Culturable and nonculturable bacterial symbionts in the toxic benthic dinoflagellate Ostreopsis lenticularis.

The toxic benthic dinoflagellate Ostreopsis lenticularis hosts a variety of symbiont bacterial flora. Laboratory cultured Ostreopsis clones require the presence of symbiotic Pseudomonas/Alteromonas bacterial strains for growth and toxicity development. Three culturable bacterial strains associated with Ostreopsis were identified as Pseudomonas/Alteromonas strain 1, Pseudomonas/Alteromonas strain 2 and Acinetobacter. Denaturing gradient gel electrophoresis (DGGE) analyses of extracted Ostreopsis associated bacterial DNAs indicated that there were three culturable and four non-culturable associated bacterial strains. The results presented here are the first report of the presence of unculturable bacterial symbionts in a toxic benthic dinoflagellate. Ostreopsis lost toxicity when exposed to elevated temperatures in the field and laboratory culture and subsequently recovered toxicity at reduced temperatures. Ostreopsis associated culturable Pseudomonas/Alteromonas bacterial strains were significantly reduced in dinoflagellate cultures exposed to elevated temperatures. The decreased toxicity of O. lenticularis exposed to elevated temperatures and their subsequent recovery of toxicity in periods of reduced thermal stress may have resulted from the effects of elevated temperature on the spectrum of culturable and unculturable bacterial species interacting with their Ostreopsis host.     

The mentored clinical casebook project at Harvard Medical School.

An excellent physician must be aware of the countless issues that affect each patient's health. Many medical education programs expose students to a broad spectrum of disparate knowledge and hope they will integrate all the pieces into a coherent whole. The authors describe an explicit approach to integration used at Harvard Medical School since 2003 that aims to enhance students' learning in medical school and throughout their medical careers: the Mentored Clinical Casebook Project (MCCP). The MCCP is constructed on the premise that such integration does not occur suddenly but, rather, is an unending process. A first-year student is assigned to one clinician and follows one patient for one year. The student is expected to spend as much time with the patient as possible, in both clinical and nonclinical settings, seek help from the clinician, and consult other experts and sources to develop a complete picture of the patient's life. The student must produce a casebook that includes, but is not limited to, the patient's history; basic science, clinical, socioeconomic, and cultural issues; and self-reflection. The MCCP is intended to allow students to develop a deeper and more diverse understanding of what comprises a patient's health care life, to discern the patient as a person and the person as a patient. This educational project has been popular with students since its inception, providing them with a personal framework from which to address the needs of future patients and introducing them to how much they will continue to learn from their patients.     

Cost effectiveness of thrombolytic therapy with streptokinase in elderly patients with suspected acute myocardial infarction.

BACKGROUND. There is a lack of consensus among cardiologists about the potential benefit of thrombolytic therapy for suspected acute myocardial infarction in older patients. To investigate this issue, we constructed a decision-analytic model for patients 75 years of age or older who present with ST-segment elevation within six hours of the onset of symptoms suggesting acute myocardial infarction. METHODS. The variables incorporated in this model were the probability that the patient has an acute myocardial infarction, the probability of in-hospital death among patients with acute myocardial infarction who do not receive thrombolytic therapy, the probability of a fatal or incapacitating complication resulting from thrombolytic therapy, and the expected relative reduction in the risk of death associated with thrombolytic therapy in patients with acute myocardial infarction. Our analyses were based primarily on the use of streptokinase as the thrombolytic agent. RESULTS. Given our base-line assumptions, the probability of dying in the hospital was 21.4 percent if thrombolytic therapy was given and 24.4 percent if it was not given. In one-way sensitivity analyses, thrombolytic therapy decreased the risk of dying if the probability that the patient had an acute myocardial infarction was assumed to be greater than 9 percent, if the probability of dying in the hospital after an acute myocardial infarction without thrombolytic therapy was assumed to be greater than 3 percent, if the rate of fatal or incapacitating complications due to thrombolytic therapy was assumed to be 4 percent or less, or if the relative reduction in the risk of death associated with thrombolytic therapy was assumed to be greater than 1 percent. On the basis of our base-line assumptions, our estimate of the cost effectiveness of streptokinase therapy (the cost per year of life saved) for an 80-year-old patient with suspected acute myocardial infarction was $21,200. For a wide range of assumptions about risks, benefits, and costs, the cost per year of life saved remained less than $55,000. CONCLUSIONS. Within the limitations imposed by the assumptions used in our analysis, thrombolytic therapy with streptokinase was found to be a beneficial and cost-effective treatment for suspected acute myocardial infarction in elderly patients in a wide variety of clinical circumstances.     

