Real-time identification of Pseudomonas aeruginosa direct from clinical samples using a rapid extraction method and polymerase chain reaction (PCR).

Pseudomonas aeruginosa has emerged as one of the most problematic Gram-negative nosocomial pathogens. Bacteremia caused by P. aeruginosa is clinically indistinguishable from other Gram-negative infections although the mortality rate is higher. This microorganism is also inherently resistant to common antibiotics. Standard bacterial identification and susceptibility testing is normally a 48-hour process and difficulty sometimes exists in rapidly and accurately identifying antimicrobial resistance. The Polymerase Chain Reaction (PCR) is a rapid and simple process for the amplification of target DNA sequences. However, many sample preparation methods are unsuitable for the clinical laboratory because they are not cost effective, take too long to perform, or do not provide a good template for PCR. Our goal was to provide same-day results to facilitate rapid diagnosis. In this report, we have utilized our rapid DNA extraction method to generate bacterial DNA direct from clinical samples for PCR. The lower detection level for P. aeruginosa was estimated to be 10 CFU/ml. In addition, we wanted to compare the results of a new rapid-cycle DNA thermocycler that uses continuous fluorescence monitoring with the results of standard thermocycling. We tested 40 clinical isolates of P. aeruginosa and 18 non-P. aeruginosa isolates received in a blinded fashion. Coded data revealed that there was 100% correlation in both the rapid-cycle DNA thermocycling and standard thermocycling when compared to standard clinical laboratory results. In addition, total results turn-around time was less than 1 hour. Specific identification of P. aeruginosa was determined using intragenic primer sets for bacterial 16S rRNA and Pseudomonas outer-membrane lipoprotein gene sequences. The total cost of our extraction method and PCR was $2.22 per sample. The accuracy and rapidness of this DNA-extraction method, with its PCR-based identification system, make it an ideal candidate for use in the clinical laboratory.

Rapid extraction from and direct identification in clinical samples of methicillin-resistant staphylococci using the PCR.

Methicillin-resistant staphylococci (MRS) are one of the most common causes of nosocomial infections and bacteremia. Standard bacterial identification and susceptibility testing frequently require as long as 72 h to report results, and there may be difficulty in rapidly and accurately identifying methicillin resistance. The use of the PCR is a rapid and simple process for the amplification of target DNA sequences, which can be used to identify and test bacteria for antimicrobial resistance. However, many sample preparation methods are unsuitable for PCR utilization in the clinical laboratory because they either are not cost-effective, take too long to perform, or do not provide a satisfactory DNA template for PCR. Our goal was to provide same-day results to facilitate rapid diagnosis and therapy. In this report, we describe a rapid method for extraction of bacterial DNA directly from blood culture bottles that gave quality DNA for PCR in as little as 20 min. We compared this extraction method to the standard QIAGEN method for turnaround time (TAT), cost, purity, and use of template in PCR. Specific identification of MRS was determined using intragenic primer sets for bacterial and Staphylococcus 16S rRNA and mecA gene sequences. The PCR primer sets were validated with 416 isolates of staphylococci, including methicillin-resistant Staphylococcus aureus (n = 106), methicillin-sensitive S. aureus (n = 134), and coagulase-negative Staphylococcus (n = 176). The total supply cost of our extraction method and PCR was $2.15 per sample with a result TAT of less than 4 h. The methods described herein represent a rapid and accurate DNA extraction and PCR-based identification system, which makes the system an ideal candidate for use under austere field conditions and one that may have utility in the clinical laboratory.

Reproductive physician-scientists for the twenty-first century.

As we enter a new century, departments of obstetrics and gynecology in American medical schools face a number of challenges. A primary concern is the relative dearth of physician-scientists to explore basic mechanisms of cell function and relate these to the diseases of women. The question arises, what can we do to revitalize the spirit of investigation in many of our academic departments? This report reviews three programs designed to develop academic investigators: the Reproductive Scientist Development Program, the American Gynecological and Obstetrical Society/American Association of Obstetricians and Gynecologists Foundation Fellowship Program, and the Women's Reproductive Health Research Career Development Centers. On the basis of a decade of experience with the first two of these programs, the prospects for the third are promising. Clearly, the opportunities for obstetrician-gynecologist basic and clinical scientists are considerable. The question remains: Will leaders in the specialty work together to meet the challenge?

Is the academic physician-scientist an oxymoron in contemporary obstetrics and gynecology?

Because of changes in health care reimbursement and decreasing federal funding, academic obstetrics and gynecology is at a pivotal point. Either the discipline can regress to the past, when the field and its practitioners were viewed negatively and failed to attract the academic upper echelons of medical students, or it can build on the immense gains it has made in recent years and develop a critical cadre of well-trained clinician-scientists who maintain the discipline at the leading edge of medicine and biology. Data from two programs in which extensive contemporary training in biomedical research is provided, the Reproductive Scientist Development Program and the American Association of Obstetricians and Gynecologists Foundation fellowship program, indicate that the superb physician-scientists in these programs are obtaining peer-reviewed funding in excess of 70%. Thus the risk of recruiting such individuals to academic faculties is small. More important, these individuals are the linchpins for an even more exciting future. The alternatives are unthinkable.

