Audio-computer-assisted survey interview and patient navigation to increase chronic viral hepatitis diagnosis and linkage to care in urban health clinics.

Intravenous drug use and sexual practices account for 60% of hepatitis C (HCV) and B (HBV) infection. Disclosing these activities can be embarrassing and reduce risk reporting, blood testing and diagnosis. In diagnosed patients, linkage to care remains a challenge. Audio-computer-assisted survey interview (Audio-CASI) was used to guide HCV and HBV infection testing in urban clinics. Risk reporting, blood testing and serology results were compared to historical controls. A patient navigator (PN) followed up blood test results and provided patients with positive serology linkage to care (LTC). Of 1932 patients surveyed, 574 (30%) were at risk for chronic viral hepatitis. A total of 254 (44.3%) patients were tested, 34 (13.5%) had serology warranting treatment evaluation, and 64% required HBV vaccination. Of 16 patients with infection, seven HCV and three HBV patients started treatment following patient LTC. Of 146 HBV-naïve patients, 70 completed vaccination. About 75% and 49% of HCV antibody and HBV surface antigen-positive patients were born between 1945 and 1965. Subsequently, automated HCV testing of patients born between 1945 and 1965 was built into our hospital electronic medical records. Average monthly HCV antibody testing increased from 245 (January-June) to 1187 (July-October). Patient navigator directed LTC for HCV antibody-positive patients was 61.6%. In conclusion, audio-CASI can identify patients at risk for HCV or HBV infection and those in need of HBV vaccination in urban medical clinics. Although blood testing once a patient is identified at risk for infection needs to increase, a PN is useful to provide LTC of newly diagnosed patients.

Reducing naltrexone-resistant hyperphagia using laser acupuncture to increase endogenous opiates.

A 28-year-old woman with acquired brain damage suffered subsequent profound mental disability and an intense hyperphagic syndrome complete with life-threatening pica. She was the single subject of two consecutive experiments. In the first, Naltrexone, an orally administered opiate blocker, was given to reduce hyperphagia and distress, but was associated with even greater urgency when eating meals and a manifest increase in distress. While distress reduced to premedication levels on withdrawal of treatment, urgency of eating did not reduce so quickly. In the second experiment a laser acupuncture procedure was used at 2.5 Hz and 10 Hz for 10 days each with an intervening 10-day placebo condition to increase the availability of the subject's endogenous opiates, and thus hopefully produce opposite effects to the first experiment and effect a positive treatment. The 10 Hz condition produced a significant but transient reduction in pica measured by attempts at pica on a supervised walk shortly after each treatment. The subject was also easier to manage on walks, and appeared happier. Further studies using physical exercise or acupressure to achieve similar or better results are discussed.

Oral labetalol versus oral clonidine in the emergency treatment of severe hypertension.

This study was designed to compare the clinical efficacy and safety of oral clonidine and oral labetalol in the treatment of severe hypertension in an emergency department setting. Thirty-six patients with severely elevated blood pressure (mean baseline blood pressure 199/132 mm Hg) without acute end-organ dysfunction were treated with either oral labetalol or oral clonidine in a randomized double-blind prospective study. Labetalol was administered as an initial dose of 200 mg, followed by hourly 200 mg doses up to 1,200 mg. Clonidine was administered as an initial dose of 0.2 mg, followed by hourly 0.1 mg doses up to 0.7 mg. Labetalol reduced diastolic blood pressure in 94% of the patients within 6 hours, with a mean reduction in blood pressure of 54/37 mm Hg. Clonidine reduced diastolic blood pressure in 83% of the patients within 6 hours, with a mean reduction in blood pressure of 57/32 mm Hg. The authors conclude that oral labetalol was comparable to clonidine in efficacy, had a similar incidence of side effects, and offered the clinician a useful alternative for the treatment of severe hypertension in an emergency department setting. Further studies are indicated to determine appropriate dosing regimens for oral labetalol in the acute treatment of severe hypertension.

Nutritional Features of Syntrophomonas wolfei.

Syntrophomonas wolfei subsp. wolfei grew poorly in a defined medium with crotonate as the energy source in the absence of rumen fluid. Thiamine, lipoic acid, biotin, cyanocobalamin, and para-aminobenzoic acid were required for growth comparable to that obtained with the rumen fluid-based medium. Iron and cobalt were also required for the growth of S. wolfei in the chemically defined medium.

Effects of Organic Acid Anions on the Growth and Metabolism of Syntrophomonas wolfei in Pure Culture and in Defined Consortia.

