Resistance in oral streptococci after repeated three-dose erythromycin prophylaxis

Ten healthy volunteers, from whom no erythromycin-resistant oral streptococci could be isolated initially, received three doses of erythromycin stearate (1.0, 0.5 and 0.5 g) on two separate occasions with a one-week interval between them. After the second administration all volunteers yielded moderately resistant strains (MIC 1-4 mg/l) and four harboured highly resistant streptococci (MIC 16- greater than 256 mg; MBC 128- greater than 256 mg/l). Erythromycin-resistant strains persisted in eight of the volunteers at 23 weeks and in five of eight volunteers at 43 weeks. Species included Streptococcus sanguis, Str. mitior and unclassified streptococci, and dextran-positive strains were encountered. Erythromycin-resistant streptococci are thus readily selected by two administrations of the three-dose regimen. Until the time of emergence of the resistant strains is further clarified a full assessment of the antibiotic sensitivity of the flora of the gingival sulcus is advisable before erythromycin prophylaxis is repeated.     

The vomiting infant: pyloric stenosis

Infantile hypertrophic pyloric stenosis is the commonest reason to perform an intra-abdominal operation on a young infant. It is thus an important condition for the trainee surgeon to understand. It illustrates many important lessons in diagnosis, preoperative preparation, operative skill and postoperative management and how to apply them to infants and babies to achieve the excellent outcome that is expected with minimal morbidity.     

Methodological issues encountered in a study of hospitalized COPD patients

A study with hospitalized chronic obstructive pulmonary disease (COPD) patients determined the feasibility of providing and evaluating a tailored education program. This article describes two methodological issues encountered. Issues included recruitment and retention, and selection of outcome measures. The COPD Self-Efficacy Scale (CSES) and Dartmouth Functional Health Status (FHS) charts provided data on evaluation and outcome measurements. Of 67 patients, 55% met eligibility criteria, 73% (n = 27) agreed to participate, and 74% (n = 20) completed the study. Results revealed acceptance and satisfaction with the educational intervention. The median CSES score, significantly (z = 3.51,p = .004) improved from 53% to 82%. In FHS, a 20% improvement occurred in all except social support. Methodological concerns with the CSES reinforced the need for further investigation of the reliability and validity for hospitalized COPD patients. Researchers' observations may assist in planning educational interventions and program evaluations with hospitalized COPD patients.     

Recovery of growth hormone secretion following cabergoline treatment of macroprolactinomas

OBJECTIVE: Cabergoline therapy normalizes prolactin levels and reduces the size of macroprolactinomas. However there are no data indicating whether cabergoline can normalize growth hormone secretion in patients who were growth hormone deficient at the time of diagnosis of a macroprolactinoma. SUBJECTS AND METHODS: We studied nine patients with biochemical and radiological evidence of a macroprolactinoma who were also growth hormone deficient (peak growth hormone response to insulin-induced hypoglycaemia < 10 mU/l). Patients were assessed before and after cabergoline therapy to assess their growth hormone secretory status, IGF-I levels, cortisol response and change in tumour size. RESULTS: Treatment with cabergoline was associated with a significant reduction in prolactin concentration (74341 +/- 31939 mU/l vs. 265.9 +/- 86.3, P = 0.009). The mean change in peak growth hormone response to insulin-induced hypoglycaemia was significantly greater following cabergoline therapy compared with pretreatment levels (33.5 +/- 11.8 mU/l vs. 4. 34 +/- 1.21 mU/l, P = 0.022). However IGF-I levels were not different after treatment when compared with baseline although a nonsignificant trend towards improvement was noted (24.2 +/- 3.97 nmol/l vs. 18.4 +/- 4.94 nmol/l, P = 0.058). The mean peak cortisol concentration was 407.7 +/- 64.1 nmol/l before treatment with a nonsignificant rise to 477.4 +/- 84.8 nmol/l, P = 0.813 after treatment. These changes were associated with a significant reduction in mean maximal tumour diameter (21.2 +/- 2.9 mm vs. 29.1 +/- 2.8 mm, P = 0.009). There was no significant difference in either prolactin concentration or tumour size pre- or post-treatment between those who recovered growth hormone secretion and those that did not. Six of the nine (67%) patients recovered a normal growth hormone response (> 10 mU/l) after cabergoline therapy. Those that remained growth hormone deficient after treatment were all panhypopituitary at baseline while those that recovered showed only partial anterior hypopituitarism. CONCLUSION: These data indicate that growth hormone secretion may recover following successful reduction of prolactin levels after cabergoline therapy for a mean of 22 months (range 6-28 months) in most but not all subjects with a macroprolactinoma. It is therefore advisable that individuals with a macroprolactinoma in whom growth hormone replacement therapy is being considered undergo repeat assessment of growth hormone secretion following medical treatment.     

