Lack of agreement in classification of the severity of acute asthma between emergency physician assessment and classification using the National Asthma Council Australia guidelines (1998)

Aims: To determine the level of agreement in classification of the severity of acute asthma at presentation to the emergency department, between emergency physician global assessment and severity classification according to the National Asthma Council Guidelines, Australia 1998 (NACG). Methods: Prospective observational study in emergency departments throughout Australia, participating in the Asthma Snapshot 2000 project. Patients between the ages of one and 60 years presenting to participating emergency departments with acute asthma between 21 August and 3 September 2000 were included. Data collected were emergency physician global assessment of asthma severity and severity classification according to the National Asthma Council Guidelines and disposition. Results: Five hundred and five subjects had completed data for emergency physician assessment of severity and for calculation of severity classification according to the National Asthma Council Guidelines. Weighted kappa for agreement in classification was 0.48 (95% confidence interval: 0.40, 0.56). Emergency physicians assess asthma as less severe compared to the National Asthma Council Guidelines assessment. Conclusions: Agreement between physician assessment of severity of acute asthma and severity classification according to National Asthma Council Guidelines is only moderate. This may have implications in treatment and disposition. This also suggests that emergency physicians may be using other methods to classify acute asthma than the National Asthma Council Guidelines classification.     

Update on Percutaneous Mechanical Mitral Commissurotomy

A reusable metallic valvotomy device has been developed with the goals of improving the results of percutaneous mitral valvotomy and increasing the cost-effectiveness of the procedure. The device consists of a detachable and reusable metallic dilator with two articulated bars screwed at the distal end of a catheter. Using transseptal catheterization, the device is placed across the valve over a traction guidewire and then opened gradually by means of pliers up to a maximum of 40 mm. To date, the device was used in 168 patients with a broad spectrum of mitral valve disease. The procedure was successful in 95% of cases and resulted in an increase in mitral valve area from 1.01 ± 0.8 to 2.20 ± 0.7 cm². No increase in mitral regurgitation was noted in 87% of cases. Bilateral splitting of the commissures was observed in 89%. Complications included the following: 2 severe mitral regurgitations (one requiring surgery), 1 pericardial tamponade, 1 transient cerebrovascular embolic event. The maximum number of consecutive patients treated with the same device was 35. The results obtained are at least comparable to those of current balloon techniques and confirm the possibility of safe multiple reuses of the device after sterilization.     

Renal concentration of alpha-tocopherol: dependence on gender and lack of effect on polycystic kidney disease in Han:SPRD rats

A gender-associated dimorphism, with males being more severely affected than females, has been observed in autosomal dominant polycystic kidney disease, acquired renal cystic disease, and the renal cystic disease of the Han:SPRD rat. A recent study has suggested that gonadal hormones may be responsible for this dimorphism. Because gonadal hormones have an effect on the concentration of alpha-tocopherol in the liver and adrenal glands and because recent studies indicate that oxidative stress may be important in the pathogenesis of polycystic kidney disease, we wanted to determine whether the renal concentration of alpha-tocopherol is higher in female than in male rats and whether this difference accounts for the gender dimorphism of polycystic kidney disease in Han:SPRD rats. At 3 weeks of age, male and female heterozygous cystic (cy/+) rats were divided into three groups fed a vitamin E-deficient diet or the same diet supplemented with either 65 IU or 10,000 IU alpha-tocopherol/kg laboratory chow. At 8 weeks of age, blood samples and kidneys were obtained for determinations of plasma creatinine and urea, renal concentration of alpha-tocopherol and glutathione, kidney weights, and histomorphometric analysis. Female rats had higher renal concentrations of alpha-tocopherol and less severe renal cystic disease, as reflected by plasma creatinine and urea values, kidney weight corrected by body weight, and histomorphometric analysis, than male rats. The difference in renal alpha-tocopherol concentration, however, could not account for the different severity of the renal cystic disease, because depletion or enrichment of vitamin E in the diet had marked effects on the renal concentration of alpha-tocopherol without affecting the severity of the renal cystic disease. Cy/+ rats had higher renal concentrations of alpha-tocopherol than +/+ animals, possibly reflecting a disturbance of redox metabolism associated with polycystic kidney disease. Renal concentrations of glutathione were unaffected by the vitamin E content of the diet. Although these results do not support the use of vitamin E in the treatment of polycystic kidney disease, observations in the Han:SPRD rat may or may not be relevant to human polycystic kidney disease.     