The effects of organic acid anions on the growth of Syntrophomonas wolfei was determined by varying the initial concentration of the acid anion in the medium. The addition of 15 mM acetate decreased the growth rate of a butyrate-catabolizing coculture containing Methanospirillum hungatei from 0.0085 to 0.0029 per hour. Higher initial acetate concentrations decreased the butyrate degradation rate and the yield of cells of S. wolfei per butyrate degraded. Inhibition was not due to the counter ion or the effect of acetate on the methanogen. Initial acetate concentrations above 25 mM inhibited crotonate-using pure cultures and cocultures of S. wolfei. Benzoate and lactate inhibited the growth of S. wolfei on crotonate in pure culture and coculture. Lactate was an effective inhibitor of S. wolfei cultures at concentrations greater than 10 mM. High concentrations of acetate and lactate altered the electron flow in crotonate-catabolizing cocultures, resulting in the formation of less methane and more butyrate and caproate. The inclusion of the acetate-using methanogen, Methanosarcina barkeri, in a methanogenic butyrate-catabolizing coculture increased both the yield of S. wolfei cells per butyrate degraded and the efficacy of butyrate degradation. Butyrate degradation by acetate-inhibited cocultures occurred only after the addition of Methanosarcina barkeri. These results showed that the metabolism of S. wolfei was inhibited by high levels of organic acid anions. The activity of acetate-using methanogens is important for the syntrophic degradation of fatty acids when high levels of acetate are present.

Phospholipid Fatty Acid Composition of the Syntrophic Anaerobic Bacterium Syntrophomonas wolfei.

The membrane phospholipid fatty acids (PLFAs) from several cocultures and a pure culture of Syntrophomonas wolfei were determined by capillary column gas chromatography. Cocultures of S. wolfei with a Desulfovibrio sp. contained PLFAs from both organisms, whereas PLFAs from a coculture with Methanospirillum hungatei contained very little biomass to analyze. The pure culture of S. wolfei grown on crotonate provided the best material for analysis of the PLFAs. The predominant PLFAs of S. wolfei were the monounsaturated 16:1omega7c and 16:1omega9c and the saturated 16:0 and 14:0. A low concentration of the diunsaturated 18:2omega6 was detected. The PLFA analysis provides additional information for consideration in the determination of the profile of PLFAs obtained from anaerobic environments. In addition, this information may aid in the understanding of the physiology and phylogeny of S. wolfei and other syntrophic bacteria.

Separation of Syntrophomonas wolfei from Methanospirillum hungatii in Syntrophic Cocultures by Using Percoll Gradients.

Percoll gradient centrifugation effectively separated Syntrophomonas wolfei cells from Methanospirillum hungatii cells, resulting in a 70- to 80-fold enrichment of S. wolfei cells relative to M. hungatii cells. The separated S. wolfei cells were viable. Gram quantities of cellular protein which was enzymatically active and had low levels of contamination by the methanogenic cofactor, factor(420), were obtained.

Preparation of cell-free extracts and the enzymes involved in fatty acid metabolism in Syntrophomonas wolfei.

Syntrophomonas wolfei is an anaerobic fatty acid degrader that can only be grown in coculture with H2-using bacteria such as Methanospirillum hungatei. Cells of S. wolfei were selectively lysed by lysozyme treatment, and unlysed cells of M. hungatei were removed by centrifugation. The cell extract of S. wolfei obtained with this method had low levels of contamination by methanogenic cofactors. However, lysozyme treatment was not efficient in releasing S. wolfei protein; only about 15% of the L-3-hydroxyacyl-coenzyme A (CoA) dehydrogenase activity was found in the lysozyme supernatant. Cell extracts of S. wolfei obtained with this method had high specific activities of acyl-CoA dehydrogenase, enoyl-CoA hydratase, L-3-hydroxyacyl-CoA dehydrogenase, and 3-ketoacyl-CoA thiolase. These activities were not detected in cell extracts of M. hungatei grown alone, confirming that these activities were present in S. wolfei. The acyl-CoA dehydrogenase activity was high when a C4 but not a C8 or C16 acyl-CoA derivative served as the substrate. S. Wolfei cell extracts had high CoA transferase specific activities and no detectable acyl-CoA synthetase activity, indicating that fatty acid activation occurred by transfer of CoA from acetyl-CoA. Phosphotransacetylase and acetate kinase activities were detected in cell extracts of S. wolfei, indicating that S. wolfei is able to perform substrate-level phosphorylation.