Aberrant right posterior sectoral duct injury necessitating liver resection.

Aberrant insertion of the right posterior sectoral duct is a particularly hazardous variation of biliary anatomy which makes it prone to injury during laparoscopic cholecystectomy. Such injuries are challenging to manage, as multiple therapeutic options are available with no clear consensus in the literature for an optimal approach. Options include conservative management, intraoperative ligation of the injured duct, Roux-en-Y reconstruction and segmental liver resection. Most cases in the literature advocate for nonoperative management or hepaticojejunostomy. We present an unusual case of aberrant right posterior sectoral duct injury in which neither of these approaches was viable, necessitating a bi-segmental liver resection.

Factors associated with risk for unprotected receptive and insertive anal intercourse in men aged 40 and older who have sex with men.

The frequency of HIV infection is increasing in men who have sex with men (MSM) aged 40 and older yet little is known about factors that influence their risky sexual behavior, such as sexual positioning. The goal of this study was to examine multi-level factors associated with unprotected receptive anal intercourse (URAI) and unprotected insertive anal intercourse (UIAI) in MSM aged 40 and older. A community-based sample of 802 self-identified MSM aged 40-94 years was recruited through targeted outreach from community venues (e.g., bars, social events) in South Florida and completed an anonymous pen-and-paper questionnaire. Logistic regression showed that younger age (i.e., aged 40-59; odds ratio [OR]=0.6; 95% confidence interval [CI]: 0.4, 0.9), HIV-positive status (OR=2.8; 95% CI: 1.9, 4.0), drug use (OR=2.6; 95% CI: 1.7, 3.7), a larger number of male sexual partners (OR=1.7; 95% CI: 1.3, 2.3), and lower scores on internalized homonegativity (OR=0.9; 95% CI: 1.0, 1.0) were associated with higher risk for URAI. Younger age (OR=0.4; 95% CI: 0.3, 0.6), HIV-positive status (OR=1.5; 95% CI: 1.0, 2.1), drug use (OR=1.6; 95% CI: 1.1, 22.3), Viagra use (OR=1.7; 95% CI: 1.2, 2.4), larger number of sexual partners (OR=2.1; 95% CI: 1.6, 2.9), and holding views more characterized by high optimism concerning the future (OR=1.1; 95% CI: 1.0, 1.1) were associated with higher risk for UIAI. These results provide useful information that may guide the development of tailored prevention interventions to reduce the growing rates of HIV among MSM aged 40 and older.

Stable isotope analysis of modern human hair collected from Asia (China, India, Mongolia, and Pakistan).

We report isotopic data (delta(2)H, delta(18)O n = 196; delta(13)C, delta(15)N n = 142; delta(34)S n = 85) from human hair and drinking water (delta(2)H, delta(18)O n = 67) collected across China, India, Mongolia, and Pakistan. Hair isotope ratios reflected the large environmental isotopic gradients and dietary differences. Geographic information was recorded in H and O and to a lesser extent, S isotopes. H and O data were entered into a recently developed model describing the relationship between the H and O isotope composition of human hair and drinking water in modern USA and pre-globalized populations. This has anthropological and forensic applications including reconstructing environment and diet in modern and ancient human hair. However, it has not been applied to a modern population outside of the USA, where we expect different diet. Relationships between H and O isotope ratios in drinking water and hair of modern human populations in Asia were different to both modern USA and pre-globalized populations. However, the Asian dataset was closer to the modern USA than to pre-globalized populations. Model parameters suggested slightly higher consumption of locally produced foods in our sampled population than modern USA residents, but lower than pre-globalized populations. The degree of in vivo amino acid synthesis was comparable to both the modern USA and pre-globalized populations. C isotope ratios reflected the predominantly C(3)-based regional agriculture and C(4) consumption in northern China. C, N, and S isotope ratios supported marine food consumption in some coastal locales. N isotope ratios suggested a relatively low consumption of animal-derived products compared to western populations.

Amblyomma americanum: a potential vector of Lyme disease in New Jersey.

