Clostridium difficile-associated diarrhea: epidemiology, risk factors, and infection control

OBJECTIVES: To evaluate the effectiveness of specific infection control measures on the incidence of Clostridium difficile-associated diarrhea (CDAD) and to identify risk factors for its development. SETTING: 370-bed, tertiary-care teaching hospital with approximately 12,000 to 15,000 admissions per year. METHODS: Several infection control measures were implemented in 1991 and 1992, and the attack rates of CDAD were calculated quarterly. Antibiotic use for 1988 through 1993 was analyzed. A case-control study was conducted from January 1992 to December 1992 to identify risk factors for acquisition of CDAD. RESULTS: From 1989 to 1992, the attack rate of CDAD increased from 0.49% to 2.25%. An increase in antibiotic use preceded the rise in the incidence of CDAD in 1991. Despite implementation of various infection control measures, the attack rate decreased to 1.32% in 1993, but did not return to baseline. Ninety-two cases and 78 controls (patients with diarrhea but with negative toxin assay) were studied. By univariate analysis, history of prior respiratory tract infections (odds ratio [OR], 3.6; 95% confidence interval [CI95], 1.2-10.4), the number of antibiotics, and the duration of exposure to second-generation cephalosporins (OR, 3.55; CI95, 1.47-9.41) and to ciprofloxacin (OR, 7.27; CI95, 1.13-166.0) were related significantly to the development of CDAD. By stepwise logistic regression analysis, only exposure to antibiotics and prior respiratory tract infections (P = .0001 and .0203, respectively) were found to be significant. CONCLUSION: Antibiotic pressure might have contributed to failure of infection control measures to reduce the incidence of CDAD to baseline.     

Human immunodeficiency virus infection and stroke in young patients

OBJECTIVE: To determine the association between human immunodeficiency virus (HIV) infection and stroke among young persons. DESIGN: Retrospective case-control study. SETTING: Large, inner-city public hospital. PARTICIPANTS: All patients aged 19 to 44 years with a diagnosis of stroke, whose HIV status was determined, admitted from January 1990 through June 1994. Controls matched for age and sex were selected from patients who were admitted during the same period for status asthmaticus whose HIV status was known. MAIN OUTCOME MEASURE: The associations of HIV infection with all strokes and with cerebral infarction, after adjustment for other cerebrovascular risk factors, were evaluated by Mantel-Haenszel stratified analyses. The subtypes and causes of stroke in HIV-infected patients were compared with HIV-seronegative patients. RESULTS: The HIV infection was associated with stroke (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.0-5.3) and cerebral infarction (OR, 3.4; 95% CI, 1.1-8.9), after adjustment for other cerebrovascular risk factors. Among patients with stroke, cerebral infarction was more frequent in HIV-infected patients than in HIV-seronegative patients (20 [80%] of 25 vs 48 [56%] of 88, P = .04). The frequency of cerebral infarctions associated with meningitis (P < .001) and protein S deficiency (P = .06) was higher in HIV-infected patients than in seronegative patients. CONCLUSIONS: Our study suggests that HIV infection is associated with an increased risk of stroke, particularly cerebral infarction in young patients. This risk is probably mediated by increased susceptibility of HIV-infected patients to meningitis and protein S deficiency.     

Direct observation of DNA translocation and cleavage by the EcoKI endonuclease using atomic force microscopy

