Purple Urine Bag Syndrome in a Patient with an Ileal Conduit and Clostridium Difficile Infection.

Purple urine bag syndrome is a potentially alarming phenomenon caused by bacterial metabolism of urinary tryptophan into indigo (blue) and indirubin (red) pigments. We report the case of a 46-year-old female with an ileal conduit who presented with a 2 week history of abdominal pain and purple discolouration of her urine. In addition, we review the literature on purple urine bag syndrome, and identify potential new risk factors and management considerations.

Echocardiographic evaluation of intracardiac venous gas emboli following in-water recompression.

Decompression sickness is a potentially fatal illness. Optimal treatment is dry recompression with hyperbaric oxygen. In-water recompression (IWR) offers expedited treatment but has insufficient evidence to recommend it as a treatment option. This trial compares IWR to standard surface oxygen treatment using 2D echocardiography as the semi-quantitative measurement for inert gas loading. Divers were randomly assigned to either IWR or normobaric oxygen (NBO2). A provocative dive profile to 33.5 meters for 25 minutes was used to stimulate bubble formation. After 60 minutes on the surface, bubble scoring was obtained using 2D echocardiography. Divers underwent either the IWR or NBO2 treatment for 82 minutes. Echocardiography was then repeated. Pre-treatment mean bubble counts were 28.1 bpf (bubbles per echo frame), [+/- 13.2 to 43.0 95% CI] for IWR, and 18.3 bpf [+/- 0.0 to 39.6 95% CI] for NBO2. After treatment, mean bubble score dropped to 0.1 bpf [+/- 0.0 to 0.2 95% CI] (p < 0.01) and 1.8 bpf [0.0 to 3.8 95% CI] (p = 0.103) respectively. IWR vs. NBO2 reduction of bubble counts was 99.7% vs. 90.1%; however, this was not found to be statistically significant. IWR reduced the central VGE load compared to NBO2, suggesting that IWR is a viable emergency treatment when a recompression chamber is unavailable.

Impact of Regional Lymph Node Dissection on Disease Specific Survival in Adrenal Cortical Carcinoma.

Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. The purpose of this study is to evaluate the impact of a more extensive regional lymph node dissection (LND) has on survival in ACC patients in the United States. Patients ≥ 15 years of age without distant metastases who underwent surgical intervention for primary ACC were identified from the SEER18 registry from 1988-2009. Patients were divided into 2 groups: having a regional LND (≥ 5 LNs removed) vs. no-LND (0-4 LNs removed). Overall survival (OS) and disease specific survival (DSS) were compared between groups. Of 259 patients with complete data on nodal resection, 243 (93.8%) underwent no-LND and 16 (6.2%) LND. There was no difference in age, sex, metastases, or ENSAT stage between groups. However, LND patients had larger tumors (p=0.004), and more frequently underwent en-bloc surgery (p=0.002). One- and 3-year OS and DSS did not differ between groups. In a cox regression model, performance of a regional LND did not significantly influence DSS. However, female gender (HR: 1.67, CI: 1.04-2.69, p=0.033) and later stage (stage III-HR: 4.78, CI: 1.14-20.00, p=0.032) or positive LNs (HR: 5.92, CI: 2.05-17.08, p=0.001) were risk factors for worse DSS. Regional LND may not improve DSS or OS in nonmetastatic ACC patients undergoing adrenalectomy. It remains controversial as an essential part of the surgical management for ACC and deserves further investigation in a larger, prospective study. However, regional LND should still be considered for staging and prognostic purposes and to standardize surgical care.

Self-sampling for community respiratory illness: a new tool for national virological surveillance.

This report aims to evaluate the usefulness of self-sampling as an approach for future national surveillance of emerging respiratory infections by comparing virological data from two parallel surveillance schemes in England. Nasal swabs were obtained via self-administered sampling from consenting adults (≥ 16 years-old) with influenza symptoms who had contacted the National Pandemic Flu Service (NPFS) health line during the 2009 influenza pandemic. Equivalent samples submitted by sentinel general practitioners participating in the national influenza surveillance scheme run jointly by the Royal College of General Practitioners (RCGP) and Health Protection Agency were also obtained. When comparable samples were analysed there was no significant difference in results obtained from self-sampling and clinician-led sampling schemes. These results demonstrate that self-sampling can be applied in a responsive and flexible manner, to supplement sentinel clinician-based sampling, to achieve a wide spread and geographically representative way of assessing community transmission of a known organism.

Rapid, highly discriminatory binary genotyping to demonstrate methicillin-resistant Staphylococcus aureus transmission in a tertiary care intensive care unit.

