Measuring laboratory-based influenza surveillance capacity: development of the 'International Influenza Laboratory Capacity Review' Tool.

OBJECTIVES: The 2005 International Health Regulations (IHR 2005) emphasized the importance of laboratory capacity to detect emerging diseases including novel influenza viruses. To support IHR 2005 requirements and the need to enhance influenza laboratory surveillance capacity, the Association of Public Health Laboratories (APHL) and the Centers for Disease Control and Prevention (CDC) Influenza Division developed the International Influenza Laboratory Capacity Review (Tool). STUDY DESIGN: Data from 37 assessments were reviewed and analyzed to verify that the quantitative analysis results accurately depicted a laboratory's capacity and capabilities. METHODS: Subject matter experts in influenza and laboratory practice used an iterative approach to develop the Tool incorporating feedback and lessons learnt through piloting and implementation. To systematically analyze assessment data, a quantitative framework for analysis was added to the Tool. RESULTS: The review indicated that changes in scores consistently reflected enhanced or decreased capacity. The review process also validated the utility of adding a quantitative analysis component to the assessments and the benefit of establishing a baseline from which to compare future assessments in a standardized way. CONCLUSIONS: Use of the Tool has provided APHL, CDC and each assessed laboratory with a standardized analysis of the laboratory's capacity. The information generated is used to improve laboratory systems for laboratory testing and enhance influenza surveillance globally. We describe the development of the Tool and lessons learnt.

Community-onset Staphylococcus aureus infections presenting to general practices in South-eastern Australia.

Community-acquired Staphylococcus aureus infections are a public health concern, yet little is known about infections that do not present to hospital. We identified community-onset S. aureus infections via specimens submitted to a community-based pathology service. Referring doctors confirmed eligibility and described infection site, severity and treatment. Isolates were characterized on antibiotic resistance, PFGE, MLST/SCCmec, and Panton-Valentine leukocidin (PVL), representing 106 community-onset infections; 34 non-multiresistant methicillin-resistant S. aureus (nmMRSA) (resistant to <3 non-ß-lactam antibiotics), 15 multiply antibiotic-resistant MRSA (mMRSA) and 57 methicillin-sensitive S. aureus (MSSA). Most (93%) were skin and soft tissue infections. PVL genes were carried by 42% of nmMRSA isolates [95% confidence interval (CI) 26-61] and 15% of MSSA (95% CI 8-28). PVL was associated with infections of the trunk, head or neck (56·4% vs. 24·3%, P=0·005) in younger patients (23 vs. 52 years, P<0·001), and with boils or abscesses (OR 8·67, 95% CI 2·9-26·2), suggesting underlying differences in exposure and/or pathogenesis.

Pseudomonas aeruginosa bacteremia over a 10-year period: multidrug resistance and outcomes in transplant recipients.

AIM: Transplant recipients are at risk for hospital-acquired infections (HAIs), including those caused by Pseudomonas aeruginosa. Of all HAIs, bloodstream infection (BSI) remains one of the most life-threatening. METHODS: Over a 10-year period, we studied 503 patients, including 149 transplant recipients, with pseudomonal BSI from the University of Pittsburgh Medical Center. Trends in antimicrobial susceptibility, risk factors for multidrug resistance (MDR), and outcomes were compared between transplant and non-transplant patients. RESULTS: Resistance to all antibiotic classes was significantly greater in pseudomonal blood culture isolates from transplant compared with non-transplant patients (P<0.001). Of isolates from transplant recipients (n=207), 43% were MDR, compared with 18% of isolates from non-transplant patients (n=391) (odds ratio [OR] 3.47; 95% confidence interval [CI] 2.34-5.14, P<0.001). Among all patients, independent risk factors for MDR P. aeruginosa BSI included previous transplantation (OR 2.38; 95% CI 1.51-3.76, P<0.001), hospital-acquired BSI (OR 2.41; 95% CI 1.39-4.18, P=0.002), and prior intensive care unit (ICU) admission (OR 2.04; 95% CI 1.15-3.63, P=0.015). Mortality among transplant recipients was 42%, compared with 32% in non-transplant patients (OR 1.55; 95% CI 0.87-2.76, P=0.108). For transplant recipients, onset of BSI in the ICU was the only independent predictor of mortality (OR 8.00; 95% CI 1.71-37.42, P=0.008). CONCLUSIONS: Transplant recipients are at greater risk of MDR P. aeruginosa BSI, with an appreciable mortality. Future management must concentrate on the implementation of effective preventative strategies.