OBJECTIVES: To determine whether antibiotic prophylaxis reduces respiratory tract infections (RTI) and overall mortality in an unselected adults intensive care population. SEARCH STRATEGY: Systematic literature search in peer-reviewed journals indexed in MEDLINE, examination of relevant proceedings of scientific meetings and personal contact with trialists. SELECTION CRITERIA: All randomised clinical trials (RCTs), published and unpublished, comparing different forms of antibiotic prophylaxis used to reduce RTIs and mortality in unselected adult intensive care units (ICUs) populations. DATA COLLECTION AND ANALYSIS: Out of the 32 RCTs eligible for this review data have been extracted from published reports and then complemented with information provided by study investigators for 29 trials. Data were available only from published reports in the remaining three RCTs. For each trial the following information has been sought: a) method of randomisation; b) use of blinding techniques; c) number of randomised patients; d) number of patients with RTIs; e) number of deaths; f) number of patients excluded from the published analysis; g) number of RTIs and number of deaths among excluded patients. Pooled estimates of treatment effects across trials have been calculated after grouping RCTs in two main, mutually exclusive, categories: a) 15 trials testing the effect of a combination of a topical and a systemic antibiotic against no prophylactic treatment; b) 17 trials where the experimental treatment was a topical antimicrobial preparation. Crude proportions of RTIs and mortality were used to calculate the overall treatment effect. We also computed the number of ICU patients who need to be treated in order to prevent one infection and one death. MAIN RESULTS: Overall 32 RCTs including 5639 patients were identified. Pooled estimates of the 15 RCTs (including 3273 patients) testing the effect of the topical and systemic antibiotic combination indicate a strong significant reduction of both RTIs (OR = 0.36, 95% CI = 0.30-0.43) and total mortality (OR = 0.80, 95% CI = 0.68-0.93). Five and 23 patients need to be treated to prevent one infection and one death, respectively, using this treatment. When data on the effect of the combination based on topical antimicrobials were pooled from the 17 available trials (including 2366 patients) a marked reduction on RTIs (OR = 0.57, 95% CI = 0.46-0.69) also emerged but no corresponding effect on overall mortality (OR = 1.01; 95% CI = 0.84-1.22) was found. CONCLUSIONS: After 15 years of clinical research this meta-analysis of 32 RCTs shows that a regimen of antibiotic prophylaxis based on a combination of a systemic and topical antibiotic can reduce both RTIs and overall mortality in ICU patients in a way that is both statistically significant and humanly worthwhile. Over and above their personal opinions intensivists should take this evidence into account when defining their policies.     

Multivariate analysis of risk factors for infection due to penicillin-resistant and multidrug-resistant Streptococcus pneumoniae: a multicenter study

Pneumococcal disease was studied prospectively to determine the risk factors associated with resistance to penicillin and other antibiotics. One hundred twelve clinically significant pneumococcal isolates were recovered from 95 patients. Approximately one-half (49.47%) of the cases were due to penicillin-resistant strains. Multivariate analysis showed that previous use of beta-lactam antibiotics (odds ratio [OR], 2.81; 95% confidence interval [CI], 0.95-8.27), alcoholism (OR, 5.22; 95% CI, 1.43-19.01), and noninvasive disease (OR, 4.53; 95% CI, 1.54-13.34) were associated with penicillin resistance, whereas intravenous drug use (OR, 0.14; 95% CI, 0.03-0.74) was not. Statistical analyses of the variables associated with resistance to multiple antibiotics detected age of younger than 5 years (OR, 16.79; 95% CI, 1.60-176.34) or of 65 years or older (OR, 4.33; 95% CI, 1.42-13.21) and previous use of beta-lactam antibiotics by patients with noninvasive disease (OR, 7.92; 95% CI, 1.84-34.06) as parameters associated with increased risk. We conclude that multivariate analysis provides clues for empirical therapy for pneumococcal infection.     

放疗联合手术治疗胃癌的Meta-分析

Objective: We carried out a meta-analysis to assess the effectiveness and safety of radiotherapy combined with surgery for gastric cancer. Methods: Randomized Clinical Trials (RCTs) in which radiotherapy (preoperative, intraoperative and postoperative), was compared with surgery alone in resectable gastric cancer were identified by searching Cochrane Library (Issue 2, 2009), PubMed (Jan 1966-Jun 2009), EMBASE (Jan 1974-Jun 2009), Chinese Biomedical Literature Database (Jan 1978-Jun 2009), Chinese Science and Technology Periodicals Database (Jan 1989-Jun 2009), China National Knowledge Infrastructure (Jan 1994-Jun 2009) and Wanfang database (Jan 1997-Jun 2009) in English and Chinese languang. Two researchers assessed the quality of included randomized controlled trials (RCT) extracted data independently. The RevMan 5.0 software was used for meta-analysis. Our researchers assessed the quality of included randomized controlled trials (RCT) extracted data independently. The RevMan 5.0 software was used for meta-analysis. Results: Nine randomized controlled trials of 1 548 patients were selected for meta-analysis. Five randomized controlled trials were related with comparison of preoperative radiotherapy plus surgery with single surgery. Two randomized controlled trials were the comparative studies between surgery plus postoperative and single surgery. The meta-analysis results showed that: (1) compared with surgery alone, preoperative radiotherapy combined with surgery can increase 3 years (OR = 1.78; 95% CI 1.14-2.78, P = 0.01), 5 years (OR = 1.67; 95% CI 1.22-2.29, P = 0.001), 10 years (OR = 1.64; 95% CI 1.03-2.60, P = 0.04) survival rate and resection rate (OR = 2.15; 95% CI 1.31-3.54, P = 0.003); reduce the of tumor recurrence rate (OR = 0.59; 95% CI 0.37-0.92, P = 0.02) and metastasis rate (OR = 0.44; 95% CI 0.27-0.73, P = 0.001); (2) The tumor recurrent rates (OR = 0.19, 95% CI 0.03-1.14, P = 0.07) and tumor metastasis rate (OR = 0.09; 95% CI 0.00-1.77, P = 0.11) had no difference between single surgery group and peri-operative radiotherapy plus surgery group; (3) Postoperative radiotherapy compared with surgery alone had no significant effects on 1 year (OR = 0.83; 95% CI 0.60-1.15, P = 0.26) and 3 years (OR = 0.75; 95% CI 0.51-1.11, P = 0.15) survival rate compared with single surgery, but the 5-year survival rates (OR = 0.57; 95% CI 0.34-0.95, P = 0.03) of the patients who received surgery alone was higher than those who received combined therapy. No difference of the tumor recurrence rate (OR = 0.59; 95% CI 0.33-1.05, P = 0.07), tumor metestasis rate (OR = 0.90; 95% CI 0.51-1.59, P = 0.71) and anastomotic leak (OR = 0.98; 95% CI 0.25-3.65, P = 0.98) were observed between the two groups. Conclusion: Preoperative radiotherapy combined surgery is more rational and effective than surgery alone of gastric cancer. However, in terms of the clinical effects of perioperarive or postoperative radoiotherapy combined with surgery, much multicenter, largescale, high-quality, double-blind and rigorously designed studies would be needed than currently available in the future.     

