100 positive specimens) and a specificity of 98.5% (138 of 140 negative specimens). Finally, TPI had a sensitivity of 52% (52 of 100 positive specimens) and a specificity of 100% (140 of 140 negative specimens). The T. pallidum SIFA was therefore highly specific, showing no equivocal reactivities with control sera, and sensitive. The results suggest the possible use of SIFA as a confirmatory test in the serologic diagnosis of syphilis.

Objective  To determine the effects of menopause on bone-related variables in Indonesian women and to compare them with corresponding data in Caucasian Australian women.Design  A study of bone-related variables in women aged 45–55 years in Jakarta compared with corresponding historical data from Caucasian Australian women.Measurements  Dietary intakes, bone mineral density (BMD) and calcium-related variables in blood and urine.Results  Dietary calcium, phosphorus and protein intakes were significantly lower in the women from Jakarta than in those from Adelaide (all P < 0·001), probably because of lower milk consumption, but energy intake was similar in the two cities. Indonesian women were shorter and lighter than Australian women (P < 0·001) but had a comparable body mass index (BMI). The Indonesians also had a lower spinal BMD than the Australians but this was accounted for by the differences in height and weight between the two populations. The differences in serum and urinary calcium and phosphate and serum alkaline phosphatase across the menopause were comparable in Indonesian and Australian women but creatinine excretion was 25% lower in Jakarta than in Adelaide (P < 0·001) and this was probably sufficient to account for higher ratios of some urinary solutes to urinary creatinine in the Indonesians. Serum 25-hydroxyvitamin D (25OHD) levels were significantly lower (P < 0·001) and serum PTH levels significantly higher (P = 0·0045) in Jakarta than in Adelaide.Conclusions  The differences in bone-related biochemical variables across the menopause were similar in the two populations, but calcium and protein intake and urine creatinine were lower in Indonesian than in Australian women. Serum 25OHD was lower and PTH higher in the Indonesian women, probably because of their darker skin, their practice of avoiding direct sunlight and the heavy atmospheric pollution in Jakarta.

Endoscopic endonasal transsphenoidal approach to the sellar region yields an alternative to classical microsurgical approaches. Endoscopes provide images that differ from microscopic view. This study aimed to highlight surgical landmarks and their anatomical relationships for pituitary surgery through endoscopic perspective. Ten sides of five adult cadaveric heads with red-colored latex injected arteries were evaluated. Endoscopic dissections were performed and measurements were done in the sphenoid sinuses before and after the removal of bony structures in all the aspects. Endoscopic vision of the sellar region enabled a wide panoramic perspective and detailed inspection. The measurements, in general, indicated the variations in the bony structures and soft tissues. The width of the pituitary, which is the distance between the medial margins of the carotid prominences, was measured as 21 6 2.5 mm and the distance between the medial margin of the carotid prominences at the lower margin of the pituitary was 18 6 3.1 mm. After the bony structures were removed, further measurements were done. The width of the pituitary, which is the distance between the medial margins of the anterior curvature of the ICA, was measured as 23.2 6 3 mm, while the distance between the posterior curvature of the ICA was 19.7 6 4.9 mm. Endoscopic view provided superior detailed visualization of the close relationships between pituitary gland, internal carotid arteries, and optic nerves. This facilitated exact evaluation for variations, which could result in more effective and safe surgery. However, these variations again emphasize the necessity of preoperative radiological evaluation in each case. Clin. Anat. 21:627-632, 2008. V V C 2008 Wiley-Liss, Inc.

From 2002 to 2003, 32 isolates of Staphylococcus hominis subsp. novobiosepticus (SHN) were recovered from 21 patients, 18 of whom were neonates, with 13 considered to have late-onset SHN sepsis. All isolates from neonates had an indistinguishable pulsed-field gel electrophoresis pattern. Our data support SHN as an important nosocomial pathogen in neonates.

Objective: The Karolinska sleepiness scale (KSS) is frequently used for evaluating subjective sleepiness. The main aim of the present study was to investigate the validity and reliability of the KSS with electroencephalographic, behavioral and other subjective indicators of sleepiness. Methods: Participants were 16 healthy females aged 33-43 (38.1G2.68) years. The experiment involved 8 measurement sessions per day for 3 consecutive days. Each session contained the psychomotor vigilance task (PVT), the Karolinska drowsiness test (KDT-EEG alpha & theta power), the alpha attenuation test (AAT-alpha power ratio open/closed eyes) and the KSS. Results: Median reaction time, number of lapses, alpha and theta power density and the alpha attenuation coefficients (AAC) showed highly significant increase with increasing KSS. The same variables were also significantly correlated with KSS, with a mean value for lapses (rZ0.56). Conclusions: The KSS was closely related to EEG and behavioral variables, indicating a high validity in measuring sleepiness. Significance: KSS ratings may be a useful proxy for EEG or behavioral indicators of sleepiness.