Significant photoreceptor rescue by treatment with a combination of antioxidants in an animal model for retinal degeneration.

The purpose of this study was to investigate the presence of oxidative DNA damage in the photoreceptors of the rd1 mouse, an animal model for retinitis pigmentosa, and to determine if antioxidants could delay the progress of photoreceptor cell death. Retinas of rd1 mice and congenic wild type controls were examined for DNA oxidation and fragmentation. To study the rescue effect of antioxidants on retinal degeneration, rd1 retinas were studied in vitro and in vivo using lutein, zeaxanthin, alpha lipoic acid and reduced l-glutathione. For the in vitro studies, antioxidants were added to the culture medium. For the in vivo studies, postnatal day (PN3) pups of rd1 mice were fed antioxidants either individually or in combination and control rd1 animals received vehicle alone. Histological evaluation was performed using hematoxylin/eosin and avidin staining, as well as terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay. Many of the rd1 rod photoreceptors at PN11 displayed oxidative DNA damage and TUNEL positive reaction which co-localized in a subset of rod photoreceptors. Avidin-labeled rod photoreceptors were more abundant than the TUNEL positive photoreceptors of the rd1 mouse, indicating that oxidative DNA damage precedes fragmentation. The number of TUNEL positive and avidin positive cells was considerably decreased upon treatment with the combination of the antioxidants. Rescue of rd1 photoreceptors was significant at PN18 and PN17, respectively, in the in vitro and in vivo studies. In conclusion individual antioxidants had no significant rescue effect but the combination slowed down the rd1 rod photoreceptor degeneration, indicating an additive or synergistic effect.

Modelling drivers and distribution of lead and zinc concentrations in soils of an urban catchment (Sydney estuary, Australia).

The human population is increasing globally and land use is changing to accommodate for this growth. Soils within urban areas require closer attention as the higher population density increases the chance of human exposure to urban contaminants. One such example of an urban area undergoing an increase in population density is Sydney, Australia. The city also possesses a notable history of intense industrial activity. By integrating multiple soil surveys and covariates into a linear mixed model, it was possible to determine the main drivers and map the distribution of lead and zinc concentrations within the Sydney estuary catchment. The main drivers as derived from the model included elevation, distance to main roads, main road type, soil landscape, population density (lead only) and land use (zinc only). Lead concentrations predicted using the model exceeded the established guideline value of 300mgkg-1 over a large portion of the study area with concentrations exceeding 1000mgkg-1 in the south of the catchment. Predicted zinc did not exceed the established guideline value of 7400mgkg-1; however concentrations were higher to the south and west of the study area. Unlike many other studies we considered the prediction uncertainty when assessing the contamination risk. Although the predictions indicate contamination over a large area, the broadness of the prediction intervals suggests that in many of these areas we cannot be sure that the site is contaminated. More samples are required to determine the contaminant distribution with greater precision, especially in residential areas where contamination was highest. Managing sources and addressing areas of elevated lead and zinc concentrations in urban areas has the potential to reduce the impact of past human activities and improve the urban environment of the future.

Vocal responses to left visual stimuli following forebrain commissurotomy.

