The impact of mucositis on alpha-hemolytic streptococcal infection in patients undergoing autologous bone marrow transplantation for hematologic malignancies

BACKGROUND: Antibacterial prophylaxis with quinolone antibiotics has resulted in an increase in streptococcal infections among bone marrow transplantation (BMT) recipients with myelosuppression. Oral ulceration (mucositis), which frequently occurs as a consequence of chemotherapy, has been implicated as a significant portal of entry for streptococci. The objectives of this study were to confirm the correlation between mucositis and streptococcal bacteremia, determine the risk associated with this correlation, and evaluate the impact of mucositis and streptococcal bacteremia on hospital course and costs associated with autologous BMT. METHODS: This was a retrospective, case-control study in which the charts of autologous BMT recipients treated for hematologic malignancies between 1990 and 1996 were reviewed. Twenty-four patients were identified who met the criteria of autologous BMT; their blood cultures confirmed (x2) alpha-hemolytic streptococcal sepsis. A control group of 45 without positive cultures was matched by gender, age, diagnosis, and treatment to the study group. RESULTS: The results confirm that ulcerative mucositis is a significant risk factor for alpha-hemolytic streptococcal bacteremia among autologous BMT patients. Of the 24 patients with bacteremia, 15 of 24 (62%) had ulcerative mucositis, compared with 16 of 45 (36%) of patients in the control population (P < 0.05). Patients with ulcerative mucositis were found to be three times as likely to develop alpha-hemolytic streptococcal bacteremia as those without ulcerative mucositis (odds ratio=3.02). Both independently and as a cofactor associated with bacteremia, mucositis adversely affected the length of hospital stay (LOS). Of all the patients studied, those with oral ulcerations had a LOS of 34 days, compared with 29 days for patients without oral ulcerations (P < 0.05). Of patients in the study group, those with oral ulcerations stayed in the hospital 6 days longer than patients without oral ulcerations (40 days vs. 34 days, P < 0.05). CONCLUSIONS: Oral ulcerative mucositis is a significant, common, and important risk factor for alpha-hemolytic streptococcal bacteremia in BMT recipients with myelosuppression; it results in longer hospital stay and increased costs.     

Cryoelectron microscopic examination of human immunodeficiency virus type 1 virions with mutations in the cyclophilin A binding loop

The human immunodeficiency virus type 1 capsid protein contains a conserved P217X4PX2PX5P231 motif. Mutation at Pro-222 decreases virion incorporation of cyclophilin A, while mutation at Pro-231 abolishes infectivity. Although viral RNA incorporation and protease cleavage of the Gag precursor were not affected by these mutations, cryoelectron microscopy revealed a loss of virion maturation in P231A particles.     

The evolution of a successful liver transplant program in 1996: the clinical and administrative role of the anesthesiologist

The establishment of a new liver transplant program requires enormous planning and resources. Extensive negotiations must take place to ensure institutional and departmental commitments to obtain the proper equipment, personnel, and other resources. The formation of a well-trained multidisciplinary team of physicians and nurses becomes the next step. Finally, ample time must be provided to adequately deploy resources, lobby referring physicians, recruit patients, and troubleshoot problems as they arise.     

The role of tonic vestibular input for postural control in rats

Removal of a vestibular organ deprives the ipsilateral vestibular nuclei of tonic excitatory inflow from vestibular afferents, and thus evokes a central asymmetry, that is imbalance between tonic activity of the left and right vestibular nuclear complexes. In the present study, the effect of the central asymmetry upon a function of different motor systems was investigated in the freely behaving rats subjected to unilateral or bilateral labyrinthectomy (UL or BL). In four sets of experiments the following results have been obtained. 1. Seven UL-evoked symptoms (which reflect impairment of different motor systems) were qualitatively characterized. The short-lasting symptoms were: (1) body twisting, (2) rolling, (3, 4) extension of the fore- and hindlimb contralateral to UL, and (5) circling. These symptoms disappeared in a fixed order during recovery from anesthesia. During of expression of the symptoms was very short (< 1 hour) with the Halothan anesthesia and much longer (approximately 8 hours) with the chloral hydrate anesthesia. The long-lasting symptoms were (6) spontaneous ocular nystagmus, that persisted for 3 days after UL, and (7) head roll tilt, that persisted for at least several weeks after UL. 2. In BL-animals, stimulation of one of the 8th nerves was performed (by means of an implanted electrode; pulses 0.3 ms, 50 Hz, current up to 400 microA). By increasing gradually the strength of the stimulating current, we could evoke all the UL-symptoms but generally in the order (7-->1) which was the reverse as compared to the order of disappearance of the corresponding symptoms during recovery after UL (1-->7). These findings suggest that different symptoms need different levels of the central asymmetry for their appearance, and these levels also determine the order of disappearance of the symptoms during recovery from UL. 3. In UL-animals, by stimulating the 8th nerve on UL-side with a properly adjusted current (200-400 microA) we could immediately abolish all the symptoms except (6), which was, however, considerably reduced. This finding suggests that stimulation of the 8th nerve in UL-rats restores the central symmetry, which results in a concerted disappearance of almost all symptoms. In addition to the intermediate effects, stimulation of the 8th nerve in UL-animals resulted in a long-lasting effect, that is a reduction of the head roll tilt which persisted for at least 10 days after stimulation. 4. In BL-animals bilateral stimulation of the 8th nerve resulted in restoration of the muscular tone, and in considerable improvement of the control of the head position.     

