SMaRT-PCR: sampling using masks and RT-PCR, a non-invasive diagnostic tool for paediatric pulmonary TB.

Key challenges in paediatric TB diagnosis are invasive sampling and poor sensitivity of standard methods. This study demonstrates the diagnostic potential of non-invasive sampling of bioaerosols from children using SMaRT-PCR, comprising mask sampling combined with reverse transcriptase-polymerase chain reaction (RT-PCR) for TB.Exhaled bioaerosols were captured on modified N-95 masks in a 10-min talk-cough-breathe process from 51 children (30 with TB confirmed using standard sampling methods and 21 without TB) aged 2-15 years. All mask samples were tested using in-house RT-PCR for 16s and rpoB RNA transcripts. Additional mask samples from children with TB were tested using Xpert® MTB/RIF (n = 3) and Xpert® MTB/RIF Ultra (n = 27).SMaRT-PCR sensitivity for detecting TB among treatment-naïve children was 96% if 16s or rpoB was present, and 75% if both genes were present, comparable to standard methods (71%) in the same cohort. Specificity was better for both genes, at 95%, than 85% for a single gene detection. Mask sampling with Xpert MTB/RIF or Ultra had a sensitivity of only 13%.This is the first study to provide evidence for testing bioaerosols as a promising alternative for detecting paediatric TB. Sampling is non-invasive and simple, with the potential for point-of-care applications. This pilot study also suggests that RNA transcript-based detection may improve TB diagnostic sensitivity in children; however, further investigation is required to establish its adaptability in clinical settings..

Adult onset grape hypersensitivity causing life threatening anaphylaxis.

BACKGROUND: Adverse reactions to foods are encountered much less frequently in adults than in the children. Adult onset hypersensitivity to grapes has not been previously reported. OBJECTIVE: Evaluation of a case of anaphylaxis that occurred as a result of the consumption of white grapes (Vitis vinifera). METHODS AND RESULTS: A 28-year-old woman experienced generalized urticaria, facial/oropharyngeal angioedema, and dizziness after eating a bunch of white grapes. She was treated in an emergency room for anaphylaxis. Previously, she had experienced two similar episodes after eating white grapes. The grape prick skin tests were strongly positive forming a pseudopod type reaction. The total serum IgE was 1918 ng/mL. The grape-specific serum IgE was weakly positive by the modified RAST and negative in the Pharmacia-Upjohn Cap System. CONCLUSION: Hypersensitivity to a commonly consumed fruit such as grapes can develop late in life causing a near-fatal anaphylaxis.

Humanized antibodies as potential therapeutic drugs.

BACKGROUND: Antibodies have been used therapeutically to treat a variety of clinical conditions. The introduction of monoclonal antibodies and more recently, engineered humanized antibodies has greatly refined and expanded the therapeutic potential of this modality of treatment. LEARNING OBJECTIVES: To reinforce the reader's knowledge of the therapeutic application of antibody in the treatment for different diseases. More specifically, to enhance reader's understanding of basic methods employed in the production and clinical use of humanized antibodies. DATA SOURCE: The MEDLINE database was used to review the humanized antibody related literature. CONCLUSION: Humanized antibodies provide a novel approach for the treatment of a broad range of diseases. Expanded use will depend on improvement in their efficacy (avidity and specificity), demonstration of their safety, and reduction of their immunogenicity.

Prevalence and causes of undernutrition in medical outpatients.