In this study, the authors both developed and validated a self-report mindfulness measure, the Toronto Mindfulness Scale (TMS). In Study 1, participants were individuals with and without meditation experience. Results showed good internal consistency and two factors, Curiosity and Decentering. Most of the expected relationships with other constructs were as expected. The TMS scores increased with increasing mindfulness meditation experience. In Study 2, criterion and incremental validity of the TMS were investigated on a group of individuals participating in 8-week mindfulness-based stress reduction programs. Results showed that TMS scores increased following treatment, and Decentering scores predicted improvements in clinical outcome. Thus, the TMS is a promising measure of the mindfulness state with good psychometric properties and predictive of treatment outcome.

Although GH replacement improves the features of GH deficiency (GHD) in adults, it has yet to be established whether cessation of GH at completion of childhood growth results in adverse consequences for the adolescent with GHD. Effects of continuation or cessation of GH on body composition, insulin sensitivity, and lipid levels were studied in 24 adolescents (13 males, 11 females, aged 17.0 ؎ 0.3, yr, mean ؎ SE, puberty stage 4 or 5) in whom height velocity was less than 2 cm/yr. Provocative testing confirmed severe GHD [peak GH < 9 mU/liter (3 g/liter)] in all cases and was followed by a lead-in period of 3 months during which the pediatric dose of GH continued unchanged. Baseline investigations were then performed using dual-energy x-ray absorptiometry (body composition), lipid measurements, and assessment of insulin sensitivity by both homeostasis model assessment and a short insulin tolerance test. Twelve patients remained on GH (0.35 U/kg⅐wk), and 12 patients ceased GH treatment. The groups were followed up in parallel with repeat observations made after 6 and 12 months.

Background: GH therapy in adult patients with GH deficiency (GHD) was approved over 10 yr ago, and the indication has subsequently gained broad acceptance. The HypoCCS surveillance database is a suitable means to examine the evolution of diagnostic patterns since 1996.

Neurological involvement may be seen in 5-30% of the patients with Behcet's disease (BD). Occasionally, parenchymal neurological involvement in BD can present as a spinal cord syndrome. However, motor neuron disease-like presentation is extremely uncommon. Here we are reporting five patients (all male; median age, 38) fulfilling both International Study Group criteria for BD and El Escorial criteria for amyotrophic lateral sclerosis (ALS). These patients were identified by a questionnaire sent to the members of the Neuro-Behcet Study Group of the International Study Group for BD. Three out of five patients had only motor presentations. In two patients, sensory and urinary manifestations were present as well. Spinal cord MRIs were normal in all, and brain MRIs were normal in four patients; one patient had nonspecific white matter changes. Two patients passed away 1-3 years after diagnosis of ALS, and two patients were lost to follow-up 3 and 11 years after admission; one patient is still alive 3 years after onset. The patients that are presented here might represent a rare form of neurological involvement in BD as well as sole coincidence. Larger prospective series are needed to further answer this issue.

PurposeAdjuvant chemotherapy for resected non–small-cell lung cancer (NSCLC) is now accepted on the basis of several randomized clinical trials (RCTs) that demonstrated improved survival. Although there is strong evidence that adjuvant chemotherapy is effective in stages II and IIIA NSCLC, its utility in stage IB disease is unclear. This report provides a mature analysis of Cancer and Leukemia Group B (CALGB) 9633, the only RCT designed specifically for stage IB NSCLC.Patients and MethodsWithin 4 to 8 weeks of resection, patients were randomly assigned to adjuvant chemotherapy or observation. Eligible patients had pathologically confirmed T2N0 NSCLC and had undergone lobectomy or pneumonectomy. Chemotherapy consisted of paclitaxel 200 mg/m2intravenously over 3 hours and carboplatin at an area under the curve dose of 6 mg/mL per minute intravenously over 45 to 60 minutes every 3 weeks for four cycles. The primary end point was overall survival.ResultsThree hundred-forty-four patients...

Purpose Primary cutaneous B-cell lymphomas (PCBCLs) are a distinct group of primary cutaneous lymphomas with few and conflicting data on their prognostic factors. Patients and Methods The study group included 467 patients with PCBCL who were referred, treated, and observed in 11 Italian centers (the Italian Study Group for Cutaneous Lymphomas) during a 24-year period (1980 to 2003). All of the patients were reclassified according to the WHO–European Organisation for Research and Treatment of Cancer (EORTC) classification. Results Follicle center lymphoma (FCL) accounted for 56.7% of occurrences, followed by marginal-zone B-cell lymphoma (MZL; 31.4%); diffuse large B-cell lymphoma (DLBCL), leg type, was reported in 10.9% of patients. Radiotherapy was the first-line treatment in 52.5% of patients and chemotherapy was the first-line treatment in 24.8% of patients. The complete response rate was 91.9% and the relapse rate was 46.7%. The 5- and 10-year overall survival (OS) rates were 94...