Augmentation of natural killer cell activity in mice by oral administration of transforming growth factor-beta

OBJECTIVE: To analyze the effect of HLA-DR genes on susceptibility to and severity of ankylosing spondylitis (AS). METHODS: Three hundred sixty-three white British AS patients were studied; 149 were carefully assessed for a range of clinical manifestations, and disease severity was assessed using a structured questionnaire. Limited HLA class I typing and complete HLA-DR typing were performed using DNA-based methods. HLA data from 13,634 healthy white British bone marrow donors were used for comparison. RESULTS: A significant association between DR1 and AS was found, independent of HLA-B27 (overall odds ratio [OR] 1.4, 95% confidence interval [95% CI] 1.1-1.8, P = 0.02; relative risk [RR] 2.7, 95% CI 1.5-4.8, P = 6 x 10(-4) among homozygotes; RR 2.1, 95% CI 1.5-2.8, P = 5 x 10(-6) among heterozygotes). A large but weakly significant association between DR8 and AS was noted, particularly among DR8 homozygotes (RR 6.8, 95% CI 1.6-29.2, P = 0.01 among homozygotes; RR 1.6, 95% CI 1.0-2.7, P = 0.07 among heterozygotes). A negative association with DR12 (OR 0.22, 95% CI 0.09-0.5, P = 0.001) was noted. HLA-DR7 was associated with younger age at onset of disease (mean age at onset 18 years for DR7-positive patients and 23 years for DR7-negative patients; Z score 3.21, P = 0.001). No other HLA class I or class II associations with disease severity or with different clinical manifestations of AS were found. CONCLUSION: The results of this study suggest that HLA-DR genes may have a weak effect on susceptibility to AS independent of HLA-B27, but do not support suggestions that they affect disease severity or different clinical manifestations.     

Antibiotic prophylaxis for permanent pacemaker implantation: a meta-analysis

BACKGROUND: Infection remains a serious complication after permanent pacemaker implantation. Antibiotic prophylaxis is frequently prescribed at the time of insertion to reduce its incidence, although results of well-designed, controlled studies are lacking. METHODS AND RESULTS: We performed a meta-analysis of all available randomized trials to evaluate the effectiveness of antibiotic prophylaxis to reduce infection rates after permanent pacemaker implantation. Reports of trials were identified through a Medline, Embase, Current Contents, and an extensive bibliography search. Trials that met the following criteria were included: (1) prospective, randomized, controlled, open or blind trials; (2) patients assigned to a systemic antibiotic group or a control group; (3) end point events related to any infection after pacemaker implantation: wound infection, septicemia, pocket abscess, purulent secretion, right infective endocarditis, inflammatory signs, a positive culture, septic pulmonary embolism, or repeat operation for an infective complication. Seven trials met the inclusion criteria. They included 2023 patients with established permanent pacemaker implantation (new implants or replacements). The incidence of end point events in control groups ranged from 0% to 12%. The meta-analysis suggested a consistent protective effect of antibiotic pretreatment (P=.0046; common odds ratio: 0.256, 95% confidence interval: 0.10 to 0.656). CONCLUSIONS: Results of the present meta-analysis suggest that systemic antibiotic prophylaxis significantly reduces the incidence of potentially serious infective complications after permanent pacemaker implantation. They support the use of prophylactic antibiotics at the time of pacemaker insertion to prevent short-term pocket infection, skin erosion or septicemia.     