Gore-Tex tubing as a conduit for repair of lingual and inferior alveolar nerve continuity defects: a preliminary report

PURPOSE: This report describes the results of using a Gore-Tex (Gore Company, Flagstaff, AZ) tube as a conduit for repair of continuity defects in the inferior alveolar or lingual nerves. PATIENTS AND METHODS: Seven nerve repairs were performed in five patients (M:F = 1:4) with an age range of 16 to 56 years. The duration from injury to repair ranged from 4 to 30 months. Two inferior alveolar and five lingual nerves were repaired. RESULTS: All seven patients had anesthesia by objective testing preoperatively and had a continuity defect at the time of operation. The size of the defects ranged from 2 to 15 mm. Two of the seven patients had some return of sensation, occurring in defects of 3 mm or smaller. CONCLUSION: The results of this pilot study indicate that Gore-Tex tubing may not be effective in the repair of continuity defects except in those defects 3 mm or smaller, in which it may act as a protective barrier membrane rather than as a conduit.     

Complications related to osteopenia in the thoracic spine on admission chest radiographs of substance abuse detoxification patients

OBJECTIVE: To assess the prevalence of complications related to osteopenia in the thoracic spine (anterior wedging and fish vertebrae) of patients admitted for substance abuse detoxification. DESIGN AND PATIENTS: We retrospectively identified 150 sequential patients admitted to our drug and alcohol detoxification ward in whom posteroanterior and lateral admission chest radiographs and clinical charts were available for review. There were 116 men and 34 women with a mean age of 37 years (range 19-67 years). Thirty-eight patients were admitted for drug detoxification, 37 for alcohol detoxification, and 75 for drug and alcohol detoxification. These patients were compared with 66 age- and sex-matched controls from our hospital's employee health service. Two radiologists reviewed all chest radiographs for the presence of anterior wedging and fish vertebrae in the thoracic spine and other nonspinal fractures. Serum calcium and inorganic phosphorus levels were recorded for the substance abuse detoxification patients. RESULTS: Forty-nine percent (n=73) of detoxification patients had complications of osteopenia in the thoracic spine including: anterior wedging (n=47), fish vertebrae (n=21), or both (n=5). Twenty-four percent (n=36) of patients had an elevated serum inorganic phosphorus level and one patient had an elevated serum calcium level. Patients with anterior wedging or fish vertebrae included: 45% (n=45) of patients below age 40 years, 35% (n=12) of women, 41% (n= 15) of drug detoxification patients, 58% (n=22) of alcohol detoxification patients, 48% (n=36) of drug and alcohol detoxification patients, and 47% (n=17) of patients with elevated serum inorganic phosphorus (P=NS). Six percent (n=9) of our study population had nonspinal fractures on their chest radiographs. Twenty-one percent (n=14) of controls had complications of osteopenia in the thoracic spine (all anterior wedging). This prevalence differed significantly (P<0.05, chi-squared) from the study population. CONCLUSION: Osteopenia-related anterior wedging and fish vertebrae in the thoracic spine are common findings on chest radiographs of patients hospitalized for substance abuse detoxification. Serum inorganic phosphorus and calcium levels did not correlate with the presence of anterior wedging or fish vertebrae.     

Faster adjustment of O2 delivery does not affect V(O2) on-kinetics in isolated in situ canine muscle

The mechanism(s) limiting muscle O2 uptake (VO2) kinetics was investigated in isolated canine gastrocnemius muscles (n = 7) during transitions from rest to 3 min of electrically stimulated isometric tetanic contractions (200-ms trains, 50 Hz; 1 contraction/2 s; 60-70% of peak V(O2)). Two conditions were mainly compared: 1) spontaneous adjustment of blood flow (Q) [control, spontaneous Q (C Spont)]; and 2) pump-perfused Q, adjusted approximately 15 s before contractions at a constant level corresponding to the steady-state value during contractions in C Spont [faster adjustment of O2 delivery (Fast O2 Delivery)]. During Fast O2 Delivery, 1-2 ml/min of 10(-2) M adenosine were infused intra-arterially to prevent inordinate pressure increases with the elevated Q. The purpose of the study was to determine whether a faster adjustment of O2 delivery would affect V(O2) kinetics. Q was measured continuously; arterial (Ca(O2)) and popliteal venous (Cv(O2)) O2 contents were determined at rest and at 5- to 7-s intervals during contractions; O2 delivery was calculated as Q x Ca(O2), and V(O2) was calculated as Q x arteriovenous O2 content difference. Times to reach 63% of the difference between baseline and steady-state VO2 during contractions were 23.8 +/- 2.0 (SE) s in C Spont and 21.8 +/- 0.9 s in Fast O2 Delivery (not significant). In the present experimental model, elimination of any delay in O2 delivery during the rest-to-contraction transition did not affect muscle V(O2) kinetics, which suggests that this kinetics was mainly set by an intrinsic inertia of oxidative metabolism.     

