An evaluation of methods for the isolation of nontuberculous mycobacteria from patients with cystic fibrosis, bronchiectasis and patients assessed for lung transplantation.

BACKGROUND: RGM medium is an agar-based, selective culture medium designed for the isolation of nontuberculous mycobacteria (NTM) from the sputum of patients with cystic fibrosis (CF). We evaluated RGM medium for the detection of NTM in patients with CF (405 samples), bronchiectasis (323 samples) and other lung diseases necessitating lung transplantation (274 samples). METHODS: In total, 1002 respiratory samples from 676 patients were included in the study. Direct culture on RGM medium, with incubation at two temperatures (30 °C and 37 °C), was compared with conventional culture of decontaminated samples for acid-fast bacilli (AFB) using both a solid medium (Löwenstein-Jensen medium) and a liquid medium (the Mycobacterial Growth Indicator Tube; MGIT). RESULTS: For all three patient groups, significantly more isolates of NTM were recovered using RGM medium incubated at 30 °C than by any other method (sensitivity: 94.6% vs. 22.4% for conventional AFB culture; P < 0.0001). Significantly more isolates of Mycobacterium abscessus complex were isolated on RGM at 30 °C than by AFB culture (sensitivity: 96.1% vs. 58.8%; P < 0.0001). The recovery of Mycobacterium avium complex was also greater using RGM medium at 30 °C compared to AFB culture (sensitivity: 83% vs. 70.2%), although this difference was not statistically significant and a combination of methods was necessary for optimal recovery (P = 0.21). CONCLUSIONS: In the largest study of RGM medium to date, we reaffirm its utility for isolation of NTM from patients with CF. Furthermore; we show that it also provides an effective tool for culture of respiratory samples from patients with bronchiectasis and other lung diseases.

Is vancomycin MIC "creep" method dependent? Analysis of methicillin-resistant Staphylococcus aureus susceptibility trends in blood isolates from North East Scotland from 2006 to 2010.

This study investigated "creep" in vancomycin and daptomycin MICs among methicillin-resistant Staphylococcus aureus (MRSA) isolates from blood cultures over a 5-year period in a hospital in the United Kingdom, using different susceptibility testing methods. Trends in vancomycin and daptomycin susceptibility were evaluated by using Etest performed prospectively on isolates in routine clinical practice from December 2007 to December 2010 (n = 102). Comparison was made to results from prospective testing of subcultures at the Scottish MRSA Reference Laboratory, using an automated system (Vitek 2) and retrospective testing (Etest and CLSI reference broth microdilution [BMD] method) of stored isolates from 2006 to 2010 (n = 208). Spearman's rank correlations revealed a significant increase in vancomycin MIC (P = 0.012) and a significant decrease in daptomycin MIC (P = 0.03) by year of study for Etest results from the time of isolation. However, neither trend was replicated in MICs from automated or retrospective testing. The Friedman test revealed a significant difference between vancomycin MICs obtained from the same samples by different testing methods (χ(2) [3 degrees of freedom] = 97; P < 0.001). MICs from automated testing and Etest analysis of stored isolates were significantly lower than those from Etest analysis at the time of isolation for both antibiotics (P < 0.001). Effects of storage on the MIC appeared within the first 6 months of storage. Inconsistent evidence on vancomycin MIC creep and the relevance of the MIC to clinical outcome may arise from differences in susceptibility testing methods, including storage of isolates. There is a need to standardize and streamline susceptibility testing of vancomycin against MRSA.

The newly described mecA homologue, mecALGA251, is present in methicillin-resistant Staphylococcus aureus isolates from a diverse range of host species.