OBJECTIVES: No previous studies of methicillin-resistant Staphylococcus aureus (MRSA) epidemiology in adult intensive care units (ICUs) have assessed the utility of rapid, highly discriminatory strain typing in the investigation of transmission events. DESIGN: Observational. SETTING: A 22-bed medical-surgical adult ICU. Patients Those admissions MRSA-positive on initial screening and all admissions <48 hours in duration were excluded, leaving a cohort of 653 patients (median age, 61 years; APACHE-II, 19). METHODS: We conducted this study of MRSA transmission over 1 year (August 1, 2011 to July 31, 2012) using a multiplex PCR-based reverse line blot (mPCR/RLB) assay to genotype isolates from surveillance swabs obtained at admission and twice weekly during ICU stays. MRSA prevalence and incidence rates were calculated and transmission events were identified using strain matching. Colonization pressure was calculated daily by summation of all MRSA cases. RESULTS: Of 1,030 admissions to ICU during the study period, 349 patients were excluded. MRSA acquisition occurred during 31 of 681 (4.6%) remaining admissions; 19 of 31(61%) acquisitions were genotype-confirmed, including 7 (37%) due to the most commonly transmitted strain. Moving averages of MRSA patient numbers on the days prior to a documented event were used in a Poisson regression model. A significant association was found between transmission and colonization pressure when the average absolute colonization pressure on the previous day was ≥3 (χ2=7.41, P=0.01). CONCLUSIONS: mPCR/RLB characterizes MRSA isolates within a clinically useful time frame for identification of single-source clusters within the ICU. High MRSA colonization pressure (≥3 MRSA-positive patients) on a given day is associated with an increased likelihood of a transmission event.

Mycoplasma pneumoniae infection in primary care investigated by real-time PCR in England and Wales.

Real-time PCR was employed to detect a conserved region of the P1 cytadhesin gene of Mycoplasma pneumoniae in combined nose and throat swabs collected from patients attending GP surgeries during 2005-2009 with symptoms of respiratory tract infection (RTI). Samples were collected as part of an annual winter epidemiological and virological linked study in England and Wales. A total of 3,987 samples were tested, 65 (1.7%, 95%CI 1.3-2.1) had detectable M. pneumoniae DNA. Positive patients were detected of both gender, aged from 9 months to 78 years, who had clinical signs of upper RTI, fever and/or myalgia, an influenza-like illness to lower RTI. Mixed infections were identified in four cases, two with influenza A H1, one with H3 and one with influenza B. Children aged 5-14 years were more likely to have detectable M. pneumoniae in samples than all other age groups (Fishers p = 0.03), attributed to the 2005-2006 season in which 6.0% (12/200, 95%CI 3.4-10.3) of 5-14 year olds had detectable M. pneumoniae in comparison to 2.2% in 2006-2007 (3/141 95%CI 0.5-6.4), 2.2% in 2007-2008 (2/89 95%CI 0.1-8.3) and 0% in 2008-2009 (0/151 95%CI 0-2.9).

Clinical use of a shortened alcohol withdrawal scale in a general hospital.

BACKGROUND: Multi-item scales for monitoring alcohol withdrawal reactions have been used since the 1970s, and since 1985 we have used a modified version of the Clinical Institute Withdrawal Assessment (CIWA) in our general hospitals. This study was conducted to determine whether a shorter version of the scale would prove easier to use without loss of accuracy. METHODS: A simultaneous 'crossover' clinical audit using two hospitals. The shortened scale was developed from the existing one, and had 10 items as opposed to the previous 18. The patients were followed throughout their course and the incidences of complication, the frequency of sedation, the delay in initiating monitoring and the ease of use were recorded. RESULTS: There were 106 patients managed with the old scale and 96 with the new. The rate of complication was not different, being 16% in patients managed using the old scale and 14.5% using the new scale; the rates of sedation were 49 and 48%, respectively. Patients managed with the new scale had a shorter course with a median duration of 27.6 h compared with 40 h. The time from admission to first recording of a score was 5.4 h for the new scale and 4.8 h for the old, which is not a significant difference. Both scores were used according to instructions, but staff reported that the shortened scale was easier to use. CONCLUSIONS: We conclude that a shortened form of the CIWA alcohol withdrawal scale works as well as the original and is simple to use.

Plucked human hair as a tissue in which to assess pharmacodynamic end points during drug development studies.

We have demonstrated the feasibility of detecting and quantifying six cell-cycle-related nuclear markers (Ki67, pRb, p27, phospho-p27 (phosphorylated p27), phospho-pRb (phosphorylated pRb), phospho-HH3 (phosphorylated histone H3)) in plucked human scalp and eyebrow hair. Estimates of the proportion of plucked hairs that are lost or damaged during processing plus the intra- and intersubject variability of each nuclear marker with these techniques are provided to inform sizing decisions for intervention studies with drugs potentially impacting on these markers in the future.