Pharmacokinetics and pharmacodynamics of sibrafiban (Ro 48-3657), an orally active IIb/IIIa antagonist, administered alone or in combination with heparin, aspirin, and recombinant tissue-type plasminogen activator in beagles

OBJECTIVE: The study aimed to determine the effectiveness of prophylactic medical intervention in reducing the incidence of cystoid macular edema (CME) and the effectiveness of medical treatment for chronic CME after cataract surgery. DESIGN: The study design was a systematic review and meta-analysis of published reports of randomized clinical trials (RCTs). PARTICIPANTS: Sixteen RCTs involving 2898 eyes examining the effectiveness of medical prophylaxis of CME and 4 RCTs involving 187 eyes testing the effectiveness of medical treatment of chronic CME were used in the study. INTERVENTIONS: Medical prophylaxis of treatment (cyclo-oxygenase inhibitors or corticosteroids) versus control (placebo or active treatment) was performed. MAIN OUTCOME MEASURES: Incidence of angiographically diagnosed CME, incidence of clinically significant CME, and vision were measured. RESULTS: Thirty-six articles reported testing a prophylactic medical intervention for CME after cataract surgery. The incidence of CME varied extensively across studies and was related to the study design used. Summary odds ratios (OR) indicated that prophylactic intervention was effective in reducing the incidence of both angiographic CME (OR = 0.36; 95% confidence interval [CI] = 0.28-0.45) and clinically relevant CME (OR = 0.49; 95% CI = 0.33-0.73). There also was a statistically significant positive effect on improving vision (OR = 1.97; 95% CI = 1.14-3.41). A combination of the results of the four RCTs testing medical therapy for chronic CME indicated a treatment benefit in terms of improving final visual acuity by two or more Snellen lines (OR = 2.67; 95% CI = 1.35-5.30). Assessment of the quality of the 20 RCTs included in the meta-analyses indicated problems in the design, execution, and reporting of a number of trials. CONCLUSION: A combination of the results from RCTs indicates that medical prophylaxis for aphakic and pseudophakic CME and medical treatment for chronic CME are beneficial. Because most of the RCTs performed to date have problems related to quality, a well-designed RCT is needed to confirm this result, using clinical CME and vision as outcomes.     

A case report of jejunal carcinoma in a patient with tuberous sclerosis]

It remains uncertain if law enforcement officers experience an elevated cardiovascular disease morbidity and, if so, whether their profession contributes to this incidence. Consequently, the self-reported incidence of cardiovascular disease (CVD) (coronary heart disease, myocardial infarction, stroke, coronary artery bypass graft surgery, angioplasty) and CVD risk factors (age, diabetes, elevated body mass index (> or = 27.8 kg.m-2), hypercholesterolemia, hypertension, tobacco use) in 232 male retirees, > or = 55 years of age, from the Iowa Department of Public Safety were compared with 817 male Iowans of similar age. CVD incidence was higher in the law enforcement officers than the general population (31.5% vs 18.4%, P < 0.001). Using multiple logistic regression, factors found to be associated with CVD included the law enforcement profession (odds ratio [OR] = 2.34; 95% confidence interval [95% CI] = 1.5-3.6), hypercholesterolemia (OR = 2.37; 95% CI = 1.7-3.3); diabetes (OR = 2.22; 95% CI = 1.4-3.6), hypertension (OR = 1.79; 95% CI = 1.3-2.5), tobacco use (OR = 1.67; 95% CI = 1.07-2.6), and age (OR = 1.06; 95% CI = 1.03-1.08). These results suggest that employment as a law enforcement officer is associated with an increased cardiovascular disease morbidity and this relationship persists after considering several conventional risk factors.     