Amblyomma americanum is a likely secondary vector of Lyme disease in New Jersey. Ticks of this species were removed from the site of the characteristic skin lesion known as erythema chronicum migrans on two patients with the disease, and the Lyme disease spirochete was isolated from nymphs and adults of this species. That A. americanum is a potential vector is supported by its similarities to Ixodes dammini, the known tick vector, in seasonal distribution and host utilization. The extensive range of A. americanum may have great implications for potential Lyme disease transmission outside known endemic areas.

Culturally competent methods to promote organ donation rates among African-Americans using venues of the Bureau of Motor Vehicles.

BACKGROUND: The diversity of the nation is one of society's greatest assets, but this feature is overshadowed by the disproportionate burden of disease that exists among America's minorities. Evidence of the disparate health status has been documented in low life expectancy, cancer, diabetes, cardiovascular, and kidney disease as well as a plethora of disorders that necessitate organ transplantation. Many minorities have been reluctant to register to become organ donors. This circumstance can be alleviated by educating the public regarding the necessity of organ transplantation. We have developed a "unique" collaborative outreach program designed to promote acceptance of organ donation in African-Americans (AAs). Our outreach curriculum at Bureau of Motor Vehicles (BMV) has resulted in increased registrations and awareness regarding the need and positive perceptions toward donation. METHODS: We developed a culturally sensitive outreach program: cultural sensitivity indicates how culture has the ability to influence communication between patients and health providers. An "Outreach Promotional Contest" was strategically targeted toward 28 Ohio BMVs to promote and assist in an outreach educational program regarding organ donation/registry. RESULTS: The consequence/results has been an increase of 3.4% in the BMV locations. The one BMV, with the highest increase was attended predominantly by AAs which moreover, won first place in the contest (6.425%; P < .05). CONCLUSION: To increase the number of people willing to register, we believe that both community education regarding the need and importance, as well as culturally sensitive promotion of organ donation, is the best way to increase organ donor registries particularly among minority populations.

Age- and gender-specific variations of the epiphyseal tilt and epiphyseal angle in adolescents without hip pathology.

PURPOSE: To determine age-and gender-dependent variation of epiphyseal tilt and epiphyseal angle using CT in adolescents without hip pathology. METHODS: Pelvic CT scans were obtained in 132 adolescents for evaluation of abdominal pain. Radially oriented planes around the femoral neck were reformatted and the epiphyseal tilt and angle were measured in the anterior, anterosuperior and superior planes. Variations in the tilt angle and epiphyseal angle were assessed by age group from 12 to 18 years and gender by using a linear mixed model analysis. RESULTS: The epiphyseal tilt did not change (p = 0.97) with increasing age. Male patients exhibited smaller tilt angle in the anterosuperior plane (p = 0.003) but no difference was detected in the anterior (p = 0.17) or superior (p = 0.06) planes. The epiphyseal angle decreased with increasing age in the anterior (p = 0.03), anterosuperior (p = 0.001) and superior (p < 0.001) planes in male patients, with no variation in female patients (p = 0.92). Male patients had larger epiphyseal angles in the anterior (p = 0.02), anterosuperior (p < 0.001) and superior (p = 0.002) planes compared with female patients. CONCLUSION: We found no age-specific variations in the epiphyseal tilt and no difference in the epiphyseal tilt in male and female patients in the superior and anterior plane. The epiphyseal angle was smaller in female patients, however, the epiphyseal angle decreased with increasing age in male patients which corresponds to an increase in epiphyseal extension. The reference values reported in this study may serve as additional information in the evaluation of adolescents with hip pain and as reference for future studies investigating slipped capital femoral epiphysis and femoroacetabular impingement development. LEVEL OF EVIDENCE: Level III Diagnostic Study.

Crystal methamphetamine: a source of added sexual risk for Hispanic men who have sex with men?

OBJECTIVES: To determine whether use of crystal methamphetamine increases HIV risk behaviors beyond the risk associated with use of other recreational drugs among Hispanic men who have sex with men (HMSM). DESIGN: We compared the sexual behaviors and psychosocial characteristics of non-recreational drug users (non-users), recreational drug users who did not use crystal (non-crystal drug users), and recreational drug users who used crystal (crystal users). METHODS: We recruited 294 HMSM from Internet and 272 from community venues. Eligible men completed an ACASI to assess socio-demographic factors, drug use, sexual behaviors and psychosocial factors and received 50 dollars. RESULTS: In the multivariate model, crystal users were more likely than non-crystal drug users to have lower Hispanicism, higher attachment to the gay community, and history of suicide attempts. Crystal users were not significantly different from non-crystal drug users in number of sex partners; however, differences in unprotected receptive anal sex approached significance. CONCLUSIONS: The additional risk of crystal above that of other recreational drugs needs to be disentangled from those associated with poly-drug use. Our data suggest that it may depend on how one defines risky sexual behavior and is influenced by psychological, physiologic and social factors.

