Appropriate laboratory use of microbiological testing for quality control and nosocomial infection control

Useful information from clinical microbiological tests is required for clinical diagnosis and treatment of infectious disease, whereas concern about the quality of information is still low. To provide reliable information in clinical microbiological testing, it is necessary to control the quality of clinical specimens, because of its random character. Through effective use of laboratory testing database, it will be possible to shift away our vague management of pre-analytic phase of quality control so far to its established system based on objective evaluation. During the past 4 years, after the introduction of microbiological tests and information system in our hospital, the characteristics of sputum have become worse contrary to our expectations. This suggests that quality control needs successive improvements, even in service departments such as clinical laboratories. Application of laboratory testing database to nosocomial infection control is considered to be a performance of post-analytic phase of quality control from the viewpoint of effective use of laboratory data. We presented in this paper our practical application of the database to the short-term and long-term control of nosocomial infection.     

Orthopedic therapy in rheumatic diseases

The treatment of rheumatic disease requires an interdisciplinary approach in which the orthopedic surgeon is also involved. His contribution includes both conservative and operative procedures. Early synovectomy applied to joints and tendons is considered a preventive measure. Arthroscopic synovectomy belongs in the hands of an experienced operator. Joints that are not directly involved in weight-bearing can be treated by means of arthroplastic procedures, provided the cooperation of the patient is ensured. Arthrodesis is used preferentially to treat articular destruction of the ankle joint, the metacarpophalangeal joint of the thumb and the middle joints of the finger. Osteoporosis represents a relative contraindication. The treatment of rheumatic diseases of the joints using endoprostheses produces good primary results. The rate of loosening is not significantly increased, but late infection is somewhat higher than in other forms of articular disease.     

Soluble HLA-I in rheumatic diseases

OBJECTIVE: To study serum levels of Class I soluble HLA (sHLA-I) in patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), polymyositis or dermatomyositis (PM/DM) or scleroderma and to assess the possible influence of ethnic factors on concentration in each disease group. METHODS: Solid-phase enzyme linked immunoassay was used to measure sHLA-I in the serum of 385 patients with varied ethnic backgrounds (American-Caucasians, African-Americans, Georgian-Caucasians) with rheumatic diseases. Studies on patients were compared to similar measurements of 189 healthy individuals. RESULTS: Mean sHLA-I levels were significantly higher in patients with SLE than those observed in healthy individuals or other rheumatic diseases. Highest concentrations were present in Georgian-Caucasian patients with SLE. American-Caucasian patients with RA or scleroderma had higher sHLA-I levels than normal Caucasian individuals. The majority of patients with PM/DM in all ethnic subgroups were low secretors of sHLA-I. CONCLUSION: Mechanisms underlying the secretion of sHLA-I appear to differ among the rheumatic diseases studied and various ethnic groups. These genetic differences in sHLA-I secretion could be associated with ethnic and pathophysiologic differences among these rheumatic diseases.     

Nail biting in rheumatic diseases

To ascertain if nail biting (usually considered a manifestation of emotional tension) was associated with fibromyalgia, 387 patients attending the Rheumatism Clinic at the Leeds General Infirmary were studied prospectively. Bitten nails appeared to be a feature of youth rather than of fibromyalgia. Patients with a full set of dentures were less likely to bite their nails than others, but it can and was done by 7%. Posing the question about nail biting worried several patients, indicating the wisdom of seeking ethical approval even for "noninvasive" studies.     

Eye involvement in children's rheumatic diseases

Rheumatoid paediatric diseases are a leading cause of uveitis in childhood. Juvenile chronic arthritis (JCA), juvenile onset spondyloarthropathies as well as sarcoidosis and other systemic diseases with arthritis may include ocular manifestations that can threaten vision, and especially so in juvenile chronic arthritis. Special risk factors concerning the eye have to be considered for JCA. The diagnosis, detection, follow-up studies and treatment in children may differ significantly from adult rheumatoid diseases because of the young age of the patients and the specific features and signs of ocular involvement. Medical and surgical treatment of such ocular manifestations may be challenging. Special attention to children's ophthalmic complications must be undertaken by paediatricians and ophthalmologists.     