OBJECTIVES: A previously unidentified mecA homologue, mecA(LGA251), has recently been described in methicillin-resistant Staphylococcus aureus (MRSA) from humans and dairy cattle. The origin and epidemiology of this novel homologue are unclear. The objective of this study was to provide basic descriptive information of MRSA isolates harbouring mecA(LGA251) from a range of host animal species. METHODS: A number of S. aureus isolates from historical animal isolate collections were chosen for investigation based on their similarity to known mecA(LGA251) MRSA isolates. The presence of mecA(LGA251) was determined using a multiplex PCR and antimicrobial susceptibility testing performed by disc diffusion. RESULTS: MRSA harbouring mecA(LGA251) were found in isolates from a domestic dog, brown rats, a rabbit, a common seal, sheep and a chaffinch. All of the isolates were phenotypically MRSA, although this depended on which test was used; some isolates would be considered susceptible with certain assays. All isolates were susceptible to linezolid, rifampicin, kanamycin, norfloxacin, erythromycin, clindamycin, fusidic acid, tetracycline, trimethoprim/sulfamethoxazole and mupirocin. Five multilocus sequence types were represented (2273, 130, 425, 1764 and 1245) and six spa types (t208, t6293, t742, t6594, t7914 and t843). CONCLUSIONS: The discovery of MRSA isolates possessing mecA(LGA251) from a diverse range of host species, including different taxonomic classes, has important implications for the diagnosis of MRSA in these species and our understanding of the epidemiology of this novel mecA homologue.

Incorporating new research into Medicare risk adjustment.

BACKGROUND: The Medicare Advantage payment system underpays health plans that enroll beneficiaries with multiple and complex chronic conditions. OBJECTIVES: This article addresses 3 major problems in the current payment system: (1) underreporting of chronic disease prevalence in fee-for-service (FFS) Medicare claims data, (2) overpayment of healthier and underpayment of sicker beneficiaries in the current payment system, and (3) underpayment for new beneficiaries in Medicare Advantage plans that require the beneficiaries to have at least one chronic disease to enroll. RESEARCH DESIGN: We incorporate 2 years of data and a count of chronic diseases in the current Medicare payment model. We develop a separate payment adjustment for new enrollees. SUBJECTS: A nationally representative sample of FFS beneficiaries in the 2004-2006 Medicare 5% claims data. MEASURES: We use predictive ratios to evaluate whether our enhanced model improves the predictive accuracy over the current model overall and for subsets of beneficiaries. RESULTS: The underreporting of chronic disease prevalence in Medicare FFS by 20% leads to systematic bias in the disease coefficients and demographic adjusters. The enhanced model reduces the level of payment for healthy beneficiaries and increases the payment for beneficiaries with multiple and complex chronic conditions. It improves payment for plans that enroll new enrollees with specific chronic conditions. CONCLUSIONS: Our enhanced model reduces financial incentives for health plans to engage in risk selection against beneficiaries with multiple chronic conditions.

Influence of menstrual cycle on circulating endothelial progenitor cells.

BACKGROUND: Endothelial progenitor cells (EPCs) are circulating mononuclear cells that participate in angiogenesis. The aim of this study was to determine the influence of the menstrual cycle on the number and function of EPCs, and to investigate their relationship with circulating concentrations of sex steroids and inflammatory mediators. METHODS: Ten healthy nulliparous, premenopausal, non-smoking women with regular menses were studied over a single menstrual cycle. Venepuncture was performed in the menstrual, follicular, peri-ovulatory and luteal phases. EPCs were quantified by flow cytometry (CD133(+)CD34(+)KDR(+) phenotype) and the colony-forming unit (CFU-EPC) functional assay. Circulating concentrations of estradiol, progesterone and inflammatory mediators (TNF-alpha, IL-6, sICAM-1 and VEGF) were measured by immunoassays. RESULTS: The numbers of CD133(+)CD34(+)KDR(+) cells were higher in the follicular phase (0.99 +/- 0.3 x 10(6) cells/l) compared with the peri-ovulatory phase (0.29 +/- 0.1 x 10(6) cells/l; P < 0.05). In contrast, the numbers of CFU-EPCs did not vary over the menstrual cycle. There were no correlations between EPCs and concentrations of either circulating sex steroids or inflammatory mediators. CONCLUSIONS: CD133(+)CD34(+)KDR(+) cells but not CFU-EPCs vary during the menstrual cycle. Our findings suggest a potential role for circulating EPCs in the normal cycle of physiological angiogenesis and repair of the uterine endometrium that is independent of circulating sex steroids or inflammatory mediators.

Cyclosporin A binding to calmodulin: a possible site of action on T lymphocytes.