Four forebrain commissurotomized patients, 12-15 yr post-surgery, along with one partially commissurotomized and three normal control subjects, were presented with a variety of stimuli to either the LVF (left visual field) or RVF. Three of four "split-brain" patients could name LVF numbers and two of four could name LVF letters. Irrespective of their accuracy, and unlike control subjects, all "split-brain" patients named LVF stimuli about twice as slowly as RVF stimuli. In addition, three of four patients could vocally categorize LVF stimuli into two classes (yes-no, odd-even, more or less than five). In this case, like the control subjects, they respond to LVG stimuli as quickly as to RVF stimuli. The results support an hypothesis that "split-brain" patients may transfer information from the right to the left cerebral hemisphere when making two-choice verbal categorizations of LVF stimuli, but are able to name some simple LVF stimuli directly from the right hemisphere. Combining categorization and naming tasks, however, can elicit interference, suggesting that the two tasks are not completely autonomous.

Bilateral visual cross-integration by human forebrain commissurotomy subjects.

Four forebrain commissurotomized patients were compared with one partially commissurotomized control subjects on their ability to cross-compare simultaneously flashed bilateral visual stimuli (colors, schematic faces, numbers, letters, patterns) as same or different, or to name the two stimuli. Two of the four patients were able to cross-compare some or all of the stimuli verbally, while another patient could name the two stimuli but not separately determine same-difference. It is hypothesized that (1) each cerebral hemisphere is capable of making separate verbal naming responses, and (2) brainstem interconnections between the 'disconnected' hemispheres allow some patients to integrate bilateral visual stimuli and make accurate same-different judgments.

Influenza A virus outbreak in a neonatal intensive care unit.

BACKGROUND: Nosocomial infections with influenza virus are rarely recognized in neonatal intensive care units (NICU). An outbreak of influenza A virus infection in the NICU of an urban county hospital during the 1997 to 1998 influenza season is reported. METHODS: Clinical and virologic data were recorded in all symptomatic NICU patients after influenza A infection was diagnosed in one infant in October, 1997. RESULTS: Influenza A/H3N2 was isolated from two of four symptomatic infants. The application of rapid diagnostic techniques for the characterization of influenza virus infection allowed the timely institution of basic infection control measures, limiting this outbreak. Resistance to amantadine was documented for the first time in this patient population by reverse transcription-PCR within 48 h of treatment in one case. CONCLUSIONS: Prevention by immunization is a priority in those caring for high risk NICU patients.

Oral nutritional supplement use in elderly nursing home patients.

OBJECTIVES: To determine why elderly nursing home patients receive liquid oral protein supplements, what nutritional assessment is utilized, and whether there is evidence of effectiveness. DESIGN: Retrospective, case control study comparing patients over 65 years of age, at two nursing homes, who were served oral supplements (OS) at least twice daily (n = 56), with a random sample of non-supplemented, non-tube fed patients (n = 53). Comparisons included medical diagnoses, medications, morbidity and mortality, weight changes, laboratory test results, and functional and behavioral status. RESULTS: Nursing home patients were begun on OS (median time after admission = 2 months, range = 0-72 months) primarily because of weight loss (71%) and poor appetite (16%). Supplemented patients were below an age-adjusted body weight on admission, unlike controls, and continued to lose weight until OS were started. On OS, weight was slowly regained over 9-10 months in a majority of patients to approximate admission weight. Some patients on OS showed improvement in albumin, total lymphocyte count, cholesterol, or hemoglobin, but too few patients had sufficient lab tests to verify any consistent effect. Mortality was higher in OS patients (8 vs 2, P = 0.057), who were also somewhat older (87.9 vs 84.5 years), but there was no statistical difference in infection or hospitalization rate. MEASUREMENTS: Nutritional assessment in these nursing homes consisted almost exclusively of (1) serial measurement of weight, (2) comparison of weight to (a) "ideal body weight" and (b) previous weight, and (3) a subjective evaluation of food consumption. No other anthropometric evaluations or laboratory tests were conducted for nutritional assessment. CONCLUSIONS: The diagnosis of and intervention in under-nutrition in nursing home patients is frequently disorganized. In addition, nutritional assessment, either for screening or for following intervention, is hampered by the lack of convenient and unambiguous assessment tools. OS use is associated with weight gain in many nursing home patients and also improves other nutritional parameters in selected individuals.

