Progressive pneumonia complicating steroid-dependent asthma.

We describe a patient who developed pulmonary nocardiosis whilst taking long term oral steroids for asthma. Nocardiosis is more common than is generally appreciated by clinicians, is notoriously difficult to diagnose, and is associated with significant mortality. This patient developed progressive pneumonia despite antibiotic therapy, which is typical of pulmonary nocardiosis. It is important to consider this treatable condition in the differential diagnosis of pneumonia.

Serological survey of chlamydial antibody in post-natal sera.

Questionnaires (3426; 72.8%) and blood samples (3890; 82.6%) were analysed from 4704 women post-natally. The answers to the questionnaire confirmed that those patients living in areas with the highest percentage employed in agriculture were most likely to be in direct or indirect contact with sheep or sheep products. When the 788 (20.3%) of the sera with group specific antibody were examined for type-specific antibody, 291 (7.5%) reacted with Chlamydia trachomatis, 153 (3.9%) with Chlamydia pneumoniae, but only one (0.03%) with Chlamydia psittaci. Thus, it would appear that C. psittaci was not an important pathogen in this survey, despite the largest proportion of blood samples being submitted from those most likely to be employed in agriculture. However, in the course of this survey the three patients who had previously suffered chlamydia-associated abortion had successful pregnancies and submitted blood specimens. Serological studies on the serial bloods from these patients showed that, despite developing antibody to the C. psittaci pool and the ovine abortion strain of C. psittaci following abortion, this antibody waned. At the time of the subsequent successful pregnancy, serological results would not have detected a previous C. psittaci infection, but one due to C. pneumoniae. Thus, the results of a survey such as this must be interpreted with caution.

Reversal of trimethoprim-induced antikaliuresis.

High-dose trimethoprim-sulfamethoxazole (TMP-SMX) causes hyperkalemia, thought to result from TMP-induced blockade of amiloride-sensitive Na(+)-channels in the distal nephron. The present study was performed in anesthetized dogs to determine if increasing distal sodium delivery affects this antikaliuretic effect. In Group 1, intrarenal infusion of vehicle did not alter renal function. In Group 2, i.v. infusion of amiloride led to diuresis, natriuresis and antikaliuresis associated with a reduction of the transtubular potassium gradient (TTKG) in both kidneys. Intrarenal infusion of TMP (0.2 mg/kg/min) into the left kidney did not further alter these parameters. In groups 3 and 4, intrarenal infusion of TMP caused an ipsilateral diuresis, natriuresis, antikaliuresis and a reduction in (TTKG) without affecting the contralateral kidney. The TMP infusion was followed by furosemide (20 mg i.v.) in group 3 and acute saline loading in group 4. Despite continuous TMP infusion, both furosemide and saline loading reversed the antikaliuretic effect of TMP in the ipsilateral kidney and was associated with a similar kaliuresis, diuresis, natriuresis and decrease in urine osmolality in both kidneys. The TTKG following furosemide or saline loading increased in the ipsilateral kidney and decreased in the contralateral kidney. In all groups the systemic and renal hemodynamics remained unchanged. These results suggest that acute administration of TMP inhibits the amiloride-sensitive Na(+)-channel and K+ secretion in the distal nephron. Maneuvers that increase distal Na+ delivery can abrogate TMP's antikaliuretic effect due, in part, to an increase of the low TTKG observed with TMP.

An outbreak of Escherichia coli O157 associated with a children's paddling pool.

In May 1992, a small, circumscribed community outbreak of infection due to verotoxin-producing Escherichia coli O157 phage type 49 occurred in a semi-rural area of south-east Scotland. On the basis of stool cultures, six cases were identified, one of whom was asymptomatic. One child developed the haemolytic uraemic syndrome. Although the source of infection of the index case was not established nor could the extent of person-to-person spread be fully determined, the clinical, microbiological and epidemiological evidence available indicated that a children's paddling pool served as the focal point in the transmission of infection causing the outbreak.

An education program to reduce unnecessary laboratory tests by residents.