Genetic aspects of rheumatic diseases

The paper presents the results of the long-term studies of the pattern of hereditary predisposition to rheumatism, rheumatoid arthritis (RA), ankylosing spondyloarthritis (AS), osteoarthrosis which have been conducted at the Institute of Rheumatology, Russian Academy of Medical Sciences. It gives data on the type of inheritance of these diseases, the affliction heritability ratio, the penetrance of three genotypes within the model of an autosomal one-allele locus (SAL-2) for rheumatism and RA. The contribution of additive and dominant components in the determination of rheumatism and RA, the results of tests of their genetic heterogeneity, associations with HLA antigens are assessed. The paper outlines the results of tests of the candidate genes COLIA2, TCRB, TCRD as major RA predisposition genes via analysis of adherence and DNA polymorphism.     

Drug interference in laboratory testing

Characteristic problems in the interpretation data when a drug or its metabolite interferes with a laboratory procedure are reviewed. Various mechanisms of interference (physical, chemical, pharmacological and drug-drug interaction) are discussed. The role of a computerized drug-test interference file in assisting in the predication as well as interpretation of apparent test results is described.     

Acupuncture in treatment of inflammatory rheumatic diseases

Seventeen studies were examined with regard to efficacy and scientific quality of acupuncture in rheumatoid arthritis, spondarthropathy, lupus erythematosus, local and progressive systemic scleroderma. Acupuncture cannot be recommended for treatment of these diseases. By far, the most studies examined failed to show sufficient quality.     

Endocrine aspects of paediatric rheumatic diseases

Compared to the now numerous studies on the endocrinology of rheumatic diseases in adults, only a small number of studies has been published on children with rheumatic diseases. Prolactin has been most extensively investigated, showing interesting parallels with the findings in adults with rheumatological diseases. Thus, analogous to adult RA most forms of JRA or JCA (with the exception of ANA-positive JRA with uveitis) appear to show, if anything, low to normal levels of prolactin. Since the prolactin levels in adult RA depend on the inflammatory activity, and the physiological prolactin secretion decreases in chronic stress (especially sleep disorders), these results are most likely to be explained as reactive non-specific mechanisms in the stress of the disease. However, specific mechanisms are also being discussed to explain the low prolactin levels in adult RA. The results of prolactin measurements in juvenile SLE, juvenile ankylosing spondylitis and ANA-positive JRA with a raised incidence of uveitis, contrast with this. These conditions sometimes show significantly higher prolactin levels compared to healthy controls. A correlation of the increase of prolactin concentration with the inflammatory activity has been described for juvenile ankylosing spondylitis. These results correlate well with those of adult forms such as diseases of the seronegative spondyloarthropathies type, SLE and iridocyclitis. Raised prolactin concentrations are also found in these diseases. The inflammation promoting and immunostimulatory effects of prolactin found especially in animal experiments are confirmed clinically in these diseases by reports of successful treatments with the prolactin inhibitor, bromocriptine. The results available up to now for human growth hormone in JRA and JCA tend to be comparable with the results for prolactin in these form of paediatric rheumatological diseases. Besides normal values above, all lowered concentrations are measured for this hormone. Apart from other non-specific factors, its diminished secretion is mainly determined by the inflammatory activity of the disease. Low levels of growth hormone are likely to be a significant factor in the growth retardation in children with inflammatory rheumatological diseases. Up to now, the small number of investigations on gonadotrophins and the sex hormones in juvenile SLE and various forms of JRA published have not as yet yielded unequivocal results. The endocrine aspects of paediatric rheumatological diseases are thus still incompletely elucidated. However, there are many promising avenues for further fruitful research in this field.     