The incidence of attempted CPR in nursing homes.

We studied the frequency with which cardiopulmonary resuscitation (CPR) is attempted on residents of American nursing homes. Each author (all members of the Clinical Practice Committee of the American Geriatrics Society) completed a questionnaire in 1989 about policy and practice regarding CPR during 1988 in each of three to seven nursing homes, by questioning the medical or nursing director or the administrator. Because of the vagaries of nursing home record-keeping, data from some homes were allowed when they were "accurate to within 10%." Data from 58 nursing homes, totalling 10,836 bed-years were available. In 33 of these homes, accounting for 5,425 bed-years, CPR was never attempted. CPR was more likely to be foregone in nursing homes with religious affiliation than in nursing homes without (13 of 17 vs 18 of 38; chi 2 = 4.0; P less than 0.05). Religious affiliation was unknown for three nursing homes. Academic affiliation (10 of 16 vs 20 of 37 in non-affiliated nursing homes) and non-profit status (14 of 19 vs 16 of 23 in for-profit nursing homes) did not significantly affect the likelihood that CPR would never be used. In 31 of 54 nursing homes with explicit do not resuscitate (DNR) policies, CPR was never performed, compared to 2 of 4 homes without such policies. For nursing homes with complete data, there were 1,196 deaths in 32 facilities where CPR was never attempted compared to 1,294 deaths for 24 nursing homes with CPR. For 22 nursing homes without CPR, there were 2,172 emergency room transfers compared to 1,363 emergency room transfers in 18 nursing homes where CPR was attempted.(ABSTRACT TRUNCATED AT 250 WORDS)

Neurohumoral and cardiopulmonary response to sustained submaximal exercise in the dog.

Neurohumoral, cardiovascular, and respiratory parameters were evaluated during sustained submaximal exercise (3.2 km/h, 15 degrees elevation) in normal adult mongrel dogs. At the level of activity achieved (fivefold elevation of total body O2 consumption and threefold elevation of cardiac output), significant (P less than 0.05) increases in plasma norepinephrine and epinephrine concentration (from 150 +/- 23 to 341 +/- 35 and from 127 +/- 27 to 222 +/- 31 pg/ml, respectively) were present, as well as smaller but significant increases in plasma renin activity and plasma aldosterone concentration (from 2.2 +/- 0.3 to 3.1 +/- 0.6 ng X ml-1 X h-1 and from 98 +/- 8 to 130 +/- 6 pg/ml, respectively). Plasma arginine vasopressin increased variably and insignificantly. The cardiovascular response (heart rate, systemic arterial and pulmonary arterial pressures, left ventricular filling pressure, and calculated total peripheral and pulmonary arteriolar resistance) closely paralleled that of human subjects. Increased hemoglobin concentration was induced by exercise in the dogs. The ventilatory response of the animals was characterized by respiratory alkalosis. These data suggest similarities between canine and human subjects in norepinephrine, plasma renin activity, and plasma aldosterone responses to submaximal exercise. Apparent species differences during submaximal exertion include greater alterations of plasma epinephrine concentration and a respiratory alkalosis in dogs.

Anorexia nervosa and bulimia in female adolescents with insulin dependent diabetes mellitus: a systematic study.

An unselected sample of 46 female adolescents with insulin-dependent diabetes mellitus (IDDM) for more than one year were assessed systematically for the presence of anorexia nervosa and bulimia. These disorders and their partial syndromes were found in 19.5% of this population. Anorexia nervosa and bulimia diagnosed on the basis of DSM-III criteria were each found in 6.5% of the population representing approximately a 6-fold and 2-fold increase respectively in the expected prevalence for similar nondiabetic individuals. Bulimic symptoms were associated with poor metabolic control as reflected in blood levels of glycosylated hemoglobin (HbAl). These findings have important implications both for the pathogenesis of anorexia nervosa and bulimia and for the management of some cases of IDDM with unstable metabolic control.

Right parasternal imaging: an underutilized echocardiographic technique.