Cyclosporin A, a potent immunosuppressive agent, has been widely used to treat patients with solid organ transplants. Although its precise mechanism of action is unknown, it appears to inhibit subsets of T lymphocytes at an early stage in cell activation. Fluorescent, fully active derivatives of cyclosporin A and calmodulin, a protein that binds calcium and is therefore essential to normal cell function, were utilized to demonstrate that cyclosporin A binds to calmodulin. Flow cytometry showed that the calmodulin inhibitors R24571 and W-7 competitively inhibited binding of cyclosporin A to cloned T lymphocytes. Cyclosporin A inhibited the calmodulin-dependent activation of phosphodiesterase in a dose-dependent manner. Binding of cyclosporin A to calmodulin may prevent the latter's role in the activation of the second messengers and enzymes required for effective cell proliferation and function in the immune response.

Rainbow smelt (Osmerus mordax) genomic library and EST resources.

Genomic resources in rainbow smelt (Osmerus mordax) enable us to examine the genome duplication process in salmonids and test hypotheses relating to the fate of duplicated genes. They further enable us to pursue physiological and ecological studies in smelt. A bacterial artificial chromosome library containing 52,410 clones with an average insert size of 146 kb was constructed. This library represents an 11-fold average coverage of the rainbow smelt (O. mordax) genome. In addition, several complementary deoxyribonucleic acid libraries were constructed, and 36,758 sequences were obtained and combined into 12,159 transcripts. Over half of these transcripts have been identified, several of which have been associated with cold adaptation. These basic resources show high levels of similarity (86%) to salmonid genes and provide initial support for genome duplication in the salmonid ancestor. They also facilitate identification of genes important to fish and direct us toward new technologies for other studies in fish biology.

Cystometrogram appearance in PUV is reliably quantified by the shape,wall, reflux and diverticuli (SWRD) score, and presages the need for intervention.

OBJECTIVE: Radiological bladder abnormalities in boys with posterior urethral valves (PUV) are well recognised; however, the assessment is subjective. The shape, wall, reflux and diverticuli (SWRD) score objectively assesses shape, wall, reflux and diverticuli in a simple way. This study was undertaken to demonstrate that the SWRD score is reliable, reproducible and correlates with bladder outcome and videourodynamic (VUD) assessment in boys with PUV. MATERIALS AND METHODS: Three blinded assessors determined the SWRD scores of PUV bladders from cystometrograms taken during VUD from September 2012 to October 2013. The scores were correlated with clinical outcome and VUD pressure measurements. Data were given as median (interquartile range), non-parametric tests used as appropriate (Mann-Whitney U test, or Kruskall-Wallis) and P < 0.05 was taken as significant. RESULTS: A total of 55 boys with PUV underwent VUD assessment, for which 52 cystometrograms were available. The SWRD score for non-operative management was 1.0 (0.1-1.9) vs 2.0 (1.0-3.3) for operative intervention, P = 0.018 (Summary Figure). The SWRD score for compliant bladders was 1.1 (0.6-2.0) vs hypercompliant 1.7 (0.5-2.8) vs non-compliant 3.3 (2.8-5.0), Kruskall-Wallis P = 0.011. The hostile detrusor overactivity (DO) bladders (Pdet >40 cmH2O) had a SWRD score of 2.0 (1.3-3.7) vs 1.0 (0.5-2.5) for low-pressure DO bladders, P < 0.05. DISCUSSION: In this series of patients, increasingly distorted bladder shape was seen to be associated with poor bladder dynamics on VUD. Patients with poorly compliant bladders had a significantly higher SWRD score than normal or megacystis patients. Severe DO was also significantly associated with a high SWRD score. Therefore, the radiological appearance of a hostile bladder represented a marker for high intravesical pressure. VUR and bladder diverticuli may lead to spurious pressure measurements during VUD; however, the SWRD score provided an independent mechanism with which to objectively assess these patients, even in the presence of gross VUR. CONCLUSIONS: The SWRD score is a simple and objective scoring system for the radiological abnormalities of PUV bladders. It correlates with clinical outcome and VUD assessment of compliance and DO, but is independent of pressure measurements and so not confounded by VUR acting as a 'pop-off' mechanism.

Reducing implant loss rates in immediate breast reconstructions.