Update on clinical trials in the rheumatic diseases

The etiopathogenesis of multiple spongy necrosis (MSN) of the pontine base was analyzed by examining the spatial relationship with intra- and extrafascicular vascular structures by reconstruction of serial sections of nine lesions from three autopsy cases. All nine lesions in the fascicles were distributed without any spatial relationship to the intrafascicular vessels. Instead, these lesions were distributed in parallel with arterial and venous transverse main branches between the anteromedial and anterolateral groups of the pontine vessels. On the other hand, all lesions in the middle cerebellar peduncle were arranged obliquely along the arterial and venous main trunks of the lateral group vessels with sparing of the perivascular narrow zone of the white matter. Moreover, narrow fascicles, even though located in the dorsomedial region of the pontine base, which is consistently involved in MSN, were spared, and thick transverse and longitudinal fascicles were selectively involved. The marginal zone of fascicles was spared, and focal coagulation necrosis was sometimes found in MSN lesions. Additionally, normal fascicles did not have their own nutritional arteries, and were nourished by arterioles and capillaries from the surrounding pontine gray matter. Neither severe organic stenosis nor occlusion of pontine vessels was found. On the basis of the close topographical relationship of MSN lesions with the pontine vascular architecture in addition to preferential involvement of thick fascicles with sparing of the marginal zone and inclusion of focal coagulation necrosis, it is proposed that the etiopathogenesis of MSN is pontine ischemia on a background of the characteristic parenchymal and vascular architecture of the pontine base. As to the cause of the ischemia, it is proposed that some functional disorder such as arterial vasoconstriction in the pontine base or the vertebrobasilar artery is responsible, rather than organic changes in the vessels.     

Vitamin E in therapy of rheumatic diseases]

Methyl t-butyl ether (MTBE) and ethyl t-butyl ether (ETBE) are commonly used in unleaded gasoline to increase the oxygen content of fuel and to reduce carbon monoxide emissions from motor vehicles. This study was undertaken to investigate: (1) the effect of administration to rats of ETBE and its metabolite, t-butanol, on the induction and/or inhibition of hepatic P450 isoenzymes; (2) the oxidative metabolism of MTBE and ETBE by liver microsomes from rats pretreated with selected P450 inducers and purified rat P450(s), (2B1, 2E1, 2C11, 1A1). ETBE administration by gavage at a dose of 2 ml/kg for 2 days induced hepatic microsomal P4502E1-linked p-nitrophenol hydroxylase and the P4502B1/2-associated PROD and 16beta-testosterone hydroxylase, verified by immunoblot experiments. t-Butanol treatments at doses of 200 and 400 mg/kg i.p. for 4 days did not alter any liver microsomal monoxygenases. Both MTBE and ETBE were substrates for rat liver microsomes and were oxidatively dealkylated to yield formaldehyde and acetaldehyde, respectively. The dealkylation rates of both MTBE and ETBE were increased c. fourfold in phenobarbital (PB)-treated rats. In rats pretreated with pyrazole, an inducer of 2E1, only the demethylation of MTBE was increased (c. twofold). When the oxidations of MTBE and ETBE were investigated with purified P450(s) in a reconstituted system, it was found that P4502B1 had the highest activities towards both solvents, whereas 1A1 and 2C1 were only slightly active; P4502E1 had an appreciable activity on MTBE but not against ETBE. Metyrapone, a potent inhibitor of P450 2B, consistently inhibited both the MTBE and ETBE dealkylations in microsomes from PB-treated rats. Furthermore, 4-methylpyrazole (a probe inhibitor of 2E1) and anti-P4502E1 IgG showed inhibition, though modest, only on MTBE demethylation, but not on ETBE deethylation. Inhibition experiments have also suggested that rat 2A1 may exert an important role in MTBE and ETBE oxidation. Taken together, these results indicate that 2B1, when expressed, is the major enzyme involved in the oxidation of these two solvents and that 2E1 may have a role, although minor, in MTBE demethylation. The implications of these data for MTBE and ETBE toxicity remain to be established.     