Renal impairment is a common complication of multiple myeloma (MM). The estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease formula is the recommended method for the assessment of renal function in patients with MM with stabilized serum creatinine. In acute renal injury, the RIFLE (risk, injury, failure, loss and end-stage kidney disease) and Acute Renal Injury Network criteria seem to be appropriate to define the severity of renal impairment. Novel criteria based on eGFR measurements are recommended for the definition of the reversibility of renal impairment. Rapid intervention to reverse renal dysfunction is critical for the management of these patients, especially for those with light chain cast nephropathy. Bortezomib with high-dose dexamethasone is considered as the treatment of choice for such patients. There is limited experience with thalidomide in patients with myeloma with renal impairment. Thus, thalidomide can be carefully administered, mainly in the context of well-designed clinical trials, to evaluate if it can improve the rapidity and probability of response that is produced by the combination with bortezomib and high-dose dexamethasone. Lenalidomide is effective in this setting and can reverse renal insufficiency in a significant subset of patients, when it is given at reduced doses, according to renal function. The role of plasma exchange in patients with suspected light chain cast nephropathy and renal impairment is controversial. High-dose melphalan (140 mg/m 2) and autologous stem-cell transplantation should be limited to younger patients with chemosensitive disease.

We studied a series of test conditions in a microtiter system to define the optimal method for determining the susceptibility of Cryptococcus neoformans to antifungal agents. Twenty-one isolates of C. neoformans were grown for 24 or 48 h in four chemically defined media: yeast nitrogen base (BYNB 7); RPMI 1640; synthetic amino acid medium--fungal (SAAMF), buffered at pH 7.0 to select the medium that best supported growth of this fastidious yeast; and yeast nitrogen base, pH 5.4 (YNB 5.4). Maximum growth of C. neoformans, at 35 degrees C, was obtained in YNB 5.4, with the next highest growth levels in BYNB 7, SAAMF, and RPMI. Growth at 24 h was uniformly poor in all media and lacked reproducibility. In contrast, incubation for 48 h gave adequate growth with low standard deviations, and 48 h was selected as the optimal incubation period for this study. Comparison of the relationship between growth kinetics and initial inoculum size for eight cryptococcal isolates showed that 10(4) cel...

Context: Metformin is widely prescribed to pregnant women with polycystic ovary syndrome (PCOS) in an attempt to reduce pregnancy complications. Metformin is not approved for this indication, and evidence for this practice is lacking. ... Objectives: Our objective was to ...

Aims. To examine the level of microbial colonisation in intravenous fluids after 24 hours of use in an acute care setting to determine the necessity of changing infusate bags on a time-related basis. Background. Catheter-related bloodstream infections are a serious and life-threatening complication of intravascular devices. Colonised intravenous fluids are one potential source of infection; however, there is little published literature on incidence rates and few recent studies. Routine intravenous fluid replacement has been advocated as an infection control method, but the effectiveness of this is unknown and the optimal duration for infusate use remains uncertain. Design. Cross-sectional study over 18 months in a 257-bed teaching hospital. Methods. Infusate specimens (n = 264) were obtained from crystalloid fluids that had been used for 24 hours or more. Microbiological culture and sensitivity testing was performed and infusate-related bloodstream infection (IRBSI) rates were recorded. Sample testing of previously unopened intravenous solutions acted as a control. Results. The infusate colonisation rate was 0AE4%, or 0AE09 per 1000 infusion hours. The only isolated organism was coagulasenegative Staphylococcus. Infusions had been in use for 24-185 hours (1-8 days). There was no difference in median duration of use for colonised (35AE0 hours) and sterile (34AE0 hours) specimens (Mann-Whitney test, p = 0AE99). There were no cases of IRBSI. Conclusion. The incidence of intravenous fluid colonisation and the risk of related bloodstream infection are low even after several days of infusate use. Current practice appears to successfully maintain the sterility of intravenous fluids. Relevance to clinical practice. Routine replacement of intravenous fluids continues in many settings, often 24 hourly, in the belief that this prevents infection. We found no relationship between duration of use and colonisation and routine replacement may be unnecessary. Further research is needed to investigate the effectiveness of routinely replacing intravenous fluids at set time points to prevent colonisation and infection.

We measured apolipoproteins (apo) A-I and B by rate immunonephelometry (rate INA) during Phase 1 of the National Health and Nutrition Examination Survey (NHANES) III. We also made the measurements by radial immunodiffusion (RID) in a 20% subset of the samples. Aliquots of this subset were also analyzed in the Northwest Lipid Research Laboratories by fixed-time INA calibrated to the World Health Organization (WHO)-International Federation of Clinical Chemistry (IFCC) First International Reference Materials for Apolipoproteins A-I and B. The CVs for the rate INA and RID measurements were: apoA-I, 4.5-7.7% and 2.5-7.6%, respectively; apoB, 2.3-5.3% and 2.3-6.4%, respectively. In NHANES III, rate INA values (x) can be transformed to WHO-IFCC Reference Material-based values (y) as follows: for apoA-I, y = 0.87x + 251.8 mg/L (r = 0.93, SEslope = 0.13, SEintercept = 17, n = 708); for apoB (mg/L), y = 1.068x + 112.8 mg/L (r = 0.98, SEslope = 0.08, SEintercept = 7, n = 646).