PURPOSE: To assess the prevalence, common causes, and frequency of recognition and treatment of undernutrition in older and younger medical outpatients using a cross-sectional survey design with 2-year follow-up of undernourished subjects. PATIENTS AND METHODS: Charts of 1017 adult patients attending a hospital outpatient department were reviewed for the presence of undernutrition, and 85 patients meeting inclusion criteria for undernutrition were evaluated and followed for 2 years. An initial evaluation focused on nutritional, cognitive, and affective status and on nutritional attitudes using two subscales of the EAT-26 eating disorder inventory. After 2 years, initial data plus outpatient records were evaluated by 2 independent reviewers to determine a primary cause of undernutrition and to assess the recognition and treatment of undernutrition by the primary physician. RESULTS: Undernutrition was identified in 46 (11%) and 44 (7%) of older and younger subjects respectively; odds ratio (OR) (95% [confidence interval (CI)]) for older versus younger=1.65 (1.06 to 2.51). The primary cause of undernutrition differed between age groups but was deemed treatable in nearly 90% of all subjects. Undernutrition was recognized in 19 (43%) older subjects and 5 (12%) younger subjects (OR=5.47 [1.87 to 16.0]), and appropriate intervention(s) were instituted in 6 (14%) and 2 (5%) of older and younger subjects, respectively (OR=3.08 [0.668 to 14.21]). Older subjects scored higher on the EAT-26 oral control subscale than did younger subjects (4.7 versus 2.5, P=0.004) but similarly on the EAT-26 dieting subscale (5.2 versus 6.3, P=0.332); these relationships did not change with control for potentially confounding variables. CONCLUSIONS: In this study, undernutrition was relatively common, usually amenable to treatment, but frequently undetected and undertreated in both older and younger medical outpatients. Older undernourished subjects exhibited higher oral control needs than younger persons, which may have implications for the pathophysiology and treatment of their malnutrition. Further improvement in detection and intervention is warranted in both younger and older age groups.

Metered dose inhaler: past, present, and future.

BACKGROUND: The metered dose inhaler (MDI) to treat respiratory diseases was introduced many years ago. Due to the recently proposed ban on chlorofluorocarbon (Freon) production, the survival of the conventional MDI is uncertain. It is therefore incumbent on asthma caretakers to familiarize themselves with newer versions of the inhaler. OBJECTIVE: To review the different modalities of aerosolized treatment employed in the management of asthma. This article is specifically focused on issues related to MDIs, the propellants, and the modifications since its introduction. DATA SOURCE: The MEDLINE database was used to review MDI related literature in the English language. CONCLUSION: Dry powder inhalers (especially the multi-dose type) and Freon-free pressurized MDIs appear promising and probably will replace conventional freon-propelled pressurized MDIs when Freon is no longer available.

The Americans With Disabilities Act and dermatologists.

The passage and implementation of the Americans With Disabilities Act of 1990 (ADA) has established certain rights in law for persons with disabilities, including patients with skin disease. For workers in workplaces employing more than 15 workers, management may not exclude a worker from a job unless it can be objectively demonstrated that their skin disease will make it impossible for them to perform the essential functions of the job. Employers, at their expense, are now required to provide those disabled with skin disease with reasonable accommodation to allow them to perform their jobs while having their skin impairment. Unless the skin impairment can be shown to place the worker or their fellow workers at material risk to their health, the employer may not exclude them from working--even if the employer is concerned that it may make their skin disease worse. The act applies both to new employees and those acquiring disabling skin disease who are employed and wish to stay at work or return to work. Arbitration of dispute between employees and management are the responsibility of the Equal Employment Opportunities Commission (EEOC), a federal agency responsible for the legislation.

Endoscopic nasoenteral feeding tube placement following cardiothoracic surgery.

UNLABELLED: Our purpose was to evaluate the safety and efficacy of nasoenteral feeding tube placement in the cardiothoracic surgery patients. This is a retrospective analysis of 15 critically ill cardiothoracic surgery patients who underwent endoscopic placement of an enteral feeding tube beyond the proximal duodenum for maintenance of nutrition. Twenty-five entriflex 10-F nasoenteral tubes were placed endoscopically using a modified technique far into the distal duodenum, and the placement was confirmed radiographically. Mean patient age was 71 years. Seven were males and 8 were females. Eleven had undergone coronary artery bypass surgery, two aortic valve replacement, and two aortic aneurysm repair. The mean duration of tube function was 8.5 days and mean duration of tube feeding was 15.7 days. Of the total 15 patients, 7 required replacement due to various reasons, the most common being self extubation by the patient and malpositioning after initial placement. No cardiac complications or any other complications were noted directly related to the endoscopic procedure. In eight patients, the mean serum albumin level did not change [before: 2.5mg/dL, after: 2.6mg/dL] for the short time (avg. 8.5 days) the tube was functional. CONCLUSIONS: 1) Endoscopic placement of the nasoenteral tubes is a safe method of providing enteral nutrition in critically ill cardiothoracic surgery patients. 2) Benefits of nasoenteral tubes compared to nasogastric tubes remain unproven, and frequent repositioning of nasoenteral tubes is required. 3) A prospective comparison of nasoenteral and nasogastric tubes is warranted.