Multigate spectral Doppler velocimetry for fast assessment of intraplacental fetal circulation: a preliminary study.

The aim of this preliminary study was to investigate the assessment of the intraplacental fetal circulation with a new multigate Doppler system. Doppler velocimetry of the umbilical artery is widely used for assessment of fetal well-being, but its sensitivity is too low for prediction and early detection of pathologic placental processes. Intraplacental velocimetry is more accurate and detects pathologic conditions of the placenta earlier. Color Doppler imaging of intraplacental circulations is a difficult process, and the multigate system was developed to enhance the assessment of intraplacental circulation. This study shows that the multigate system is accurate and is a successful means of fast evaluation of the intraplacental circulation.

Prenatal sonographic assessment of early, rapidly growing fetal cervical teratoma.

Although malignant transformation of fetal cervical teratoma is extremely rare, perinatal morbidity is high and usually related to the size of the tumour, which may compromise fetal swallowing and subsequently lead to upper airway obstruction. We present a case in which mid-trimester serial sonography demonstrated markedly rapid early growth of a lesion of this type between 17 and 19 weeks' gestation indicating the aggressive nature of this tumour, assisting parental decision to terminate the pregnancy. Histopathology confirmed grade 3 immaturity of the lesion.

Color Doppler imaging and in vivo assessment of the anatomy and physiology of the early uteroplacental circulation.

OBJECTIVE: To evaluate in vivo the anatomy and physiology of the normal early uteroplacental circulation. DESIGN: Forty-six women were included, all of whom continued their pregnancy into the second trimester. Color Doppler was used to identify peritrophoblastic flow, and spectral Doppler was used to analyze waveforms obtained from the different segments of the uteroplacental circulation. RESULTS: Flow was detected in the spiral arteries of the peritrophoblastic region in all patients. Flow was detected within the intervillous space in only one case. CONCLUSIONS: This study demonstrated that color Doppler imaging can be employed as an in vivo means of studying the uteroplacental circulation. The study confirmed the in vitro findings that trophoblastic invasion of the decidual spiral arteries occurs at 5 to 6 weeks' gestation. The study also confirmed the fact that there is no noticeable blood flow within the intervillous space during most of the first trimester of a normal pregnancy. Both of these findings may serve to protect the early gestation from the forces of arterial blood flow.

Sonographic measurement of the fetal iliac bone: growth and relation to femur length in assessment of gestational age.

Diagnostic ultrasonography has given us the opportunity to diagnose several congenital malformations in utero. Skeletal dysplasias is a heterogeneous group of disorders of the skeleton. Although disorders of bone growth are often diagnosed in utero, it is usually a general diagnosis because the exact syndrome cannot be specified. This is due to the fact that many anomalies of the skeleton have similar features. The wing of the iliac bone can be either affected or normal in skeletal dysplasias and its appearance may help in the differential diagnosis. This study was undertaken to establish values for the width of the iliac bone wing during normal gestations and thus enable us to use it in the evaluation of fetal growth and the recognition of specific congenital anomalies.

Color Doppler imaging in the assessment of uteroplacental blood flow in abnormal first trimester intrauterine pregnancies. An attempt to define etiologic mechanisms.

The addition of color Doppler imaging (CDI) to the vaginal probe now enables sonographers to study more accurately the maternal-fetal circulation at the early stages of the gestation. Doppler studies of normal intrauterine first trimester gestations have been published, and our investigation was an attempt to study uteroplacental blood flow in abnormal intrauterine first trimester gestations. Although the calculated indices did not differ significantly from those found in normal gestations, we did find a higher rate of color detection in gestations defined as anembryonic as compared to those defined as missed abortions. Circulation abnormalities probably play a significant role in early pregnancy failures, and we believe CDI will help define the different etiologic mechanisms causing these early complications.

Transvaginal color Doppler imaging in the assessment of uteroplacental blood flow in the normal first-trimester pregnancy.

Characteristic changes of low resistance and high diastolic blood flow velocity were identified by Doppler studies starting in the early phase of the second trimester. These changes were attributed by some authors to trophoblastic invasion of the uterine vasculature converting the uterus into a low-resistance organ. Because of technical limitations previous studies were confined to the uterine artery and its main branches. With the development of color Doppler and transvaginal ultrasonography we can now identify blood flow in various small vessels in the placental bed. This study was performed to assess the ability of color Doppler ultrasonography to evaluate subtrophoblastic blood flow by color identification in the early phase of normal pregnancy from 5 to 9 weeks' gestation. Results show that the characteristic increase in diastolic blood flow is evident as early as 5 weeks' gestation.

An Assessment of Psychiatric Residents' Knowledge and Attitudes Regarding ECT.