Chronic low back pain (LBP) is an extremely common problem in practice, where it is often labeled idiopathic. No sufficient studies have been conducted to analyze the contribution of hypovitaminosis D to the etiology of chronic LBP in populations wherein vitamin D deficiency is endemic. The present study was, therefore, carried out to examine hypovitaminosis D and its determinants in female patients with chronic LBP during the childbearing period. Sixty female patients complaining of LBP lasting more than 3 months were clinically studied rheumatologically and neurologically. Questionnaires and indices quantifying risk factors associated with vitamin D deficiency were utilized. Biochemical assays of serum calcium, phosphorus, alkaline phosphatase (ALP), parathormone (PTH), and 25-hydroxyvitamin D (25 OHD) were performed and compared to those of 20 matched healthy controls. The determinants of vitamin D levels in patients were examined by stepwise regression. Patients with LBP had significantly lower 25 OHD levels (p<0.05) and significantly higher PTH (p<0.05) and ALP (p<0.001) than controls, although there were no significant group differences in calcium and phosphorus. Hypovitaminosis D (25 OHD < 40 ng/ml) was found in 49/60 patients (81%) and 12/20 (60%) of controls, with an odds ratio of 2.97. Although many risk factors related to sun exposure, clothing, diet, and pregnancy were significantly correlated with vitamin D levels in patients, only limited duration of sun exposure, contributing 55% to the variance of 25 OHD, limited areas of skin exposed (13%), and increased number of pregnancies (2%), were significant determinants of vitamin D levels in patients. Despite the sunny climate, hypovitaminosis D is prevalent among Egyptian women in the childbearing period, especially those presenting with chronic LBP, where it is associated with hyperphosphatasia and hyperparathyroidism, without alterations in serum calcium. The major determinant of hypovitaminosis D in our patients is limited sun exposure.

OBJECTIVE To study the effects of long-term growth hormone (GH) treatment on lipid metabolism and carbohydrate tolerance in GH-deficient adults. DESIGN Open trial of GH treatment for 4 years. GH dose was (median, range) 0·025 (0·010-0·050) IU/kg daily. PATIENTS Thirteen GH-deficient hypopituitary adults (seven men, six women), aged (median, range) 47 (24-65) years were followed for 4 years. MEASUREMENTS Fasting lipids, lipoproteins, apolipoproteins, glucose and insulin concentrations were measured at yearly intervals during GH therapy. A 75-g oral glucose tolerance test (OGTT) was also performed yearly, during which circulating glucose and insulin were measured at 30-minute intervals for 3 h. RESULTS Fasting total and low density lipoprotein (LDL) cholesterol concentrations decreased on GH therapy, but no change was observed in fasting triglyceride or high density lipoprotein (HDL) concentrations. Compared to pretreatment values, total and LDL cholesterol levels were significantly lower at 1 year (mean Ϯ SEM) (6·39 Ϯ 0·46 vs. 5·71 Ϯ 0·38 mmol/l, P < 0·05; 4·46 Ϯ 0·36 vs. 3·24 Ϯ 0·20 mmol/l, P < 0·01, respectively) and the reductions were maintained for

Steady-state levels of IgG in the blood of adult mice, and likely all mammals, depend on IgG catabolism mediated in part by the MHC class I-related Fc receptor, FcRn (1). FcRn also mediates vectorial transport of IgG across certain epithelial barriers. In suckling mice and rats, intestinal absorption of maternal IgG from breast milk into the systemic circulation depends on FcRn (2). In humans, maternofetal transfer of IgG across the placenta also likely depends on FcRn (3). Thus, FcRn plays critical and well-documented roles in the regulation of IgG metabolism in adults and in the acquisition of humoral immunity in early life. These effects on the physiology of IgG in vivo result from the action of FcRn as an intracellular trafficking receptor (4).

Retinal vascular diseases such as diabetic retinopathy and retinopathy of prematurity are major causes of visual loss. Although the focus of a great deal of research has been on the aetiology of vascular growth, it is now emerging that anomalies in other retinal cell types, especially glial cells, occur very early in the course of the disease. Glial cells have major roles in every stage of disease, from the earliest subtle variations in neural function, to the development of epi-retinal membranes and tractional detachment. Therefore, having a firm understanding of the function of retinal glia is important in our understanding of retinal disease and is crucial for the development of new treatment strategies.

Young CC, Mark JB, White W, DeBree A, Vender JS, Fleming A. Clinical evaluation of continuous noninvasive blood pressure monitoring: accuracy and tracking capabilities. J Clin Monit 1995;11:245-252 ABSTRACT. A continuous, noninvasive device for blood pressure measurement using pulse transit time has been recently introduced. We compared blood pressure measurements determined using this device with simultaneous invasive blood pressure measurements in 35 patients undergoing general endotracheal anesthesia. Data were analyzed for accuracy and tracking ability of the noninvasive technique, and for frequency of unavailable pressure measurements by each method.