UK best practice guidelines for oncoplastic breast reconstruction were published in 2012. Implant-based reconstruction quality indicator (QI) targets for readmission, return to theatre and implant loss rates were set at 5% by 3 months, along with guidance to achieve these targets. The aims of this study were to quantify complication rates following implant-based reconstruction before and after the implementation of the guidelines. A retrospective audit of 86 patients with 106 implants in the 12 months to June 2013 was performed, C1. Following institutional changes including reducing antibiotic usage, a prospective audit was performed on 89 patients with 105 implants to June 2014, C2. Extended follow-up of salvaged implants was also performed. Demographics were not significantly different between the two cohorts apart from smoking. Implant loss rates fell from 7.5%(C1) to 1.9%(C2), p = 0.054 but at the cost of an increase in the return to theatre rate (14.2%-18%, p > 0.05). The implant salvage rate increased from 47% in C1 to 89.5% in C2, however, 3 of the implants that were salvaged were lost in the long term giving an overall salvage rate of 82.4% in C2. While an implant loss rate of <5% at 3 months appears achievable with less antibiotic use, this was made possible by the institution of an aggressive readmission and salvage policy. We would question the QI standards for readmission and return to theatre for immediate implant-based breast reconstruction, given that our implant loss rate of 1.9% was achieved with a return to theatre rate of 18%.

The characterization and sequence analysis of thirty CTG-repeat containing genomic cosmid clones.

We have systematically isolated and characterized DNA containing large CTG (n > 7) repeats from a human cosmid genomic DNA library. Using a CTG10 probe, more than 100 cosmid clones were identified, and 30 of these have been extensively characterized. The sequenced cosmids contain repeats that are between three and 19 perfect units (average 10 perfect repeats). The cosmids map to at least 12 different chromosomes. Sequence analysis of flanking regions suggests that more than one third of the repeats occur in exons, and many share strong sequence identity with databank sequences, including the gene involved in dentatorubral pallidoluysian atrophy (DRPLA). Genotyping of human DNA samples demonstrates that more than half of the repeats are polymorphic. This and similar collections of clones containing trinucleotide repeats should aid in the identification of genes that may contain expansions of trinucleotide repeats involved in human disease.

Eating disorders in children. Diagnosis and age-specific treatment.

The symptoms of children with eating disorders change as these children age. In each age group, the diagnosis, evaluation, and treatment should be tailored to the developmental level of the child and should address the needs of the child's family. With early diagnosis and treatment comes the opportunity to avoid long-term sequelae of chronic eating disorders in adults. Pediatric eating-disordered patients are not "miniature adults" who can be treated by an adult protocol or unit that does not address their developmentally specific needs. With appropriate evaluation and treatment, eating disorders can be stopped in childhood.

The transition from good to poor health: an econometric study of the older population.

This is a study of the influence of socioeconomic factors on the state of health of older Canadians. Three years of panel data from the Survey of Labour and Income Dynamics are used to model the transition probabilities between good and poor health. Care is taken to avoid the problem of endogeneity of income in modelling its effects, and to adjust reported income to free it from its strong association with age at the time of the survey. Of particular note are the significant effects found for income, in spite of universal public health care coverage. Significant effects are found also for age, education, and other variables.

Performance-based assessment of clinical ethics using an objective structured clinical examination.

PURPOSE: To further examine the objective structured clinical examination (OSCE) as a performance-based assessment method for clinical ethics. METHOD: In the spring of 1993, a volunteer sample of 88 final-year medical students from all five Ontario medical schools took a four-station OSCE that used standardized patients and involved decisions to forego life-sustaining treatment. Performance was scored on a checklist of behaviors unique to each case. Data were analyzed for reliability using intraclass correlation coefficients and the Spearman-Brown prophecy formula. RESULTS: Reliability of the test was only .28 as a result of a low average inter-station correlation of .07. To achieve a test reliability of .8, 41 stations (almost seven hours of testing time) would be required. CONCLUSION: Because of its low test reliability, the OSCE is not a feasible stand-alone method for summative evaluation of clinical ethics. This performance-based evaluation method should be combined with other, more reliable evaluation methods. The OSCE has promise for formative evaluation.

Case study. Risperidone-Induced neuroleptic malignant syndrome in an adolescent.

Neuroleptic malignant syndrome (NMS) is a potentially fatal complication of neuroleptic therapy, characterized by fever, rigidity, mental status changes, and autonomic instability. Although NMS was previously associated with the use of high-potency neuroleptics, cases have begun to emerge with atypical neuroleptics. This article presents a risperidone-induced case in the youngest patient to date, raising issues concerning our perceptions, the safety of newer neuroleptics, and treatment of NMS.