The changing face of reoperative parathyroidectomy: a single-centre comparison of 147 parathyroid reoperations

IntroductionReoperative parathyroidectomy for persistent and recurrent primary hyperparathyroidism is dependent on radiology. This study aimed to compare outcomes in reoperative parathyroidectomy at a single centre using a combination of traditional and newer imaging studies.Materials and methodsRetrospective case note review of all reoperative parathyroidectomies for persistent and recurrent primary hyperparathyroidism over five years (June 2014 to June 2019; group A). Imaging modalities used and their positive predictive value, complications and cure rates were compared with a published dataset spanning the preceding nine years (group B).ResultsFrom over 2000 parathyroidectomies, 147 were reoperations (101 in group A and 46 in group B). Age and sex ratios were similar (56 vs 62 years; 77% vs 72% female). Ultrasound use remains high and shows better positive predictive value (76% vs 57 %). 99mTc-sestamibi use has declined (79% vs 91%) but the positive predictive value has improved (74% vs 53%). 4DCT use has almost doubled (61% vs 37%) with better positive predictive value (88% vs 75%). 18F-fluorocholine positron emission tomography-computed tomography and ultrasound-guided fine-needle aspiration for parathyroid hormone are novel modalities only available for group A. Both carried a positive predictive value of 100%. Venous sampling with or without angiography use has decreased (35% vs 39%) but maintains a high positive predictive value (86% vs 91%). Cure rates were similar (96% vs 100%). Group A had 5% permanent hypoparathyroidism, 1% permanent vocal cord palsy and 1% haematoma requiring reoperation. No complications for group B.ConclusionOptimal imaging is key to good cure rates in reoperative parathyroidectomy. High-quality, non-interventional imaging techniques have produced a shift in the preoperative algorithm without compromising outcomes.     

Screening for subclinical sleep-disordered breathing

We evaluated self-administered questionnaires and short sleep studies in screening for sleep-disordered breathing (SDB) in 40 hypertensive men ages 36-66 unselected for symptoms. Each subject completed a questionnaire including questions on sleep-related symptoms and underwent overnight polysomnography in which we evaluated the apnea-hypopnea index (AHI) and the percentage of time during which arterial O2 saturation was less than 90% (T90). The first 90 min of overnight study was evaluated separately, and 10 subjects with an AHI greater than or equal to 10 also underwent late afternoon nap study. By overnight polysomnography, 48% of the cohort had an AHI greater than or equal to 10, and 35% had a T90 greater than or equal to 10%. Using linear regression, we found no features of the symptom questionnaire that strongly predicted AHI. Only self-reported snoring and baseline arterial Po2 significantly predicted T90. The AHI and T90 were not significantly correlated. Considering an AHI greater than or equal to 10 in the overnight study as "abnormal" and an AHI greater than or equal to 10 on the short study as a "positive" test, the specificity of the AHI in the first 90 min was 100% (21/21), and the sensitivity was 42% (8/19). The sensitivity of the nap study was 60% (6/10). We conclude that in a cohort unselected for symptoms, the ability of self-administered questionnaires to predict SDB was low; short studies were only moderately sensitive for detecting an AHI greater than or equal to 10, and the AHI was not a major determinant of nocturnal desaturation.