Purpose: A postoperative nomogram for prostate cancer was developed at Baylor College of Medicine. This nomogram uses readily available clinical and pathologic variables to predict 7-year freedom from recurrence after radical prostatectomy. We evaluated the predictive accuracy of the nomogram when applied to patients of four international institutions.

We compared PCR to conventional culture for the detection of vancomycin-resistant enterococci (VRE) in 30,835 rectal samples over a 3-year period. The positive and negative predictive values of vanB PCR were 1.42% and 99.9%, respectively. A positive vanB result by PCR is poorly predictive and necessitates culture for differentiation of VRE-positive and -negative individuals.

Uninephrectomized rats drinking 1% sodium chloride were given aldosterone (Aldo, 0.75 gg/h, subcutaneous Is.c.I infusion), deoxycorticosterone (DOC, 20 mg/wk, s.c.), corticosterone (B, 2 mg/d, s.c.), or the antiglucocorticoid-antiprogestin RU486 (2 mg/d, s.c.) for 8 wk, and hemodynamic and tissue responses were compared with a non-steroid-treated control group. Aldo and DOC markedly increased systolic BP and caused considerable (40-50%) cardiac hypertrophy; B and RU486 caused neither hypertension nor cardiac hypertrophy. Measurements of ventricular cross-sectional areas showed hypertrophy due to an increase in mass of the left ventricle only. Cardiac hydroxyproline concentration was increased considerably by Aldo and DOC, to a lesser degree by RU486, and not by B. Aldo markedly elevated left ventricular interstitial collagen (2.5-fold vs control, P < 0.01 vs all groups); other steroid treatments also increased interstitial collagen over control (DOC X 1.8-, RU486 X 1.6-, B X 13-fold), with identical responses for right and left ventricles (r = 0.94). A different pattern of perivascular fibrosis was noted; DOC elevated perivascular collagen (2.1-fold vs control, P < 0.01 vs all other groups); RU486 raised levels 1.4-fold vs control, but neither Aldo nor B significantly affected perivascular collagen. These data are consistent with interstitial cardiac fibrosis reflecting type I (mineralocorticoid) receptor occupancy by administered Aldo or DOC, or by elevated endogenous B after type II (glucocorticoid) receptor blockade after RU486 administration; perivascular fibrosis may reflect a composite response after type I receptor agonist/type II glucocorticoid receptor antagonist occupancy. (J. Clin. Invest. 1994.93:2578-2583

Lesioning or chronic deep brain stimulation (DBS) of the nucleus ventralis intermedius results in abolition of tremor in the contralateral limbs in Parkinson's disease (PD) and also in essential tremor. Recently, chronic DBS of the subthalamic nucleus has also proved to be very effective in reducing contralateral limb tremor in PD. These targets have been less effective in controlling the complex limb tremor often seen in multiple sclerosis (MS). Consequently, other targets have been sought in cases of MS with tremor. We describe a patient with MS with disabling proximal and distal involuntary arm movements in whom we were able to obtain sustained control of contralateral arm tremor and achieve functional improvement of the affected arm by chronic DBS of the region of the zona incerta. We also highlight the important role played by local field potentials recorded from the brain, with simultaneous recording of corresponding EMGs, in target localisation.

A total of 129 clinical isolates of Mycobacterium tuberculosis representing 91 patients were typed by a combination of direct-repeat (DR)-based spoligotyping and an inter-IS6110-PGRS (polymorphic GC-rich region)-PCR, also designated double-repetitive-element PCR (DRE-PCR). During the first phase of this investigation, 72 clinical strains representing 52 patients were initially typed by IS6110-restriction fragment length polymorphism (RFLP) and DR-RFLP, followed by spoligotyping and DRE-PCR. In the second phase of this investigation, the discriminating ability of spoligotyping plus DRE-PCR was studied for 57 isolates from 39 patients who were suspected to be epidemiologically linked, and the typing results were later confirmed by IS6110-RFLP and DR-RFLP analyses. The molecular clustering of the isolates remained identical irrespective of the methods used. These results show that the association of two PCR-based fingerprinting techniques for molecular epidemiology of tuberculosis has ...