An evaluation of the value of group education in recently diagnosed diabetes mellitus.

Diabetic patients have a 12% to 25% lifetime risk of developing foot complications leading to significant morbidity and mortality. The objective of this study was to assess the effectiveness of group education in improving patient awareness of foot care. The authors evaluated the effect of group size and areas in which knowledge seemed to be most affected. Patients attending a 2-hour teaching session between November 2005 and March 2006 were recruited. Patients filled in an 18-part questionnaire before and after the teaching session to assess knowledge. Fifty-nine patients recently diagnosed with diabetes mellitus or foot complications were recruited for 7 sessions. Analysis of the data showed a statistically significant improvement in foot care knowledge after the teaching session compared with before (69% to 85%, P < .001). Patients in the smaller group (n < 10) had significantly higher scores compared with the bigger groups (n > 10; P < .025). These data show the benefit of group education about foot care for patients with diabetes. Smaller groups benefited more than larger ones did, which could be attributed to the sizes allowing for better interaction between the tutor and patient. As patient knowledge is variable from individual to individual, smaller teaching sessions may allow patients to address specific concerns.

Excision of visual cortex does not affect the facilitatory and inhibitory effects of a light flash prepulse on the acoustic startle reflex in the rat.

We studied the inhibitory (PPI) and facilitatory (PPF) behavioural effects of brief light flashes presented as prepulses just prior to the acoustic startle reflex (ASR) in intact rats and in rats that had a bilateral excision of visual cortex (VC). The VC-lesioned and control groups (n=5, 5) were near identical in PPF for flashes presented 5-20 ms before the ASR and near identical in PPI for flashes presented 60 ms before the ASR. These findings differ from those of a case report of a human patient following occipital cortex resection, for whom light flashes failed to produce either acoustic startle PPF or PPI if the flash were presented to the portion of the visual field in which she could not see; they differ also from data obtained in functionally decorticate rats, for which a light flash produced no startle PPI, but instead a late-appearing exaggerated PPF. In the present experiment the lesion was restricted to VC, while in contrast the occipital resection in the human patient included posterior areas of the parietal and temporal lobe, and functional decortication in the rat disengaged the entire cortex. The greater extent of these two effective surgical procedures may have been responsible for their greater behavioural effects; otherwise, the complete loss of reflex control by photic stimulation in the human patient but not in the rat may reflect the greater functional importance and anatomical complexity of the VC in humans.

Low-income African American women's attempts to convince their main partner to use condoms.

In this cross-sectional study the authors examine condom use attempts and condom use among 305 high-risk, low-income African American women who reported having a main partner. Women who had recently attempted to convince their main partner to use condoms were almost 10 times more likely to have recently used condoms with their partner than women who had not made an attempt. Among the subsample of 116 women who had recently made a condom use attempt with their main partner, having a history of childhood abuse and having one's main partner raise infidelity questions in response to the condom use attempt were negatively associated with recent condom use with this partner. Findings provide initial insights into the importance of women's condom use attempts, as well as subgroups of women who may encounter special challenges convincing their main partner to use condoms.

Pivotal phase III trial of two dose levels of denileukin diftitox for the treatment of cutaneous T-cell lymphoma.