What are often called "little-ticket" items--X-rays and laboratory tests--account for 25-30% of all health care costs. Two such items were the focus of this study, which took place at an inner-city community health center operated by the Department of Family Medicine of Cook County Hospital and involved 20 family practice residents over a period of nine weeks. The first item was the complete blood count (CBC) with differential, a prototype of a low-cost, high-volume test often ordered by reflex; the second, the thyroid stimulating hormone (TSH) test, a high-cost, low-volume test normally associated with a differential diagnosis or clinical reasoning. Through the use of a simple educational intervention based on quality of care, not cost-containment, and an audit feedback system, the authors were able to reduce significantly the rates of ordering TSH tests (p less than .0001) and CBCs (p = .05). This effect on the rates persisted five months after the intervention terminated. In addition, the percentage of TSH tests clinically indicated by explicit criteria increased significantly (p less than .001) during the intervention. However, this effect showed signs of diminishing five months after the intervention ended. The percentage of CBCs clinically indicated did not change significantly as a result of this intervention.

Major isozymes of rat liver microsomal cytochrome P-450 involved in the N-oxidation of N-isopropyl-alpha-(2-methylazo)-p-toluamide, the azo derivative of procarbazine.

Seven isozymes of cytochrome P-450 were tested to establish whether they could N-oxidize azoprocarbazine to form the two isomeric azoxy metabolites after optimizing the reconstitution of various purified isozymes with regard to substrate concentration, exogenous lipid, and reduced nicotinamide adenine dinucleotide phosphate-cytochrome c (P-450) reductase concentration. Two isozymes, cytochromes P-450PB-C (an isozyme present in untreated rats or in rats treated with phenobarbital or beta-naphthoflavone) and P-450 beta NF-B (the major beta-naphthoflavone-induced isozyme), had appreciable turnover numbers for the N-oxidation reaction. The product ratio [N-isopropyl-alpha-(methyl-ONN-azoxy)-p-toluamide formation relative to N-isopropyl-alpha-(methyl-NNO-azoxy)-p-toluamide formation] obtained with cytochrome P-450PB-C was nearly identical to those values obtained with liver microsomes from untreated and phenobarbital-treated rats. In addition, cytochrome P-450 beta NF-B and liver microsomes from beta-naphthoflavone-treated rats had nearly identical product ratios. Specific inhibitory antibodies to four purified isozymes were used to titrate the N-oxidase activity of liver microsomes from untreated, phenobarbital-, pregnenolone-16 alpha-carbonitrile-, or beta-naphthoflavone-treated rats. Anti-cytochrome P-450PB-C globulin inhibited more than 70 to 90% of the formation of N-isopropyl-alpha-(methyl-ONN-azoxy)-p-toluamide in microsomes from untreated, phenobarbital-, and pregnenolone-16 alpha-carbonitrile-treated rats, respectively, but only 20 to 50% of N-isopropyl-alpha-(methyl-NNO-azoxy)-p-toluamide formation. A small amount (25 to 30%) of inhibition was observed with anti-cytochrome P-450PB/PCN-E globulin. Anti-cytochrome P-450 beta NF-B globulin inhibited more than 85% of the synthesis of either azoxy isomer catalyzed by liver microsomes from beta-naphthoflavone-treated rats. These results demonstrate that two isozymes are responsible for the oxidative metabolism of azoprocarbazine and can account for the major portion of this N-oxidase activity in liver microsomes from untreated and phenobarbital-, pregnenolone-16 alpha-carbonitrile-, or beta-naphthoflavone-treated rats.

Quantification of the fate of dietary fiber in humans by a newly developed radiolabeled fiber marker.

A radiolabeled cellulose (131I-fiber) that retains the essential physical and chemical properties of this class of fiber was developed in our laboratory. We quantified the fate of orally ingested 131I-fiber in healthy individuals by external gamma camera monitoring and fecal collections. The marker passes virtually intact through the human gastrointestinal tract with negligible release and absorption of the label in the gut. Comparison of the gastric emptying rate of 131I-fiber with that of a predominantly aqueous marker, 99mTc-diethylenetriamine pentaacetic acid (99mTc-DTPA), showed that 131I-fiber strands were evacuated more slowly than intragastric fluids. An important finding was that some 131I-fiber emptying occurred during most time periods, even before liquids were completely evacuated. This suggests that the human stomach is able to empty simultaneously liquids and fiber strands (1-15 mm in length) that are resistant to grinding by antral mechanical forces and to digestion by acid-peptic secretion. Thus, some nondigestible solids may be emptied with the bulk of a meal, although at a slower rate. 131I-Fiber may be a useful marker for quantifying gastric emptying of nondigestible solids. Further, the stability of 131I-fiber in the gut, as opposed to most other physiologic solid labels, should enable future investigation of intestinal and colonic transit of fiber, which is an important component of the human diet.