If the echocardiographer uses only standard imaging planes, he or she may fail to obtain vital information about the aorta, atrial septum, superior and inferior vena cavae, and the coronary arteries. The evaluation of caval-to-systemic venous atrial connections (Senning or Mustard) in transposition of the great arteries of systemic vena caval or right atrial-to-pulmonary anastomosis (Fontan) in tricuspid atresia and single ventricle may not be adequately seen when only the standard left parasternal, apical, subcostal, and suprasternal imaging planes are used. Therefore, the use of the right parasternal imaging plane may help to provide crucial information regarding these areas when the standard views are unable to delineate them adequately. The right parasternal window is an additional echocardiographic window that should become part of a complete echocardiographic examination.

Hospital admission for xanthine toxicity.

A follow-up study of 35,909 outpatients who filled more than 220,000 prescriptions for theophylline over 9 years revealed 30 hospitalizations for xanthine toxicity. The overall estimated incidence rate of 7.8/10,000 person-years at risk indicates that in this population, hospitalization for xanthine toxicity is a relatively rare event.

Filicidal behavior: behavioral correlates and role of sensory systems.

The administration of para-chloro-D,L-phenylalanine (PCPA) produces a high incidence of filicidal (pup-killing) behavior in female rodents. The present series of experiments determined the major behavioral, sensory, and temporal correlates of filicidal behavior in nulliparous adult Sprague-Dawley female rats. In Experiment 1, behavioral episodes involving the interaction of test pups and PCPA-induced filicidal females were videotaped, and subsequent analyses of behaviors related to locating, carrying, mauling, attacking, gnawing, and consuming the prey object were performed. Analysis indicated that the primary behavioral correlates in the PCPA animals included location, initiation of the attack (mauling), and killing of the pup (filicide). Only location was observed in control animals. Experiment 2 evaluated the effects of sensory impairments on location, mauling, and filicide. Sensory impairment occurred at 24 days of age for enucleation and 62 days of age for olfactory bulbectomies and/or auditory destruction. Animals were injected either at 110 or 130 days of age with PCPA for three consecutive days and tested for filicide for five additional days. Locating of the test pup was not affected by sensory impairment. Mauling was reduced significantly in the enucleation/auditory destructed animals. Filicide was significantly lower in animals with visual/auditory destruction, and, compared to controls, was reduced in all sensory impaired groups.

A new metabolite from Streptomyces hygroscopicus I. Fermentation and isolation.

A deoxypentulose has been isolated from the fermentations of a new soil isolate of Streptomyces hygroscopicus (UC-5601). It was found to inhibit weakly and specifically the growth of one strain of Mycobacterium avium (UC-159).

The GAIN (Geriatric Anorexia Nutrition) registry: the impact of appetite and weight on mortality in a long-term care population.

PURPOSE: To investigate nursing home residents at high nutritional risk to determine: 1) which baseline nutrition or health status indicators correlated with subsequent weight gain or appetite improvement; and, 2) whether a continued weight loss correlated with higher mortality. METHODS: At study entry, nutritional, health status, and demographic data were extracted from the nursing home chart or the MDS. Each subject was tracked for 6 months with survival, weight gain of 5%, and appetite improvement the primary outcome measures. RESULTS: During the 6-month study, younger age was the strongest correlate of appetite improvement. The odds of gaining weight were negatively correlated with BMI, age, and feeding dependency. Subjects who were receiving appetite stimulants (orexigenics) at study entry had a 70% greater probability of gaining weight than those who were not. A weight loss during the 6-month period was associated with a nearly two-fold increase in the likelihood of dying (adjusted RR: 1.95, 95% CI 1.43 to 2.66). CONCLUSION: The course of nutritional problems within nursing homes is highly variable. Continued weight loss, however, appears to have ominous implications for mortality. Younger residents who are not dependent on others for feeding assistance, and who receive orexigenics tend to experience weight gain.

The acute hemodynamic effects of milrinone in dogs with severe idiopathic myocardial failure.