Timely diagnosis of leptospirosis is important to ensure a favorable clinical outcome. The definitive serologic assay, the microscopic agglutination test (MAT), requires paired sera and is not useful for guiding early clinical management. The only screening test approved for use in the United States, the indirect hemagglutination assay (IHA), has not undergone extensive field evaluation. To assess the performance of the leptospirosis IHA in Hawaii, serum from patients evaluated for leptospirosis between 1992 and 1997 were tested with the IHA at the Hawaii State Laboratories Division and with the MAT at the Centers for Disease Control and Prevention. Leptospirosis was considered confirmed by a fourfold rise in MAT titer and/or a positive culture. A total of 92 (41%) of 226 specimens from 114 persons with confirmed leptospirosis were found positive by IHA. Only 18 (15%) of 119 specimens obtained within 14 days of onset were IHA positive, compared to 74 (69%) of 107 specimens collected more than 14 days after onset (P <0.001). Repeat testing ultimately resulted in 78 (68%) of the confirmed cases having at least one specimen found positive by IHA. Thirteen different presumptive infecting serogroups were identified among 251 specimens with an MAT titer of >200 and obtained from persons with confirmed or probable leptospirosis. Fifty (68%) of 73 specimens with Icterohaemorrhagiae as the presumptive infecting serogroup were found positive by IHA, compared to 44 (47%) of 93 specimens with Australis as the presumptive infecting serogroup (P, 0.01). The IHA test was positive for 3 (1%) of 236 specimens from 154 persons without leptospirosis. The sensitivity of the leptospirosis IHA in Hawaii was substantially below figures reported previously, particularly early in the course of illness, limiting its usefulness for diagnosing acute infection. Since the presumptive infecting serogroup affected IHA results and the prevalence of serovars varies with geography, the performance of the IHA should be assessed locally. More sensitive leptospirosis screening tests are needed in Hawaii.

Impairment of varicella zoster virus (VZV)-specific cell-mediated immunity, including impairment due to immunosenescence, is associated with an increased risk of developing herpes zoster (HZ), whereas levels of anti-VZV antibodies do not correlate with HZ risk. This crucial role of VZV-specific cell-mediated immunity suggests that boosting these responses by vaccination will be an effective strategy for reducing the burden of HZ. Other strategies focus on preventing the major complication of HZ-post-herpetic neuralgia. These strategies include pre-emptive treatment with drugs such as tricyclic antidepressants, anticonvulsants and analgesics.

White blood cell (WBC) count is a known risk factor for atherosclerotic vascular disease in adult women. Polycystic ovary syndrome (PCOS) is potentially a risk factor for atherosclerosis and cardiovascular disease. The aim of the present study was to investigate leukocyte count in PCOS. One hundred and fifty PCOS women matched for age and body mass index with 150 healthy women were enrolled. WBC count, C-reactive protein, and a complete anthropometrical, metabolic, and hormonal evaluation were performed in both groups. Serum insulin, glucose level, and lipid profile were also measured in each subject. WBC count was significantly higher (P < 0.0001) in PCOS with (interquartile range in parentheses) 7260 (393) cells/mm 3 , compared with controls with 5220 (210) cells/mm 3. C-reactive protein levels were significantly increased (P < 0.0001) in PCOS with 2 (1) mg/liter compared with healthy women with 0.7 (0.8) mg/liter. In both groups, there was a significant (P < 0.0001) linear correlation between WBC count and homeostasis model assessment score (PCOS, r ‫؍‬ 0.94; controls, r ‫؍‬ 0.91). Multiple linear regression analysis showed that other hormone levels are not predictors of leukocyte count both in PCOS and control women. In conclusion, our data demonstrate that PCOS women have an increased WBC count that correlates with homeostasis model assessment values.

Objectives: Development and validation of a direct enzymatic HbA1c assay that utilizes a single channel on chemistry auto-analyzers without the need to run separate glycated hemoglobin and total hemoglobin assays. Design and methods: An enzyme based single channel assay was developed to measure %HbA1c in human whole blood samples. The performance characteristics of the Diazyme Direct Enzymatic HbA1c Assay were evaluated on the Hitachi 917 auto-analyzer using whole blood samples, appropriate controls and a reference lot of manufactured reagents. Accuracy studies were completed by comparing the Direct Enzymatic Assay to existing HPLC and immunoassay methods. Interference testing was performed to determine the effect of total hemoglobin, glycated serum proteins, chemical substances and hemoglobin variants in patient samples. Results: The Direct Enzymatic HbA1c Assay showed within run precision and total precision results of ≤ 2% CV for both normal and abnormal level samples. Method comparison studies showed that there was a good correlation between the Direct Enzymatic HbA1c and the HPLC (R 2 = 0.98) or the immunoassay (R 2 = 0.97) methods. The assay measured within the range of 4-16% HbA1c and showed excellent performance with variant hemoglobin in samples. Conclusions: Diazyme Direct Enzymatic HbA1c Assay is accurate and precise when compared to currently marketed medical devices. The assay is designed to report %HbA1c values directly without need for a separate measurement of total hemoglobin and is not adversely affected by interferences from common hemoglobin variants in samples. It is a cost effective, user-friendly method and is adaptable to most general chemistry analyzers.

Breast cancer radiotherapy can be an emotionally difficult experience. Despite this, few studies have examined the effectiveness of psychological interventions to reduce negative affect, and none to date have explicitly examined interventions to improve positive affect among breast cancer radiotherapy patients. The present study examined the effectiveness of a multimodal psychotherapeutic approach, combining cognitive-behavioral therapy and hypnosis (CBTH), to reduce negative affect and increase positive affect in 40 women undergoing breast cancer radiotherapy. Participants were randomly assigned to receive either CBTH or standard care. Participants completed weekly self-report measures of positive and negative affect. Repeated and univariate analyses of variance revealed that the CBTH approach reduced levels of negative affect [F(1, 38)=13.49; p=.0007, ω2=.56], and increased levels of positive affect [F(1, 38)=9.67; p=.0035, ω2=.48], during the course of radiotherapy. Additionally,...