Prostate cancer: 4. Screening

OBJECTIVES: To evaluate the association between tamoxifen (TAM) treatment and rate of bone fractures in older, nursing home residents. PARTICIPANTS: A total of 93,031 women, aged 65 years and older, whose data were part of the 1993 New York State MDS and for whom there was documentation of treatment with at least one medication. SETTING: New York State long-term care facilities. DESIGN: Cross-sectional study via secondary analysis of 1385 matched sets of residents. Each set included one resident who was receiving TAM treatment and up to four residents who were not. MEASUREMENTS: Measurements included age, ethnicity, TAM treatment, hormone replacement therapy, vision impairment, any bone fractures, and, specifically, hip fractures. RESULTS: During the 1.5-year period for which bone fractures are documented in the 1993 MDS, the fracture rates were: 7.62% in women not treated with TAM, 3.20% in women receiving 10 mg TAM daily, and 6.73% in women receiving 20 mg TAM daily. The odds ratio (OR) for bone fractures among women receiving 20 mg TAM daily compared with nontreated women was 0.916 (95% confidence interval (CI): 0.720-1.164; P = .472), and was 0.312 (95% CI: 0.112-0.865; P = .025) for those receiving 10 mg daily. The rates of hip fracture were 4.98%, 2.40%, and 4.57% for controls and women receiving 10 mg and 20 mg TAM daily, respectively. Whereas the hip fracture rate for women receiving 20 mg daily was statistically similar to that of the controls (OR = .963; 95% CI: 0.718-1.291; P = .800), the difference between the controls and those receiving 10 mg daily approached significance (OR: 0.313; 95% CI: 0.096-1.018; P = .054). CONCLUSION: Although standard treatment of 20 mg TAM daily offers no apparent protection against bone fracture in older nursing home residents, a daily 10 mg dose seems to be protective.     

Community-acquired bacterial meningitis: risk stratification for adverse clinical outcome and effect of antibiotic timing

BACKGROUND: Community-acquired bacterial meningitis causes substantial morbidity and mortality in adults. OBJECTIVE: To create and test a prognostic model for persons with community-acquired bacterial meningitis and to determine whether antibiotic timing influences clinical outcome. DESIGN: Retrospective cohort study; patients were divided into derivation and validation samples. SETTING: Four hospitals in Connecticut. PATIENTS: 269 persons who, between 1970 and 1995, had community-acquired bacterial meningitis microbiologically proven by a lumbar puncture done within 24 hours of presentation in the emergency department. MEASUREMENTS: Baseline clinical and laboratory features and times of arrival in the emergency department, performance of lumbar puncture, and administration of antibiotics. The target end point was the development of an adverse clinical outcome (death or neurologic deficit at discharge). RESULTS: For the total group, the hospital mortality rate was 27%. Fifty-six of 269 patients (21 %) developed a neurologic deficit, and in 9% the neurologic deficit persisted at discharge. Three baseline clinical features (hypotension, altered mental status, and seizures) were independently associated with adverse clinical outcome and were used to create a prognostic model from the derivation sample. The prediction accuracy of the model was determined by using the concordance index (c-index). For both the derivation sample (c-index, 0.73 [95% CI, 0.65 to 0.81]) and the validation sample (c-index, 0.81 [CI, 0.71 to 0.92]), the model predicted adverse clinical outcome significantly better than chance. For the total group, the model stratified patients into three prognostic stages: low risk for adverse clinical outcome (9%; stage I), intermediate risk (33%; stage II), and high risk (56%; stage III) (P=0.001). Adverse clinical outcome was more common for patients in whom the prognostic stage advanced from low risk (P=0.008) or intermediate risk (P=0.003) at arrival in the emergency department to high risk before administration of antibiotics. CONCLUSIONS: In persons with community-acquired bacterial meningitis, three baseline clinical features of disease severity predicted adverse clinical outcome and stratified patients into three stages of prognostic severity. Delay in therapy after arrival in the emergency department was associated with adverse clinical outcome when the patient's condition advanced to the highest stage of prognostic severity before the initial antibiotic dose was given.     

Risk factors for septic arthritis in patients with joint disease. A prospective study

OBJECTIVE: To quantify potential risk factors for septic arthritis, in order to identify a basis for prevention. METHODS: The occurrence of potential risk factors for septic arthritis in patients with joint diseases attending a rheumatic disease clinic was prospectively monitored at 3-month intervals over a period of 3 years. Potential risk factors investigated were type of joint disease, comorbidity, medication, joint prosthesis, infections, and invasive procedures. The frequencies of risk factors in patients with and those without septic arthritis were compared using multiple logistic regression analysis. RESULTS: There were 37 patients with and 4,870 without septic arthritis. Risk factors for developing septic arthritis were age > or = 80 years (odds ratio [OR] = 3.5, 95% confidence interval [95% CI] 1.4-8.6), diabetes mellitus (OR = 3.3, 95% CI 1.1-10.1), rheumatoid arthritis (OR = 4.0, 95% CI 1.9-8.3), hip and/or knee prosthesis (OR = 15, 95% CI 4.1-54.3), joint surgery (OR = 5.1, 95% CI 2.2-11.9), and skin infection (OR = 27.2, 95% CI 7.6-97.1). CONCLUSION: These findings indicate that preventive measures against septic arthritis in patients with joint diseases should mainly be directed at those with joint prostheses and/or skin infection.     