Fibronectin in the synovium of chronic inflammatory joint disease

Summary The localisation of fibronectin in the synovial membrane of rheumatoid arthritis (RA) and other chronic inflammatory joint diseases has been studied using a peroxidase-antiperoxidase immunohistochemical method. Synovia were studied from seven cases of seropositive RA three cases of seronegative RA, six cases of ankylosing spondylitis, four cases of Reiter's syndrome and five of psoriatic arthritis. Six were small biopsies and the remaining tissues were obtained at open surgery for orthopaedic procedures or biopsies.Fibronectin was demonstrated in all of the synovia examined and was present in intimal cells, synovial giant cells, the walls of small blood vessels, basement membrane of larger vessels and deposits of fibrin. No difference in this distribution of fibronectin was found in seropositive and seronegative RA, ankylosing spondylitis, Reiter's syndrome or psoriatic arthritis, neither was there any difference in the amount of fibronectin at various sites.     

Tuberculosis and its incidence, special nature, and relationship with chronic obstructive pulmonary disease

Tuberculosis (TB) and chronic obstructive pulmonary disease (COPD) carry a significant burden in terms of morbidity and mortality worldwide. This review article focuses on different aspects of Tuberculosis in terms of the relationship with COPD such as in the development of chronic airflow obstruction as a sequel to active TB and reviewing the key role of cigarette smoking in the pathogenesis of both conditions. Patients diagnosed with TB may often have extensive co-morbidity such as COPD and the effect of an underlying diagnosis of COPD on outcomes in TB is also reviewed.     

Cost estimates for treatment of cardiac ischemia (from the Asymptomatic Cardiac Ischemia Pilot [ACIP] study)

Costs for management of myocardial ischemia are enormous, yet comparison cost and outcome data for various ischemia treatment strategies from randomized trials are lacking and will require cost and resource utilization data from a large prospective trial. The Asymptomatic Cardiac Ischemia Pilot provided feasibility data for planning such a trial and an opportunity to estimate the long-term costs of different treatment strategies. Economic implications for ischemia management were compared in 558 patients with stable coronary artery disease and myocardial ischemia during both stress testing and daily life. Participants were randomized to 3 different initial treatment strategies and followed for 2 years. Based on cost trends over follow-up, costs for subsequent care were estimated. As expected, due to initial procedural costs, at 3 months, estimated costs for revascularization were approximately 10 times greater than costs for a medical care strategy. Extrapolated costs for anticipated resource consumption for care beyond 2 years, however, were approximately 2 times greater for an initial medical care strategy than for initial revascularization. This was due to increased need for drugs and hospitalizations for both late revascularizations and other ischemia-related events. Estimated costs for anticipated care in the medical strategies reached the anticipated cost of the revascularization strategy within 10 years. Because this cost-equal time period is well within the median life expectancy for such a patient population, these findings could have important public health implications and require testing in a full-scale prognosis trial. We anticipate that over the patients' life expectancy, early revascularization is likely to become either cost-neutral or cost-effective.     

Body weight is a predictor of biphasic shock success for low energy transthoracic defibrillation

We studied the performance of external chest compression by 20 fourth year medical students on 2 study days, separated by 5-7 weeks, 4-8 months after they had been initially trained in cardiopulmonary resuscitation (CPR). Our hypotheses were (1) that a given individual would perform external chest compressions in the same manner each time CPR was performed and (2) that the pattern of performance of chest compressions would be determined, in part, by the anthropometric characteristics of the rescuer. A Laerdal Skillmeter Resusci-Anne CPR manikin chest compression transducer was interfaced with an analogue-to-digital conversion board in a Macintosh LC III computer. Each subject on each study day performed four cycles of 15 compressions and two ventilations twice, once on a table (which raised the surface of the manikin sternum to 95 cm) and once on the floor. For each individual, on each attempt, we calculated the depth and rate of compressions, duty cycle, peak compression velocity, time to peak compression velocity and time to peak compression depth. In addition, we calculated the regression slope of compression depth versus compression number for each cycle of 15 chest compressions and over four cycles of compressions. Statistically significant correlations were observed between the first and second study days in each of the variables of chest compression measured, indicating that the performance of chest compressions was constant over time for a given individual. We observed that the depth of compression, duty cycle, time to peak compression, time to peak velocity and regression slope of depth of compressions versus compression number were significantly related to the height and weight of the rescuer.