Epidemiology of rheumatic diseases in historical aspect]

The paper summarizes the results of the long-term study of the epidemiology of rheumatic diseases, which has been carried out by the Institute of Rheumatology. The main directions of the study are the development and improvement of diagnostic criteria, the prevalence and incidence of rheumatic diseases among urban and rural populations, at industrial enterprises, in different ethnic groups, genetic and environmental risk factors, disability, the development and introduction of preventive and rehabilitative programmes of drug therapy, etc. A number of combined national programmes was carried out. The paper presents specific results of their implementation.     

Health assessment in the rheumatic diseases of childhood

Assessment of children and adults with rheumatic diseases, both in clinical practice and controlled clinical trials in rheumatology, has traditionally focused on the measurement of disease activity. More recently emphasis has been placed on the need to incorporate estimates of physical, social, and mental functioning into health assessment. Thus there has been a tremendous growth in the development of measurement instruments that evaluate health status, functional status, disability, and quality of life. This type of measurement has become essential, particularly for clinical trials in adults with rheumatic diseases, for which the AIMS (Arthritis Impact Measurement Scales), the HAQ (Health Assessment Questionnaire), and the MACTAR (McMaster-Toronto arthritis) patient preference questionnaire have been the most widely used. In the past few years, similar measures have been developed for application in children with rheumatic diseases. These include the CHAIMS (Childhood Arthritis Impact Measurement Scales), the CHAQ (Childhood Health Assessment Questionnaire), the JAFAR (Juvenile Arthritis Functional Assessment Report), the JASI (Juvenile Arthritis Self-report Index), the JAQQ (Juvenile Arthritis Quality of Life Questionnaire), and the CAHP (Childhood Arthritis Health Profile). In this review, the development and measurement properties of these childhood instruments are discussed, with particular emphasis on their potential roles as supported by recent literature.     

Nerve growth factor and autoimmune rheumatic diseases

The effect of intestinal lymph on blood pressure in rats was observed by the methods of lymph drainage and lymph infusion. The results obtained are as follows: (1) After 150 min of the lymph drained through the cannula of intestinal lymph duct, the blood pressure was significantly lower than that of the sham group (P < 0.05). (2) Equivalent albumin or intralipid infusion was not able to prevent the decrease in blood pressure when the lymph was lost. But in jugular-intestinal lymph duct shunt group, no significant blood pressure decrease could be seen during the drainage procedure for 4 h. (3) The blood pressure of rat with serious hemorrhagic shock could be increased significantly with a little amount of intestinal lymph infusion, and the rats survived longer than those of the control group (P < 0.05-0.01). The above results suggest that the intestinal lymph may play an important role in maintenance of blood pressure, in addition to the known function of lymphatic system by returning tissue fluid to blood and maintaining circulating blood volume.     

Cyclophosphamide pulse therapy for refractory rheumatic diseases

Meta-analysis was proposed more than 20 years ago as an innovative technique for pooling the results of a series of clinical studies. This technique has a two-fold purpose: i) to retrieve pertinent clinical information without introducing selection biases; ii) to combine these clinical data obtained from different sources into a single synthetic index that summarises all available information. This review highlights the current perspectives in the application of meta-analysis and places particular emphasis on discussing the limitations of this technique that have been identified in recent years. Specific controversies in this area include: i) comparison between meta-analysis of the literature and meta-analysis of individual patient data; ii) heterogeneity of the clinical material introduced in the meta-analytic pooling; and iii) survival meta-analysis as a method for pooling long-term outcome data. After debating these three controversial points, this review examines the newest uses of meta-analysis that have been proposed for the evaluation of cost-effectiveness data and tries to identify the meta-analytic applications that will probably be expanded in the near future as opposed to those that will instead be developed less and less.