Reduced ventromedial hypothalamic neuronal nitric oxide synthase and increased sensitivity to NOS inhibition in dietary obese rats: further evidence of a role for nitric oxide in the regulation of energy balance.

Inhibition of hypothalamic nitric oxide (NO) decreases energy intake, and changes in hypothalamic NO synthase (NOS) have been observed in genetically obese rodents, but it is not known if NO is involved in the development of diet-induced obesity (DIO). We therefore measured changes in hypothalamic neuronal NOS (nNOS) in DIO and investigated effects of peripheral and central inhibition of NOS in this model. Expression of nNOS in relation to changes in nutritional state was measured by immunohistochemistry, with radiochemical detection. The effect of chronic intraperitoneal (i.p.) administration of the NOS inhibitor N(G)-nitro-L-arginine methyl ester (L-NAME, 50 mg/kg/day) on energy intake, bodyweight and hypothalamic nitric oxide content was assessed in both chow-fed and DIO animals. Twenty-four hour energy intake after acute intracerebroventricular (i.c.v.) of L-NAME was also measured. Diet-induced obese animals had a statistically significant 32% reduction in the number of nNOS-immunolabelled cells in the ventromedial hypothalamus compared to chow-fed controls. Intraperitoneal administration of L-NAME decreased hypothalamic NO content in both chow-fed and DIO. Energy intake was reduced by 16% in DIO over 16 days, whereas energy intake was only reduced by 11% in chow-fed animals, although both were statistically significant. L-NAME significantly reduced body weight gain in DIO but not in chow-fed rats. L-NAME administered i.c.v. decreased 24 h energy intake to a greater extent in DIO rats, by 18%, compared with a 10% reduction in chow-fed rats. Ventromedial hypothalamic expression of nNOS is sensitive to changes in nutritional state. Despite having reduced nNOS, dietary obese rats were more sensitive to the effects of NOS inhibition than lean controls, suggesting a role for NO in the development of hyperphagia and obesity in rats fed a palatable diet.

Unwanted pregnancy and contraceptive knowledge: identifying vulnerable groups from a randomized controlled trial of educational interventions.

OBJECTIVES: The aim of this study was to identify predictors of contraceptive pill knowledge and their relationship to educational interventions. METHODS: A total of 636 women attending for a follow-up appointment for repeat prescription of the combined oral contraceptive pill with a GP or practice nurse were randomized to receive leaflets (simple summary leaflet or FPA leaflet), advice or neither. Sociodemographic details and contraceptive knowledge were determined using a validated contraceptive knowledge questionnaire sent after 3 months by post. The main outcomes were sociodemographic, contraceptive, attitudinal and educational predictors of knowledge. RESULTS: A total of 522 (82%) had complete questionnaires. After controlling for educational intervention and other confounding variables, independent predictors of knowledge were further education (adjusted odds ratio 2.98, 95% confidence interval 1.78-4.99); number of years on the pill (0-5, 6-10, >10 years) 1.0, 0.56 (0.33-0.95) and 0.34 (0.19-0.59), respectively; past emergency contraception (1.87, 1.18-2.97); and importance attached to not falling pregnant (1.83, 1.02-3.29). These predictors are less powerful than the impact of most educational interventions (range of odds ratios for interventions: 1.85-6.81), and there was no evidence of a separate effect of educational intervention in any subgroup, except that leaflets have a larger effect in women who have needed emergency contraception in the past (no past use or simple summary and FPA leaflets, 1.74 and 0.90, respectively; with past use, 3.47 and 3.83; interaction term chi-square 6.92, P = 0.03). CONCLUSION: Educational interventions are as important as sociodemographic features in determining knowledge. With limited time for full educational interventions in practice, priorities for intervention should be women who have used emergency contraception in the past-who will benefit most-and those on the pill for >5 years or with no further education who are at highest risk due to poor knowledge.

The role of glutathione in the neurotoxicity of artemisinin derivatives in vitro.