Isoniazid preventive therapy in human immunodeficiency virus-infected persons. Long-term effect on development of tuberculosis and survival

BACKGROUND: Although the short-term benefit of isoniazid prophylaxis in patients coinfected with human immunodeficiency virus (HIV) and tuberculosis has been shown, long-term benefits are unknown. METHODS: Historical cohort study in an acquired immunodeficiency syndrome unit at a tertiary referral hospital. A sample of 121 HIV-infected patients with positive results on a purified protein derivative test were followed up for development of active tuberculosis and survival. Patients who received isoniazid prophylaxis were compared with patients who did not receive prophylaxis. RESULTS: Of the 121 patients examined, 29 (24%) completed a 9- to 12-month course of isoniazid prophylaxis (median follow-up, 89 months), and 92 (76%) did not receive the drug (median follow-up, 60 months). Active tuberculosis developed in 46 patients (38%). The incidence of tuberculosis was higher among patients with no prophylaxis (9.4 per 100 patient-years) than among patients with isoniazid prophylaxis (1.6 per 100 patient-years) (P = .006). Risk for development of tuberculosis was associated with the absence of isoniazid prophylaxis (relative risk [RR], 6.55; 95% confidence interval [CI], 2.02-21.19). Death during the period of study was more frequent in patients who did not receive isoniazid (50/92 or 54%) than in patients who received isoniazid (7/29 or 24%) (P = .008). Median survival was more than 111 months in patients who received isoniazid compared with 75 months in patients who did not receive isoniazid (P < .001). In a proportional hazards analysis, the development of tuberculosis (RR, 1.88; 95% CI, 1.09-3.27), the absence of isoniazid prophylaxis (RR, 2.68; 95% CI, 1.16-6.17), and a CD4+ cell count lower than 0.20 x 10(9)/L (RR, 3.03; 95% CI, 1.39-6.61) were independently associated with death. Patients who received isoniazid had a longer survival after stratifying for the CD4+ cell count. CONCLUSIONS: Preventive therapy with isoniazid confers long-term protection against tuberculosis and significantly increases survival in patients dually infected with HIV and Mycobacterium tuberculosis.     

Calcium intake and the incidence of forearm and hip fractures among men

High calcium intakes are thought to be associated with strong bones and lower risk of fractures. However, findings from epidemiologic studies have not been consistent. In addition, the vast majority of such studies were conducted among women, leading to a relative lack of data concerning men. The objective of this study therefore was to investigate the relation between adult calcium intake and risk of fractures among men in the Health Professionals Follow-up Study (HPFS). During 331,234 person-years of follow-up over an 8-y period, 201 forearm and 56 hip fractures due to low or moderate trauma were reported among 43,063 men 40-75 y of age in 1986 when they first completed a questionnaire about diet and lifestyle factors. After controlling for age, smoking status, body mass index (BMI), physical activity, alcohol consumption and total energy intake, the relative risk (RR) of forearm fractures for men in the highest quintile of calcium intake (from foods plus supplements) compared with those in the lowest quintile was 0.98 [95% confidence interval (CI) = 0.59-1.61; P for trend = 0.78]; for hip fractures, the comparable RR was 1.19 (95% CI = 0.42-3.35; P for trend = 0.58). Relative risks for consuming >2.5 glasses (600 mL) of milk per day compared with one (240 mL) or fewer per week were 1.06 (95% CI = 0.69-1.62; P for trend = 0.82) for forearm fractures and 0.97 (95% CI = 0.39-2.42; P for trend = 0.56) for hip fractures. In conclusion, these results do not support a relation between calcium intake and the incidence of forearm or hip fractures in men.     