PURPOSE: The objective of this phase III study was to determine the efficacy, safety, and pharmacokinetics of denileukin diftitox (DAB389IL-2, Ontak [Ligand Pharmaceuticals Inc, San Diego, CA]) in patients with stage Ib to IVa cutaneous T-cell lymphoma (CTCL) who have previously received other therapeutic interventions. PATIENTS AND METHODS: Patients with biopsy-proven CTCL that expressed CD25 on > or = 20% of lymphocytes were assigned to one of two dose levels (9 or 18 microg/kg/d) of denileukin diftitox administered 5 consecutive days every 3 weeks for up to 8 cycles. Patients were monitored for toxicity and clinical efficacy, the latter assessed by changes in disease burden and quality of life measurements. Antibody levels of antidenileukin diftitox and anti-interleukin-2 and serum concentrations of denileukin diftitox were also measured. RESULTS: Overall, 30% of the 71 patients with CTCL treated with denileukin diftitox had an objective response (20% partial response; 10% complete response). The response rate and duration of response based on the time of the first dose of study drug for all responders (median of 6.9 months with a range of 2.7 to more than 46.1 months) were not statistically different between the two doses. Adverse events consisted of flu-like symptoms (fever/chills, nausea/vomiting, and myalgias/arthralgias), acute infusion-related events (hypotension, dyspnea, chest pain, and back pain), and a vascular leak syndrome (hypotension, hypoalbuminemia, edema). In addition, 61% of the patients experienced transient elevations of hepatic transaminase levels with 17% grade 3 or 4. Hypoalbuminemia occurred in 79%, including 15% with grade 3 or 4 changes. Tolerability at 9 and 18 microg/kg/d was similar, and there was no evidence of cumulative toxicity. CONCLUSION: Denileukin diftitox has been shown to be a useful and important agent in the treatment of patients whose CTCL is persistent or recurrent despite other therapeutic interventions.

Endogenous interleukin-1 can regulate the autonomous growth of the blast cells of acute myeloblastic leukemia by inducing autocrine secretion of GM-CSF.

We have studied peripheral blood blast cells from a patient with acute myeloblastic leukemia (AML) whose cells proliferated autonomously at high cell density, but only in the presence of adherent cells. At low cell density in suspension culture and in a clonogenic assay, blast cell growth was stimulated by recombinant granulocyte macrophage colony stimulating factor (GM-CSF) and recombinant interleukin-1 (IL-1) independently. The response to rIL-1 was inhibited (less than 90%) by anti-GM-CSF, suggesting that the proliferative response to IL-1 was mediated by GM-CSF. This was supported by experiments which demonstrated that blast cell conditioned medium prepared in the presence of IL-1 contained GM-CSF activity which stimulated the growth of normal granulocyte-macrophage precursors (CFU-GM) and of homologous GM-CSF responsive AML blasts. As IL-1 but no GM-CSF activity was detected in BCCM prepared without exogenous IL-1 and a neutralizing antibody to IL-1 inhibited the autonomous growth of blasts in suspension culture, we conclude that the endogenous secretion of IL-1 by leukemic cells stimulated autocrine GM-CSF secretion, inducing autonomous growth of the blast cell population.

Predictors of HIV testing and intention to test among Hispanic farmworkers in South Florida.

CONTEXT AND PURPOSE: This study examined the predictors of HIV testing and factors associated with intention to accept a free HIV test among 244 Hispanic migrant/seasonal farmworkers in South Florida. METHODS: Time and space sampling procedures were used to recruit participants in public venues. Bilingual staff interviewed eligible respondents in these settings. FINDINGS: Despite high rates of sexual risk, only 21% of respondents had been tested for HIV. The majority of those tested were females tested during prenatal care. In multivariable logistic regression analyses, being female (odds ratio [OR] = 3.73), having at least 12 years of education (OR = 4.46), earning more than $201 per week (OR = 2.76), and ever having used marijuana (OR = 3.31) were positively associated with having been tested for HIV, while not being documented (OR = 0.24) and having rated one's health as "very good" or "good" (OR = 0.42) were negatively associated with testing. The multivariable predictors of intention to accept a free HIV test were having visited a health care provider and/or an emergency room in the past 12 months (OR = 1.97), having been tested for HIV (OR = 2.36), preferring an HIV test that used a finger stick for specimen collection with results given in 30 minutes (OR = 4.47), and worrying "some" or "a lot" about getting HIV (OR = 3.64). Women (OR = 0.52) were less likely than men to intend to accept a free HIV test. CONCLUSIONS: Our findings highlight the importance of routinely offering HIV testing to sexually active individuals in high HIV prevalence areas. They also suggest the need to make testing more accessible to migrant and seasonal farmworkers.