Graduating psychiatric residents in the Philadelphia area were surveyed about their attitudes, training experiences, and knowledge regarding electroconvulsive therapy (ECT). Twenty-nine residents were interviewed. Although the majority of respondents expressed positive attitudes about the use of ECT, only two (7%) expressed confidence in their own ability to perform the treatment without supervision. The residents' general attitudes regarding ECT as a therapeutic modality were consistent with those of previous surveys of practicing psychiatrists. The level of knowledge of the residents interviewed was not related to reported didactic or practical experience. Significant gaps in training were noted. The need for more thorough, standardized training in ECT is discussed.

Quantitative assessment of the ontogeny of met-enkephalin, norepinephrine and epinephrine in the human fetal adrenal medulla.

The catecholamine producing cells of the adrenal medulla of fetal as well as adult mammals contain enkephalins. We have quantified met-enkephalin and the catecholamines, norepinephrine and epinephrine, in human fetal adrenal glands during the late first trimester and throughout the second trimester of intrauterine life. Met-enkephalin (ME) was detectable in human fetal adrenals of 11 to 25 weeks' gestation by RIA. ME concentrations were low through 14 weeks (mean 279 +/- 199 pg/gland), higher but extremely variable from 15 to 20 weeks (mean 1100 +/- 1000 pg/gland), and then lower with somewhat less variation through 25 weeks (mean 865 +/- 625 pg/gland). In contrast, catecholamine concentrations were below 1100 ng/gland through 16 weeks, then increased markedly by 21 weeks. Approximately equal concentrations of norepinephrine and epinephrine were measured throughout the gestational age period studied. Our data demonstrate that enkephalin is present in the human fetal adrenal at least by 11 weeks' gestation and suggest that the fetal adrenal may be capable of secreting enkephalins as well as catecholamines. The functional significance of adrenal enkephalin secretion remains to be elucidated.

Use of an agonistic analog of gonadotropin-releasing hormone (nafarelin) to treat leiomyomas: assessment by magnetic resonance imaging.

The purposes of this study were to investigate the effect of a superactive agonistic analog of gonadotropin-releasing hormone, nafarelin, on uterine leiomyomas and to assess the use of magnetic resonance imaging in monitoring uterine and myoma size. Eleven women with uterine leiomyomas were treated with 800 micrograms of nafarelin per day for 6 months. Serum gonadotropin and estradiol concentrations were suppressed during treatment. The mean +/- SEM serum luteinizing hormone level decreased from 11.1 +/- 1.4 to 5.6 +/- 0.42 mlU/ml and follicle-stimulating hormone from 9.5 +/- 0.66 to 7.5 +/- 0.72 mlU/ml by 3 months of treatment (p less than 0.01). The estradiol level decreased from a pretreatment follicular phase mean +/- SEM of 43 +/- 8.3 to 19.8 +/- 3.1 (p less than 0.05) and 14.8 +/- 2.2 pg/ml (p less than 0.01) at 3 and 6 months of treatment, respectively. Mean pretreatment androgen levels (testosterone, androstenedione, and dehydroepiandrosterone sulfate) were low in these women and did not change significantly during treatment. Ten women had magnetic resonance imaging, which provided excellent resolution of individual uterine myomas. As assessed by magnetic resonance imaging, the largest myoma decreased in size in nine of 10 women; the mean decrease was 46% +/- 9%. Uterine volume decreased in all 10 patients; the mean decrease was 57% +/- 7%. In several women myomas reenlarged after discontinuance of nafarelin treatment. Posttreatment myomectomy was carried out in four women; there was minimal blood loss and no surgical complications. These data indicate that suppression of ovarian estrogen production with nafarelin is associated with a decrease in uterine myoma size in many women but that myomas may regrow with reinstitution of ovarian function. Magnetic resonance imaging is an excellent method by which to monitor treatment as changes in the size of the uterus, as well as individual myomas, can be assessed. The optimal use of gonadotropin-releasing hormone analogs may be in perimenopausal women or as presurgical treatment to decrease uterine and myoma size to facilitate myomectomy.

Use of claims data systems to evaluate health care outcomes. Mortality and reoperation following prostatectomy.

Data maintained by medical insurance plans can be used to evaluate the incidence of death and nonfatal complications following medical care, to test hypotheses about the outcomes of care, and to identify hospitals with unusually high or low death rates. These uses are illustrated for prostatectomy, utilizing claims data from the Maine Medicare and Manitoba Health Services Commission files. The study shows important differences in death rates between individual hospitals and higher cumulative probability of reoperation following transurethral compared with open prostatectomy. The advantages of claims data are low cost, ease of patient follow-up over long periods, and the absence of reporting bias. The limitations are the adequacy of the data used to control for patient comorbidity and the lack of outcome information on functional status. The effective use of claims data for monitoring requires the active participation of physicians in improving the data base and interpreting the findings.

Flexible fiberoptic sigmoidoscopy in family medicine.

Flexible fiberoptic sigmoidoscopy is easily mastered by family physicians. Self-study, along with a minimal amount of supervision, seems to provide adequate training. Patient preparation is essential and is best accomplished with enemas "until clear" rather than with the standard two enemas. Patients prefer the flexible sigmoidoscope to the rigid instrument, and the greater depth of penetration achieved with the former--even with the 35-cm sigmoidoscope--enables the physician to detect significantly more pathologic lesions.