Automated system for measuring air-exchange rate and radon concentration in houses.

We have developed an automated system for continuously measuring the air-exchange rate and 222Rn (radon) concentration in an occupied residence. The air-exchange rate is measured over 90-min intervals by tracer gas decay using sulfur hexafluoride as the tracer gas. The radon concentration is measured over 3-hr intervals using a flow-through scintillation cell. Temperatures at up to seven points are measured every half hour. A microcomputer system controls the measurements, performs preliminary data analysis, and logs the data and the results. Continuous measurement of ventilation rate and radon concentration permits the effective radon source magnitude to be calculated as a function of time. The first field application of this system was a study in Rochester, NY, of residential air-exchange rates and indoor air quality. For the 8 houses monitored, the mean values over 4- to 14-day periods ranged from less than 0.2 to 2.2 pCi l-1 for radon, from 0.22 to 1.16 hr-1 for air-exchange rate and from less than 0.05 to 0.75 pCi l-1 hr-1 for radon source magnitude.

The use of childhood injury surveillance within a general accident and emergency department.

The prevention of accidental injury is a government priority in the United Kingdom. Following the recent Government White Paper, towards a Healthier Scotland (Scottish Office 1999), the issue of poverty and inequalities in health has come to prominence. This study, at Glasgow Royal Infirmary, looked at the socio-economic context of injuries and aimed to identify if there was a relationship between the frequency of injuries and the deprivation status of the patient. This paper examines one method of data collection, the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) which is currently being used at the local children's hospital. The practical difficulties of collecting this data within a busy, general Accident and Emergency (A&E) department are examined. The questionnaire uses narrative and sequence text to provide descriptive information relating to the injury and the events leading up to it. Findings demonstrated that a large percentage of children's injuries were treated at the child's local general hospital. Differences between the two hospitals were also found relating to the children's ages and where the injuries took place. Results also showed that the socio-economic distribution of childhood accidents is still a major problem in this city. Therefore, this study recommends that injury data should be collected at all A&E departments to establish an accurate picture of the pattern of injuries within the city.

The economic legacy of divorce and separation for women in old age.

Although progress has been made over the last 20 years, the burden of a low income in old age is still carried by unattached women. Few researchers, however, have examined exactly where the burden of poverty falls within the category of unattached older women or what the nature of this poverty is. Like any other group of older Canadians, unattached women are not a homogeneous population. The category of unattached includes the separated, divorced, widowed, and ever single, all of whom face different circumstances in old age because of differences over the life course. Using Survey of Labour and Income Dynamics (SLID) data, we examine income and sources of income from 1993 to 1999 to identify differences among these groups. The findings indicate that the separated and divorced are the poorest of all older unattached women in Canada. A key source of the difference is the differential growth in private pension incomes.

Healthy aging at older ages: are income and education important?

Being higher on the socio-economic scale is correlated with being in better health, but is there is a causal relationship? Using 3 years of longitudinal data for individuals aged 50 and older from the Canadian Survey of Labour and Income Dynamics, we study the health transitions for those who were in good health in the first year, focusing especially on income and education. The initial good health restriction removes from the sample those whose incomes may have been affected by a previous history of poor health, thus avoiding a well-known problem of econometric endogeneity. We then ask, for those in good health, whether later transitions in health status are related to socio-economic status. We find that they are-that changes in health status over the subsequent 2 years are related, in particular, to income and education.

Role of the nurse: introducing theories and concepts.

This article is a descriptive analysis of the work of nurse theorists in relation to the role of the nurse. It is clear from the literature that nursing is difficult to define but it is possible to identify the core values of nursing and the commonalities that run through the profession. The core components identified by an examination of the literature are the development of systems for the delivery of care, coordinating care, teaching, defending the frail and vulnerable, caring for the ill and the well, and providing technical care. This article aims to provide a baseline picture of what nursing is and how it is described in nursing models allowing readers to examine and compare their own values and image of nursing with what the theorists have written.

Clarifying outcomes in clinical practice.

The word 'outcome' is very much in vogue within today's healthcare system, yet its meaning varies between different levels of service, occupational groups and care environments. Using practical examples, this article aims to clarify the concept of outcome, and to explore some of the issues surrounding its use.