Biological control of nematode parasites of livestock in Fiji: screening of fresh dung of small ruminants for the presence of nematophagous fungi

OBJECTIVE: To assess risk factors and outcomes associated with nuchal cord at birth. STUDY DESIGN: A population-based, case-control study was conducted using linked birth and hospitalization records. Three thousand newborns were randomly selected from all singleton births with nuchal cord as noted on the birth record (n = 5,426) in King County, Washington, 1992-1993. For comparison, 3,000 controls were randomly selected from the 46,952 unaffected singleton births. RESULTS: An increased risk of nuchal cord was associated with induction of labor (odds ratio [OR] adjusted for maternal age and parity 2.0, 95% confidence interval [CI] 1.7-2.3), African American infant race (OR 1.3, 95% CI 1.0-1.6), primiparity (OR 1.2, 95% CI 1.0-1.5) and male sex (OR 1.2, 95% CI 1.0-1.3). After exclusion of selected obstetric complications, the risk of nuchal cord associated with induction of labor increased (OR 2.4, 95% CI 2.0-3.0). Nuchal cord was associated with increased risks of fetal distress (OR 2.7, 95% CI 2.1-3.4), meconium staining (OR 2.1, 95% CI 1.7-2.6), five-minute Apgar score < 7 (OR 1.6, 95% CI 1.1-2.4) and assisted ventilation < 30 minutes (OR 1.9, 95% CI 1.4-2.6). Although hospital charges for newborns with nuchal cord were slightly greater than for those without (P = .02), hospital lengths of stay did not differ significantly. CONCLUSION: Induction of labor was identified as an independent risk factor for nuchal cord. Certain adverse perinatal outcomes are increased in neonates with nuchal cord. However, neonates with nuchal cord do not have significantly longer neonatal hospital stays, and thus the adverse effects of nuchal cord may be transient.     

TNF-alpha receptor knockout mice are protected from the fibroproliferative effects of inhaled asbestos fibers

We performed a prospective observational cohort study of the epidemiology and etiology of nosocomial pneumonia in 358 medical ICU patients in two university-affiliated hospitals. Protected bronchoscopic techniques (protected specimen brush and bronchoalveolar lavage) were used for diagnosis to minimize misclassification. Risk factors for ventilator-associated pneumonia were identified using multiple logistic regression analysis. Twenty-eight cases of pneumonia occurred in 358 patients for a cumulative incidence of 7.8% and incidence rates of 12.5 cases per 1, 000 patient days and 20.5 cases per 1,000 ventilator days. Staphylococcus aureus, Streptococcus pneumoniae, Pseudomonas aeruginosa, and Hemophilus species made up 65% of isolates from the lower respiratory tract, whereas only 12.5% of isolates were enteric gram-negative bacilli. Daily surveillance cultures of the nares, oropharynx, trachea, and stomach demonstrated that tracheal colonization preceded ventilator-associated pneumonia in 93.5%, whereas gastric colonization preceded tracheal colonization for only four of 31 (13%) eventual pathogens. By multiple logistic regression, independent risk factors for ventilator- associated pneumonia were admission serum albumin <= 2.2 g/dl (odds ratio [OR] 5.9; 95% confidence interval [CI] 2.0-17.6; p = 0.0013), maximum positive end-expiratory pressure >= 7.5 cm H2O (OR, 4.6; 95% CI, 1.4 to 15.1; p = 0.012), absence of antibiotic therapy (OR, 6.7; 95% CI, 1.8 to 25.3; p = 0.0054), colonization of the upper respiratory tract by respiratory gram-negative bacilli (OR, 3.4; 95% CI, 1.1 to 10.1; p = 0.028), pack-years of smoking (OR, 2.3 for 50 pack-years; 95% CI, 1. 2 to 4.2; p = 0.012), and duration of mechanical ventilation (OR, 3. 4 for 14 d; 95% CI, 1.5 to 7.8; p = 0.0044). Several of these risk factors for ventilator-associated pneumonia appear amenable to intervention.     

Risk factors for multiple intracranial aneurysms

OBJECTIVE: Risk factors that predispose to the formation of multiple intracranial aneurysms, which are present in up to 34% of patients with intracranial aneurysms, are not well defined. In this study, we examined the association between known risk factors for cerebrovascular disease and presence of multiple intracranial aneurysms. METHODS: We reviewed the medical records and results of conventional angiography in all patients with a diagnosis of intracranial aneurysms admitted to the Johns Hopkins University hospital between January 1990 and June 1997. We determined the independent association between various cerebrovascular risk factors and the presence of multiple aneurysms using logistic regression analysis. RESULTS: Of 419 patients admitted with intracranial aneurysms (298 ruptured and 121 unruptured), 127 (30%) had multiple intracranial aneurysms. In univariate analysis, female gender (odds ratio [OR] = 1.9; 95% confidence interval [CI], 1.1-3.3) and cigarette smoking at any time (OR = 1.8; 95% CI, 1.1-3.0) were significantly associated with presence of multiple aneurysms. In the multivariate analysis, cigarette smoking at any time (OR = 1.7; 95% CI, 1.1-2.8) and female gender (OR = 2.1; 95% CI 1.2-3.5) remained significantly associated with multiple aneurysms. Hypertension, diabetes mellitus, and alcohol and illicit drug use were not significantly associated with presence of multiple aneurysms. CONCLUSION: Cigarette smoking and female gender seem to increase the risk for multiple aneurysms in patients predisposed to intracranial aneurysm formation. Further studies are required to investigate the mechanism underlying the association between cigarette smoking and intracranial aneurysm formation.     