Prevalence of Hepatitis A Antibody in Travelers from Hawaii

Background: Hepatitis A is the most frequent vaccine-preventable infection in travelers to developing countries. Hepatitis A vaccine and immune serum globulin (IG) offer safe, effective protection against hepatitis A. Some travelers are already immune, however, and it is useful to try to identify subgroups with an anticipated high prevalence of antibody to hepatitis A (anti-HAV). Screening for antibody in these groups would often be a cost-effective alternative to routine use of hepatitis A vaccine or IG prior to travel.
Methods: Prospective travelers to developing countries from Hawaii (n = 476) were tested for anti-HAV. Total antibody was measured by an enzyme immunoassay. Age, sex, birthplace, previous travel experience, and past history of hepatitis or jaundice were recorded for each traveler.
Results: Overall prevalence of anti-HAV was 35.3%. Antibody prevalence increased progressively with age and varied significantly with birthplace and travel experience. Antibody prevalence was particularly high in travelers with a history of hepatitis or jaundice.
Conclusions: Screening for preexisting immunity to hepatitis A is often worthwhile in extended stay or repeat travelers. This study suggests that screening may also be a cost-effective alternative to routine use of hepatitis A vaccine or IG in those travelers (i) born in the United States (including Hawaii) before 1930;(ii) born in Europe, Australasia, or Japan before 1950, (iii) born in developing countries; (iv) with increased travel experience; and (v) with a history of hepatitis or jaundice.     

Stromal cells from human long-term marrow cultures are mesenchymal cells that differentiate following a vascular smooth muscle differentiation pathway

In human long-term marrow cultures connective tissue-forming stromal cells are an essential cellular component of the adherent layer where granulomonocytic progenitors are generated from week 2 onward. We have previously found that most stromal cells in confluent cultures were stained by monoclonal antibodies directed against smooth muscle- specific actin isoforms. The present study was carried out to evaluate the time course of alpha-SM-positive stromal cells and to search for other cytoskeletal proteins specific for smooth muscle cells. It was found that the expression of alpha-SM in stromal cells was time dependent. Most of the adherent spindle-shaped, vimentin-positive stromal cells observed during the first 2 weeks of culture were alpha- SM negative. On the contrary, from week 3 to week 7, most interdigitated stromal cells contained stress fibers whose backbone was made of alpha-SM-positive microfilaments. In addition, in confluent cultures, other proteins specific for smooth muscle were detected: metavinculin, h-caldesmon, smooth muscle myosin heavy chains, and calponin. This study confirms the similarity between stromal cells and smooth muscle cells. Moreover, our results reveal that cells in vivo with the phenotype closest to that of stromal cells are immature fetal smooth muscle cells and subendothelial intimal smooth muscle cells; a cell subset with limited development following birth but extensively recruited in atherosclerotic lesions. Stromal cells very probably derive from mesenchymal cells that differentiate along this distinctive vascular smooth muscle cell pathway. In humans, this differentiation seems crucial for the maintenance of granulomonopoiesis. These in vitro studies were completed by examination of trephine bone marrow biopsies from adults without hematologic abnormalities. These studies revealed the presence of alpha-SM-positive cells at diverse locations: vascular smooth muscle cells in the media of arteries and arterioles, pericytes lining capillaries, myoid cells lining sinuses at the abluminal side of endothelial cells or found within the hematopoietic logettes, and endosteal cells lining bone trabeculae. More or less mature cells of the granulocytic series were in intimate contact with the thin cytoplasmic extensions of myoid cells. Myoid cells may be the in vivo counterpart of stromal cells with the above-described vascular smooth muscle phenotype.     

Leptospirosis in Hawaii, 1974-1998: epidemiologic analysis of 353 laboratory-confirmed cases

The epidemiologic characterization of leptospirosis in the United States has been limited by difficulties associated with both case detection and confirmation. In addition, leptospirosis was eliminated from the list of National Notifiable Diseases in 1995. From 1974 until the cessation of national surveillance, Hawaii consistently had the highest reported annual incidence rate in the United States. From 1974 through 1998, 752 leptospirosis cases were reported in the State of Hawaii. Of these, 353 had exposures within the state and were laboratory confirmed. The mean annual incidence rate was 1.29 per 100,000. Cases were predominately male. Rates were highest in rural areas. Occupational exposures diminished over time while recreational exposures increased. This series represents the first large U.S. leptospirosis surveillance report since 1979. With leptospirosis recently being identified as a re-emerging zoonosis, continued national surveillance and case reporting should be reconsidered.     