Physical and biological predictors of changes in whole-lung function following thoracic irradiation

PURPOSE: To develop methods of predicting the pulmonary consequences of thoracic irradiation (RT) by prospectively studying changes in pulmonary function following RT. METHODS AND MATERIALS: 100 patients receiving incidental partial-lung irradiation during treatment of tumors in or adjacent to the thorax had whole-lung function assessed via symptoms and pulmonary function tests (PFTs: FEV1-forced expiratory volume 1 s; DLCO-diffusion capacity) before and repeatedly 6-48 months following RT. All had computed tomography-based three-dimensional (3D) dose calculations with lung density heterogeneity corrections for dose-volume histogram (DVH) and normal tissue complication probability (NTCP) calculations. Functional DVHs (DVfH) based on SPECT (single photon emission computed tomography) lung perfusion scans, and serial transforming growth factor-beta (TGF-beta1) levels were available in 50 and 48 patients, respectively. The incidence and severity of changes in whole-lung function were correlated with clinical, physical, and biological factors. Exploratory statistical analyses were performed using chi-square, Pearson correlations, logistic regression, and multiple linear regression. RESULTS: RT-induced symptoms developed in 21 patients. In the overall group, the single best predictor for the development of symptoms was the NTCP (p < 0.05). Pre-RT PFTs alone were less predictive (p = 0.1 for FEV1, p = 0.08 for DLCO). A multivariate model based on pre-RT DLCO and CT-based NTCP was strongly predictive for the development of symptoms (p < 0.001). NTCPs based on SPECT-derived DVf Hs and TGF-beta1 levels did not appear to provide additional predictive value. The presence or absence of pulmonary symptoms was correlated with the decline in PFT 6 months following RT (p < 0.05). In the overall group, the degree of decline in PFTs was not well correlated with any of the dose-volume variables considered. In patients with "good" pre-RT PFTs, there was a relationship between the percent reduction in PFT and dose-volume parameters such as the percent of lung volume receiving > 30 Gy (p < 0.05). CONCLUSION: The extent of alteration in whole-lung function (symptoms or PFT changes) appears to be related to both dose-volume and pre-RT PFT parameters. The data suggest that no one variable is likely to be an adequate predictor and that multivariate predictive models will be needed. Additional studies are underway to develop better predictive models that consider physical factors such as the DVH and regional perfusion, as well as biological/clinical factors such as pre-RT PFTs and TGF-beta1.     

Attitudes of veterinarians, animal control directors, and county prosecutors in Michigan regarding enforcement of state animal cruelty legislation

OBJECTIVES: To determine attitudes of veterinarians, animal control directors, and country prosecutors in Michigan toward enforcement of state animal cruelty legislation and to identify factors associated with whether veterinarians would report suspected cases of animal cruelty. DESIGN: Survey. SAMPLE POPULATION: Questionnaires were sent to 1,146 Michigan Veterinary Medical Association member veterinarians, 139 animal control directors, and 83 county prosecutors in Michigan. RESULTS: 740 (65%) veterinarians, 70 (50%) animal control directors, and 43 (52%) prosecutors responded. Six hundred forty six of 735 (88%) veterinarians reported having treated an animal that they believed had been a victim of animal cruelty, but only 192 of 719 (27%) had ever reported a case of animal cruelty, and only 217 of 734 (30%) had ever testified in an animal cruelty case. Logistic regression analysis of responses revealed that the only factor associated with whether veterinarians would report cases of suspected animal cruelty was the potential reactions of the involved clients to the accusation of animal cruelty. Veterinarians who rated reaction of the involved client as important, very important, or essential to their decision whether to report a case of animal cruelty were less likely to report such cases than were veterinarians who rated potential client reaction as somewhat important or unimportant. CLINICAL IMPLICATIONS: Concern about potential client reaction was the most important factor in whether veterinarians would report cases of suspected animal cruelty.     

Dermatomyositis with subclinical myositis and spontaneous pneumomediastinum with pneumothorax: case report and review of the literature

Dermatomyositis (DM) is a clinical entity characterized by a distinctive cutaneous rash and inflammatory myopathy. Besides skin and muscle, the disease can also involve other internal organs, especially the lungs. We describe a patient with dermatomyositis and incomplete signs of myositis who developed pneumomediastinum, pneumothorax and massive subcutaneous emphysema. This case illustrates a rare pulmonary complication of DM, and underscores that muscular involvement in this disease is not always reflected in laboratory and/or histological abnormalities.