Half a loaf is better than waiting for the bread truck. A computerized mini-medical record for outpatient care.

We describe a locally developed system for partial computer storage of medical data, called the mini-medical record system. The system produces a typed face sheet prior to each patient visit. The face sheet, which also serves as a progress note, contains patient demographic data, medical problem lists, previous vital signs, allergies, medication profile, and health maintenance reminders. Between regularly scheduled visits, all computerized data are available by computer printout for unscheduled visits to walk-in clinics and the emergency department. Structured reports are generated by the system that describes each resident and faculty members' practice. Quality assurance reports are also available. Since the system draws from several already existing databases, new data entry requirements are modest and cost to the institution is low. Partially computerized systems can be developed inexpensively and are well received in multispecialty practices, where interphysician communication is vital.

Gastric inhibitory polypeptide responses to nutrients in Caucasians and American Indians with obesity and noninsulin-dependent diabetes mellitus.

Serum gastric inhibitory polypeptide (GIP), insulin, and glucose responses to either a 75-g oral glucose challenge or a 500-cal liquid test meal were determined in 141 Caucasians and American Indians. The Caucasians were normal weight, averaging 101 +/- 3% (+/-SEM) ideal BW (IBW), or were obese (168 +/- 21% IBW) and had normal glucose tolerance (n = 77), impaired glucose tolerance (IGT; n = 12), or noninsulin-dependent diabetes mellitus (NIDDM; n = 19). The American Indians were all obese (144 +/- 6% IBW) and had either normal glucose tolerance (n = 22) or NIDDM (n = 11). In all study subjects, including obese individuals with and without glucose intolerance, diabetic patients both thin and obese, and lean subjects with impaired glucose tolerance, fasting serum insulin and GIP, and incremental glucose, insulin, and GIP were greater than they were in normal lean subjects, especially during the first hour of the tests. Obese subjects and diabetic patients exceeded lean normal subjects by up to 620% for glucose, up to 640% for insulin, and up to 360% for GIP during the first hour after glucose ingestion or the test meal. Exceptions were two groups with the most severe diabetes in whom incremental insulin values after oral glucose were only 70% (thin Caucasians) and 110% (obese Indians) that of lean normal subjects. The smallest differences in GIP responses occurred between lean normal subjects and obese nondiabetic Caucasians tested with either a meal or oral glucose, whereas American Indians consistently had the greatest insulin and GIP responses to the tests. High fasting GIP and exaggerated GIP increments in response to nutrients could be attributed to neither obesity nor diabetes alone nor to the type of nutrient used to stimulate its release, but, instead, may be genetic or dietary in origin or may be due to other as yet unidentified factors. High basal GIP and exaggerated nutrient-stimulated GIP release were associated with hyperinsulinemia, except in the most severe diabetic patients. These observations suggest that exaggerated GIP release, along with a greater rise in serum glucose in response to nutrients, may play a role in the pathogenesis of the hyperinsulinemia of obesity and early NIDDM.

Antigen gene transfer to cultured human dendritic cells using recombinant avipoxvirus vectors.

Advances in understanding the role of dendritic cells (DCs) as the major antigen (Ag)-presenting cell type of the immune system combined with the recent development of methods for the ex vivo expansion of human DCs have opened the possibility for the transfer of tumor Ags to DCs with a view toward tumor immunotherapy. In this study, we examined the feasibility of Ag transfer to cultured human DCs using the host range-restricted avipoxvirus, fowlpoxvirus (FWPV). FWPV was found to infect and express a lacZ marker gene in a number of mammalian cell lines of fibroblastic, epithelial, and hemopoietic lineage origins. LacZ recombinant FWPV (rFWPV) was found subsequently to infect human DCs that had been cultured ex vivo from peripheral blood monocytes. Using rFWPV containing lacZ under the control of a vaccinia virus (VV) early/late promoter (p7.5K) and a 10 plaque-forming units per cell multiplicity of infection, >80% of cells expressed the lacZ marker gene. Quantitative analysis showed that the level of expression continued to rise for 5 days postinfection, at which point the experiments were terminated. Replication-competent recombinant VV (rVV) was also shown to be capable of transferring the marker gene to primary DC cultures. However, neither rFWPV nor rVV were able to express transgenes under the control of late viral promoters, indicating that both rFWPV and rVV infections are arrested at an early stage in human DCs. Infection of CD83 + DCs by rFWPV was confirmed by double-staining cytochemistry. We conclude that host range-restricted FWPV can be used efficiently to transfer Ag genes to human DCs ex vivo and may have a role in the development of tumor immunotherapy protocols.