Historical perspective Asthma is a disease whose ability to cause episodic symptomatology has been appreciated since antiquity. Although the fine points of the definition can be debated, it is reasonable to think of asthma as a pulmonary disorder characterized by the generalized reversible obstruction of airflow and to define reversibility as a greater than 12% increase in the patient's forced expiratory volume in 1 second (FEV 1) that occurs either spontaneously or with therapy. Airway hyperresponsiveness, an exaggerated bronchospastic response to nonspecific agents such as methacholine and histamine or specific antigens, is the physiologic cornerstone of this disorder. A diagnosis of asthma is established based on a history of recurrent wheeze, cough, or shortness of breath, reversible airway obstruction demonstrated by pulmonary-function testing, and, in cases where questions exist, a methacholine challenge demonstrating airway hyperresponsiveness. It has long been assumed that patients with asthma experience intermittent attacks and have relatively normal lung function during intervening periods. More recent studies have demonstrated that asthma can cause progressive lung impairment and, in some patients, eventuate in partially reversible or irreversible airway obstruction. Any discussion of asthma must take into account the recent increase in its prevalence. Since approximately 1980, the frequency of this disorder has almost doubled. As a result of this "epidemic," asthma now affects approximately 8-10% of the population in the US, is the leading cause of hospitalization among children less than 15 years of age, and costs society billions of dollars annually. This increase in prevalence is not simply due to diagnostic transference or increased diagnostic awareness, since asthma mortality rates have also increased during this interval.

The self-reported family support and stress of 249 ambulatory adult patients, aged 1849 years, were studied relative to their self-reported functional health. Support from family members was found to be related positively with emotional function. Stress from family members was associated negatively with symptom status, physical function. and emotional function. Patients' severity of illness was related negatively to their symptom status, physical function, and social function, but not to their emotional function. During the study a new self-report instrument, the Duke Social Support and Stress Scale (DUSOCS), was developed to measure family and non-family support and stress. Also, a new chart audit methodology, the Duke Severity of Illness Scale (DUSOI), was designed to assess severity in the ambulatory setting. Reliability and validity of the DUSOCS and the DUSOI were supported. The importance of the patient's perception of health and its family determinants is emphasixed. Health status Family relations Social support Severity of Illness In&x Health status indicators Life change events Psychological stress Mental health Family health Social environment

The incidence and ossification of sesamoid bones in the hands and feet were studied in 922 radiographs (400 hands and 522 feet) in an Arab population from Bahrain, 5-83 years of age and consisting of 549 adults (393 men and 156 women) and 373 children (286 boys and 97 girls). All radiographs of the hand and foot in the adult population showed two sesamoid bones in the thumb metacarpophalangeal (MCP) joint and in the hallucal metatarsophalangeal (MTP) joint, respectively. Only 2.3% and 1.5% of hands showed sesamoids at the MCP joints of the middle and ring fingers respectively compared to a reported incidence of 7.1% for each digit in Caucasians. The incidence of sesamoids in the MTP joints of third and fourth toes (0.6% each) and inferior to the hallucal interphalangeal joint (3.1%) is probably the lowest reported so far in the literature. In the hands, ossification commenced first in the thumb sesamoids, at the age of 10 years in females and 11 years in males and was completed by the age of 13 and 14 years, respectively. In the feet, ossification began first in the hallucal sesamoids at the age of 8 years in females and 9 years in males and was completed by the age of 10 years in both sexes. The incidence and ossification of sesamoids in the hands and feet in the Arab population from Bahrain seem to differ considerably from reports in other populations. The clinical significance of our findings is discussed.

Background Mucus hyper-secretion is a feature of several airways diseases such as chronic rhinosinusitis, asthma, and cystic fibrosis (CF). Since mucins are major components of mucus, the knowledge of their distribution and regulation in nasal tissues is likely to improve mucus hyper-secretion therapy. Objective The aim of this study was to evaluate and compare mucin gene expression at epithelial and glandular levels, and to identify potential mucin expression patterns for specific upper airways pathologies. Methods Immunohistochemistry for MUC1, MUC2, and MUC4-MUC8 mucins was performed on healthy nasal mucosa (NM; n = 12), bilateral nasal polyps (NP; n = 38), NP from CF patients (n = 10), and antrochoanal (AC) polyps (n = 11). MUC2, MUC4, MUC5AC, and MUC6 mRNA expression were also analysed by in situ hybridization. Results MUC1, MUC4, and MUC5AC mucins were highly expressed in the epithelium and their expression pattern was similar in all NP types, MUC1 and MUC4 being increased and MUC5AC decreased compared with NM. MUC8 was highly detected at both epithelial and glandular levels with marked variability between groups. MUC5B was mainly detected in glands and the expression in all polyp types was higher than in NM. Moreover, MUC5B expression was higher in NP epithelia from CF patients than in bilateral NP and healthy NM. Although MUC2 expression was low, especially in AC polyps, it was detected in most samples. In NM, MUC6 and MUC7 were scarcely detected and MUC7 expression was restricted to glands. Conclusions These results suggest that NP have a different pattern of mucin expression than healthy NM and that CF polyps (increased MUC5B) and AC polyps (decreased MUC2) have a different mucin expression pattern than bilateral NP.