New developments in the regulation of intestinal copper absorption

The transition metal copper is an essential trace element involved in many enzymatic processes that require redox-chemistry. The redox-activity of copper is potentially harmful. Severe imbalance of copper homeostasis can occur with some hereditary disorders of copper metabolism. Copper is acquired from the diet by intestinal absorption and is subsequently distributed throughout the body. The regulation of intestinal copper absorption to maintain whole-body copper homeostasis is currently poorly understood. This review evaluates novel findings regarding the molecular mechanism of intestinal copper uptake. The role of recently identified transporters in enterocyte copper uptake and excretion into the portal circulation is described, and the regulation of dietary copper uptake during physiological and pathophysiological conditions is discussed.     

Prevention by retinoids of azoxymethane-induced tumors and aberrant crypt foci and their modulation of cell proliferation in the colon of rats

Retinoids are proposed chemopreventive agents that inhibit cell proliferation and induce differentiation. Their ability to prevent azoxymethane (AOM)-induced aberrant crypt foci (ACF) and tumors and to modulate cell proliferation was investigated in the colon of male F344 rats. Thirteen retinoids were evaluated for prevention of ACF and two of them, 9-cis-retinoic acid (RA) and 4-(hydroxyphenyl)retinamide (4- HPR), were also evaluated for prevention of colon cancer. The retinoids were administered continuously in the diet starting 1 week prior to the first of two weekly 15 mg/kg i.p. injections of AOM and for a total of either 5 or 36 weeks in order to evaluate their effect on colonic ACF and tumors. At a concentration of 1 mmol/kg diet, 2- (carboxyphenyl)retinamide caused the greatest reduction (57.7%) in the yield of ACF. 9-cis-RA was toxic at 1 mmol/kg so that it was evaluated at 0.1 mmol/kg, resulting in a 41.6% reduction in ACF. The ability of the retinoids to reduce the proliferating cell nuclear antigen (PCNA) labeling index in ACF and in non-involved crypts correlated with their ability to prevent ACF. Both 9-cis-RA (0.1 and 0.2 mmol/kg diet) and 4- HPR (1 and 2 mmol/kg diet) were highly effective in decreasing the yield of AOM-induced colon tumors. In summary, retinoids were demonstrated to reduce cell proliferation and to prevent ACF and tumors in the colon, suggesting promise as preventive agents for colon cancer.      

Adhesive capsulitis of the wrist: arthrographic diagnosis

Persistent pain and decreased range of motion are disabling complications of wrist trauma. Between 1978 and 1986, in ten patients with persistent pain following trauma, arthrography depicted changes characteristic of adhesive capsulitis. Adhesive capsulitis has been described in the shoulder, hip, and ankle, but little mention has been made of this entity in other joints. Confirmation of this diagnosis requires arthrography, since there are no characteristic findings on plain radiographs. Typical arthrographic findings include decreased capacity, small volar and styloid recesses, and adhesions preventing complete opacification of the joint. The arthrographic diagnosis allows proper institution of appropriate therapy.     

EFFECTS ON GROWTH HORMONE SECRETION FOLLOWING INTRAVENOUS AND SUBCUTANEOUS INJECTIONS OF GROWTH HORMONE-RELEASING FACTOR (hGRF-44 NH2): COMPARISON OF IMMUNOREACTIVE PLASMA GRF LEVELS

The effects of subcutaneous administration of three doses of human growth hormone-releasing factor (hGRF-44 NH2 or hGRF) at doses of 100, 300 and 600 micrograms were studied in six normal young men. GH responses obtained with 100 and 300 micrograms were negligible. In contrast, the 600 micrograms dose gave a profile of response comparable in timing and magnitude to that obtained with i.v. hGRF at maximal effect doses (20, 80, 100 micrograms). Plasma immunoreactive hGRF levels (IR-hGRF) were compared after s.c. and i.v. hGRF. Mean maximal plasma concentrations were comparable with s.c. 600 micrograms and i.v. 20 micrograms. Peaks occurred earlier with i.v. hGRF (5 min as opposed to 15 min): however, return to undetectable values was obtained between 90 and 120 min after s.c. or i.v. injections. These data suggest a great loss of the peptide between the subcutaneous space and blood, without delayed absorption. High variability in plasma IR-hGRF concentrations between the subjects after the same s.c. doses was observed.