Impoverished stimulus input does not simulate the slowed visual kinetics of retinal damage.

In the rat with normal sight, the acoustic startle reflex to a sound burst is suppressed when the sound is preceded by a brief light pulse. This effect of light in the rat with retinal damage is reduced and peak suppression is seen at a greater delay. Both observations are expected consequences of the loss of visual sensitivity that should accompany photoreceptor loss. However, in an early stage of retinal damage, the peak of the suppressive effect is so delayed that at long lead times the light flash is a more effective stimulus in the rat with the damaged retina than in the normal rat. Two experiments tested the hypothesis that this crossing over of the two groups is a secondary consequence of a nonspecific loss of visual sensitivity in the visually impaired rat. If the hypothesis is correct, reductions in the intensity or duration of the light flash and the degree of dark adaptation should model the effect in normal rats. The overall amount of reflex suppression was diminished with these manipulations, but none diminished the temporal development of reflex suppression to a degree sufficient to produce the paradoxical crossover effect characteristic of retinal damage. These data indicate that decrements in the speed of visual processing are not secondary to the changes in sensitivity that accompany retinal damage, but should be viewed as a separate and independent form of visual impairment.

THE EFFECTS OF SOIL TEMPERATURE ON PLANT GROWTH, NODULATION AND NITROGEN FIXATION IN CASUARINA CUNNINGHAMIANA MIQ.

The effects of soil temperatures between 15 and 30°C on plant growth, nodulation and nitrogen fixation in seedlings of Casuarina cunninghamiana Miq. inoculated with Frankia from two different sources were examined. The optimum soil temperature for the growth of plants dependent on symbiotic nitrogen fixation was 25°C. Decreasing the soil temperature below 25°C markedly decreased plant growth that was reliant on symbiotically fixed nitrogen; effects on the growth of plants supplied with mineral nitrogen were much smaller. At 15°C there was no response in plant growth to inoculation after 148 d, whereas plants supplied with nitrogenous fertilizer were 10 times the weight of uninoculated plants. Nodulation was delayed at 15 and 20°C with nodules formed at 15°C fixing no nitrogen in these studies. The production of fewer nodules at 20°C than at 25°C was partly compensated by the production of larger nodules. Nodule growth at 20 to 30°C was a prime determinant of nitrogen fixed, with the exception of one Frankia at 20°C. The amount of nitrogen-fixed g-1 nodule was the same for the two Frankia sources at 25 and 30°C, differences in effectiveness being due to nodule development. However, differences in the effectiveness of the two Frankia sources at 20°C were related to differences both in nodule development and in nitrogen-fixing ability. The absence of nitrogen fixation at 15°C would be expected to limit the natural distribution of Casuarina species reliant on symbiotically fixed nitrogen to areas where soil temperatures exceed 15°C for a major part of the potential growing season.

Temporal resolution of gaps in noise by the rat is lost with functional decortication.

In Experiment 1 (n = 8), the rat's ability to detect brief gaps in white noise was measured by gap-produced inhibition of an acoustic startle reflex, elicited 100 ms after the gap. After bilateral application of KCl to the cortex, gaps as long as 15 ms provided no reflex inhibition; in contrast, the inhibitory threshold was between 2 and 4 ms in the saline control condition. In Experiment 2 (n = 13), noise pulses of 40, 50, or 70 dB were presented 20-500 ms before the startle stimulus, and in Experiment 3 (n = 5) noise offsets occurred so that the startle stimulus was presented at the end of a 2-30-ms gap. Noise pulses and offsets both inhibited reflex expression equally in saline- and KCl-treated animals. Differences between the normal (saline) functions of noise offsets and gaps suggest additional sensory processing with the longer lead time. The loss of gap sensitivity after KCl application indicates that gap processing, unlike pulses and offsets, depends on cortical mechanisms.