Pain and dermal reaction caused by injected glycerin in immunotherapy solutions.

BACKGROUND: Fifty percent glycerin preserves immunotherapy solution potency for at least 3 years but must be diluted before injection to reduce glycerin-induced pain and inflammation. We studied pain, erythema, induration, and bruises caused by glycerin (0% to 30%). METHODS: In 15 healthy subjects we compared, in double-blind fashion, pain scores, injection site erythema, induration, and bruising caused by subcutaneous injections in randomized order of 0.1, 0.5, and 1 ml of glycerin 0%, 10%, 20%, and 30%. RESULTS: Injection volume did not significantly influence pain scores from diluent alone (0% glycerin) (p greater than 0.1). Pain scores of subjects given glycerin (0.1 to 1 ml, 10% to 30%) increased significantly as both injection volume (p less than 0.001) and glycerin concentration (p less than 0.001) increased. Pain scores correlated with total glycerin dose administered (volume x concentration) (rs = 0.67, p less than 0.0005) but varied widely, from minimal to severe, in those given the same dose. Injection site erythema, induration, and bruising occurred in some subjects with significant positive correlations between total glycerin dose and both frequency and diameters of erythema and induration. However, these dermal reactions were of trivial clinical importance. CONCLUSION: Injected glycerin produces pain that is proportional to total injected dose of glycerin, but individual variation in perceived discomfort is substantial. Total glycerin doses of less than 0.05 ml rarely produce clinically important pain.

Psyllium laxative-induced anaphylaxis, asthma, and rhinitis.

A 69-year-old nurse was evaluated for a recent episode of anaphylaxis that had occurred after psyllium ingestion. She had experienced recurrent rhinitis and asthma related to psyllium exposure for the past 15 years. The diagnosis of psyllium hypersensitivity was established by a positive psyllium puncture skin test, an elevated psyllium-specific IgE level in serum, and a confirmatory soluble-antigen competitive inhibition test. The patient was symptomatic for several years, and this diagnosis was not considered until she suffered potentially life-threatening anaphylaxis. Psyllium hypersensitivity may be a more common phenomenon than is currently appreciated by physicians and other health-care providers.

Oral sodium phosphate versus sulfate-free polyethylene glycol electrolyte lavage solution in outpatient preparation for colonoscopy: a prospective comparison.

BACKGROUND: Biochemical abnormalities induced by oral sodium phosphate and the risk of cardiac arrhythmias as potential sequelae have yet to be investigated. METHODS: We studied 98 outpatients scheduled to undergo diagnostic colonoscopy and prospectively randomized them to receive oral sodium phosphate or sulfate-free polyethylene glycol electrolyte lavage solution (SF-PEG-ELS) as recommended by the manufacturers. RESULTS: Forty-nine patients received sodium phosphate and 49 received SF-PEG-ELS. There was no significant difference in tolerance or quality of preparation as judged by blinded endoscopists. Significant changes in serum sodium, potassium, chloride, calcium, ionized calcium, and inorganic phosphorus levels were noted following sodium phosphate preparation when compared to values before preparation. A significantly greater number of patients who received sodium phosphate preparation had serum potassium and ionized calcium levels that fell into the abnormal range. Ambulatory electrocardiogram monitors placed 24 hours before the preparation and removed after colonoscopy showed no increase in ventricular premature contractions or other serious arrhythmias in either group during preparation or colonoscopy. CONCLUSIONS: (1) Sodium phosphate and SF-PEG-ELS are equally well tolerated and effective in preparation for outpatient colonoscopy, and (2) sodium phosphate preparation at the recommended dose causes significant alterations in serum sodium, potassium, chloride, calcium, ionized calcium, and phosphorus levels.

Pseudohyponatremia in multiple myeloma.

Severe hyponatremia in any asymptomatic patient should alert the clinician to the possibility that pseudohyponatremia may be attendant with chylomicronemia or paraproteinemia. In cases of chylomicronemia, the serum is creamy, and in paraproteinemia the serum has increased viscosity. In such cases, the calculated serum osmolality will be decreased but the measured value will be within the normal range. Hyponatremia in an asymptomatic patient demands careful evaluation before institution of therapy. In addition, the presence of a normal serum sodium level in a patient with multiple myeloma should alert the clinician to the possibility that hypernatremia and hypertonicity may be present.