Differences in risk factors for being either a hepatitis B carrier or anti-hepatitis C+ in a hepatoma-hyperendemic area in rural Taiwan

This is a study of the differences in the risk factors for being either hepatitis B surface antigen positive [HBsAg(+)] or antibody to hepatitis C virus positive [Anti-HCV(+)] in A-Lein, a rural area in southern Taiwan, an area which also has a high hepatoma mortality rate. Three hundred eighty-five patients age > or =40 years participated in hepatoma screening at the A-Lein Community Health Center during 1995. Those who were HBsAg(-) and anti-HCV(-) or had coinfection of HBsAg(+) and anti-HCV(+) were excluded, leaving 293 patients: 109 HBsAg(+) and 184 anti-HCV(+). The anti-HCV(+) patients had a lower socioeconomic status (as defined by level of education and type of occupation) and were older than HBsAg(+) patients (P < 0.05). Those with higher alanine aminotransferase levels (ALT) also had a higher anti-HCV(+) to HBsAg(+) odds ratio (OR), and a dose response relationship was found, P < 0.0001. Anti-HCV(+) patients were more likely than HBsAg(+) patients to have a spouse who shared the infection, OR = 5.11; 95% CI, 2.30-11.28. Anti-HCV(+) patients were more likely than HBsAg(+) patients to have had blood transfusions (OR = 2.66; 95% CI, 1.20-5.89), frequent medical injections (OR = 2.64; 95% CI, 1.62-4.31), or injections by non-licensed medical providers (OR = 1.91; 95% CI, 1.18-3.09). Multiple logistic regression analysis showed that the significant factors for anti-HCV(+) patients vs. HBsAg(+) patients are drinking habit (OR = 3.45; 95% CI, 1.02-11.60), age (OR = 6.33; 95% CI, 2.93-13.68), and frequent medical injections (OR = 2.88; 95% CI, 1.65-5.03). The transmission of hepatitis C in A-Lein is closely related to low socioeconomic status, age, alcohol abuse, spouses being anti-HCV(+), and frequent medical injections, especially from non-licensed medical providers, including both pharmacists and those with no medical licensing whatsoever. These nonlicensed medical providers sometimes reuse needles to save money, which is a likely route of infection.     

Cardiovascular morbidity in patients with obstructive sleep apnea in relation to the severity of respiratory disorder

BASIC PROBLEM AND OBJECTIVE: Untreated patients with obstructive sleep apnoea (OSA) have an increased risk of death from cardiovascular (cv) disease. This study was undertaken to determine the disease spectrum in patients with sonographically proven OSA (apnoea-hypopnoea index > or = 5), with special reference to cv risk factors and accompanying diseases in relation to the severity of their respiratory abnormalities. The study's aim was to clarify what risk factors and accompanying diseases were associated with different degrees of OSA. PATIENTS AND METHODS: A systematic recording of cv risk factors and accompanying diseases as well as their association to the severity of nocturnal respiratory disorders was made for 175 patients (165 men, 10 women, mean age 54 +/- 10.2 years) with sonographically proven OSA (mean apnoea-hypopnoea index 37 +/- 24.4). RESULTS: The body mass index (BMI) was significantly related to the severity of the respiratory disorder (apnoea-hypopnoea index, AHI, P < 0.05, odds ratio [OR]: 1.95; 95% confidence interval [CI]: 1.15-3.31). In a multivariate analysis, nocturnal breathing pause (P < 0.05; OR: 3.8; 95% CI: 1.3-11.1), left ventricular hypertrophy (P < 0.01; OR: 3.9; 95% CI: 1.5-10.3) and diabetes mellitus (P < 0.05; OR: 4.2, 95% CI: 1.2-14.7) were independently associated with a high-grade breathing disorder (AHI > or = 20). The incidence of left ventricular hypertrophy rose with an increasing severity of nocturnal OSA. CONCLUSION: These data indicate that in patients with high-grade OSA (AHI > or = 20) there is a further grouping together of cardiovascular risk factors, namely increasing body weight, diabetes mellitus, arterial hypertension and left ventricular hypertrophy; they explain the increased mortality rate among these patients from vascular complications.