To examine the effects of acute oral milrinone administration (0.75 mg/kg) on dogs with severe idiopathic myocardial failure and the effect of prolonged milrinone administration on survival time, we measured hemodynamics before and 2 hours after drug administration and recorded survival time and cause of death in 13 dogs with dilated cardiomyopathy. Hemodynamics were measured using a Swan-Ganz catheter and femoral artery puncture along with recording an M-mode echocardiogram. Cardiac index increased from 1.92 +/- 0.54 to 3.06 +/- 0.81 L/min/m2, stroke volume index increased from 11.3 +/- 4.3 to 16.7 +/- 6.3 ml/beat/m2, and pulmonary capillary wedge pressure decreased from 23 +/- 8 to 12 +/- 8 mmHg. A clinically significant increase in heart rate was observed in seven dogs, resulting in a statistically significant increase in heart rate for the group from 174 +/- 34 to 194 +/- 44 beats/minute. Mean arterial blood pressure did not change significantly for the group but did decrease more than 20 mmHg in three dogs, suggesting a predominant primary vasodilating effect of milrinone in these dogs. An increase in contractility appeared to be the predominant reason for the improved hemodynamics in seven dogs. Eight dogs died of causes other than worsening heart failure, including four of eight Doberman pinschers that died suddenly, presumably from an acute tachyarrhythmia. Two dogs that had the greatest increase in an index of contractility are alive more than 2 years after the initiation of milrinone administration.

Submaximal exercise testing using lactate threshold and venous oxygen tension as endpoints in normal dogs and in dogs with heart failure.

Twelve normal dogs and 7 dogs with experimentally induced heart failure were chronically instrumented to measure hemodynamic variables and blood gas tensions at rest and during graded treadmill exercise. Three groups of 4 normal dogs each (group 1, 15 to 20 kg; group 2, 21 to 30 kg; group 3, 31 to 40 kg) were exercised on a treadmill at a 16% grade at 1, 2, and 3 miles per hour, and at a 22% and a 26% grade at 3 miles per hour (5 total exercise levels) until blood lactate concentration increased to a value greater than 1 mmol/L. Blood lactate concentration and blood gas tensions were measured 5 and 15 minutes after starting exercise, and cardiac output was measured between 8 and 10 minutes of exercise. Results indicated that the same exercise protocol could be used for dogs ranging in size from 15 to 40 kg. Blood lactate concentration increased in normal dogs at varying workloads, but always at or above a workload of 3 miles per hour at a 16% grade. Dogs with class IV heart failure always experienced an increase in blood lactate concentration when walked at 1 mile per hour at a 16% grade for 5 minutes. A femoral vein PO2 between 21 and 24 mm Hg in normal dogs, and between 16 and 22 mm Hg in dogs with heart failure was always associated with an increase in blood lactate concentration. The primary problem with this exercise protocol was the unwillingness of some dogs to walk on the treadmill during the preselection phase. We conclude that we have devised a submaximal exercise test that can be used to evaluate exercise capability in dogs ranging in size from 15 to 40 kg, that the described exercise protocol can be used to identify decreased flow reserve in dogs with class IV heart failure induced by rapid ventricular pacing, and that either femoral vein oxygen tension or blood lactate concentration can be used as the endpoint for submaximal exercise testing in dogs.

Homogeneous sample preparation of raw shrimp using dry ice.

Sample homogeneity is critical to accurate and reproducible analysis of trace residues in foods. A method of uniform sample preparation using dry ice is described for shrimp. Other sample preparation techniques for raw shrimp produce nonhomogeneous samples. Sample homogeneity was determined through analysis of chloramphenicol added to intact tiger or white shrimp prior to sample preparation. Simulated chloramphenicol residue levels were 50, 15, 10, and 5 ppb. No significant differences were noted when analyses of shrimp inoculated with chlor-amphenicol prior to sample preparation with dry ice were compared with analyses of shrimp spiked after grinding with dry ice. Grinding shrimp with dry ice produced samples with homogeneous chloramphenicol residues. This technique should be applicable to other tissues and vegetable products.