Background: The Musculoskeletal Disorders (MSDs) have a considerable socio economic impact. First, they drive up costs for workers, companies, and society in general. This applies to both direct and indirect costs associated with occupational diseases and industrial accidents. Nursing students experienced the MSD with increased cases amongst nursing staff. Nursing students continue to face the problems of MSD due to the misuse of the good technique to protect them self during clinical training hours. The study aimed to assess work-related musculoskeletal disorders among nursing students during clinical training. A cross-sectional study design used to achieve this aim. Convenience sampling technique was used to include all consenting nursing students from fifth level to eighth level (3rd and 4th year) (n=253) student who were having clinical training. The study took place at the Faculty of Nursing, Princess Nourah Bint Abdulrahman University. The first part include demographic data questions. The second part is a self-reported pain using standardized Nordic questionnaire for the analysis of musculoskeletal symptoms that will assess different body parts namely upper limb, lower limb, and trunk sections of the body. The study illustrated that more than half of students reported pain (71.1%) and ankle or feet (43.9%) during the last 12 months. Consistent also with students who reported MSD in the last seven days, 48.2% of them reported lower back problem. There is significant relationship between number of clinical days (p = 0.05) and MSD, and no significant relationship between the MSDs and the number of the clinical hours per day (p =0.973), weight (p = 0.806). The main conclusion drawn from the current study is that the majority of nursing students are high risk for MSDs due to improper body mechanics or wrong posture.

There are few data on the practice of evidence based medicine in the developing world, nor on the actual sources of evidence that clinicians use in practice. To test the hypothesis that there was variation between and within developing countries in the proposed management of a patient with hospital acquired pneumonia, and that part of the variation can be explained by the sources of evidence used. Questionnaire responses to hypothetical case history. Investigators from 6 centres within the International Clinical Epidemiology Network (INCLEN) in China, Thailand, India, Egypt, and Kenya. Doctors chosen to represent primary and secondary hospital practice in the regions of the study centres. Investigations and initial treatments which would be ordered for a hypothetical 60-year-old woman who develops pneumonia 5 days after hospital admission, whether local data on antibiotic sensitivities are available and where information would be obtained to guide management. Chest x-ray and sputum gram stain/culture were consistently the most commonly ordered investigations, there being much greater variation in the initial treatment choices with either penicillin, a third-generation cephalosporin or aminoglycoside being the most popular choice. Textbooks were the commonest form of information source, and access to a library, textbooks and journals were statistically significantly associated with appropriate choice of investigations, but not treatment. Access to local antibiotic sensitivities was associated with appropriate initial treatment choice. Improving access to information in the literature and to local data may increase the practice of evidence-based medicine in the developing world.

Context: Excess production of aldosterone or cortisol has profound effects on cardiovascular function and impacts other major organ systems. The mechanisms leading to the autonomous hypersecretion of aldosterone or cortisol in aldosterone-producing adenoma (APA) or cortisol-producing adenoma (CPA) are unknown.

Background Subcutaneous immunotherapy is effective for the treatment of respiratory allergy, and it is largely used in Italy, but no systematic safety assessment has been carried out so far.Objective To assess prospectively the safety of injection immunotherapy in a multicentre, real-life survey.Methods Eleven Italian allergy departments recorded the clinical characteristics of systemic reactions (SRs) due to immunotherapy. Vaccines were prescribed according to guidelines; only standardized depot extracts were used. SRs were graded according to the EAACI recommendations, and were classified as immediate or delayed.Results One thousand seven hundred and thirty-eight patients (847 males, age range 5–71) received immunotherapy from eight different manufacturers, for a total of 2038 courses (300 patients received two extracts). A total of 60 785 injections were given over a mean immunotherapy duration of 3 years. Overall, 95 reactions were observed in 57 patients (3.28%), corresponding to 4.7% of the courses and 1.56/1000 injections. Twenty-five patients experienced more than one adverse event. There were 34 grade 2, 60 grade 3 and one grade 4 reactions and no fatality. SRs occurred more frequently in patients with asthma than in patients with rhinitis alone (4.1% vs. 1.1%), and were equally distributed between the build-up and the maintenance phase. Ragweed and grass extracts caused significantly more side effects than other allergens.Conclusion In this large prospective study, the rate of SRs was low, thus confirming that injection immunotherapy has an acceptable risk/benefit ratio when prescribed and carried out according to recommendations.