The role of antioxidants in the neurotoxicity of the antimalarial endoperoxides artemether and dihydroartemisinin was studied in vitro by quantitative image analysis of neurite outgrowth in the neuroblastoma cell line NB2a. Intracellular glutathione concentrations were measured by high performance liquid chromatography with fluorescence detection. Both dihydroartemisinin (1 microM) and a combination of artemether (0.3 microM) plus haemin (2 microM) significantly inhibited neurite outgrowth from differentiating NB2a cells to 11.5 +/- 11.0% (SD) and 19.6 +/- 15.2% of controls, respectively. The inhibition by artemether/haemin was prevented by the antioxidants superoxide dismutase (109.7 +/- 47.8% of control), catalase (107.0 +/- 29.3%) glutathione (123.8 +/- 12.4%), L-cysteine (88.0 +/- 6.3%), N-acetyl-L-cysteine (107.8 +/- 14.9%), and ascorbic acid (104.3 +/- 12.7%). Dihydroartemisinin-induced neurotoxicity was completely or partially prevented by L-cysteine (99.5 +/- 17.7% of control), glutathione (57.9 +/- 23.4% of control), and N-acetyl-L-cysteine (57.3 +/- 9.5%), but was not prevented by superoxide dismutase, catalase, or ascorbic acid. Buthionine sulphoximine, an inhibitor of gamma-glutamylcysteine synthetase, significantly increased the neurotoxic effect of non-toxic concentrations of artemether/haemin (0.1 microM/2 microM) and dihydroartemisinin (0.2 microM), suggesting that endogenous glutathione participates in the prevention of the neurotoxicity of artemether/haemin and dihydroartemisinin. Artemether/haemin completely depleted intracellular glutathione levels, whereas dihydroartemisinin had no effect. We conclude that although glutathione status is an important determinant in the neurotoxicity of endoperoxides, depletion of glutathione is not a prerequisite for their toxicity. This is consistent with their mechanisms of toxicity being free radical-mediated damage to redox-sensitive proteins essential for neurite outgrowth, or alteration of a redox-sensitive signalling system which regulates neurite outgrowth.

Exposure assessment for a large epidemiological study of aircraft manufacturing workers.

Methods were developed to assess exposure to a wide variety of chemicals for nearly 80,000 workers involved in manufacturing aircraft since 1928. The facilities, now closed, consisted of four major plants, over 200 buildings, and a changing workforce during 60 years of operation. To access chemical exposures by specific jobs and calendar years, we reviewed complete work histories, examined detailed job descriptions available going back to 1940, interviewed long-term employees, conducted walk-through visits of aircraft manufacturing plants, reviewed comprehensive environmental assessment reports and industrial hygiene surveys on the facilities, and built on experience gained in previous studies of the aircraft industry. Using computer-based imaging systems, we examined and evaluated the complete work histories found on service record cards for the cohort and abstracted detailed information on all jobs held among the factory workers who had been employed for at least one year. Jobs were classified into one of three exposure categories related to the use of specific chemicals: routine, intermittent, and none, and these classifications were subsequently used in the epidemiological analyses. The approach to exposure assessment began with the most general categorization of employees (i.e., all workers) and then became progressively more specific, that is, factor workers, job families (similar activities), job titles, and jobs with chemical usage (exposure potential). Because exposure surveys were limited or absent during the early years of plant operations, we did not assign quantitative measures of exposure to individual job activities. Instead, we used as our exposure metric, the length of time spent in jobs with potential exposure to the chemical. Important occupational exposures included chromate-containing compounds such as used in paint primers, trichloroethylene and perchloroethylene used as vapor-state degreasing solvents, and a broad range of other solvents.

Isoflurane does not depress the hypoxic response of rabbit carotid body chemoreceptors.

UNLABELLED: Whether volatile anesthetics have an effect on the peripheral chemoreceptors is controversial, possibly because of differences in end-tidal CO(2) concentrations. We studied the effect of isoflurane on the hypoxic chemosensitivity of carotid body chemoreceptors at three different PaCO(2) levels before and during the administration of 1.0% isoflurane (0.5 minimum alveolar anesthetic concentration) in six normothermic New Zealand white rabbits anesthetized with thiopental. The response of the chemoreceptors was fitted to the equation: Frequency (Hz) = a + b x PaCO(2) + c x (1/PaO(2)) + Dx (1/PaO(2))(2). Mean values for the coefficients a, b, c and d for the control state were -4.5, 0.13, 771, and 6332, respectively. This relationship was not changed by addition of isoflurane at 1.0% end-tidal concentration (P = 0.40, analysis of variance). We conclude that isoflurane at 1.0% end-tidal concentration does not depress the hypoxic response of rabbit carotid body chemoreceptors during either hypo-, normo-, or hypercapnia. IMPLICATIONS: By measuring single-fiber chemoreceptor activity in anesthetized rabbits, we showed that isoflurane at 1.0% end-tidal concentration does not depress the hypoxic chemosensitivity of peripheral chemoreceptors during either hypo-, normo-, or hypercapnia in this species.

Molecular and immunological analyses of the Borrelia turicatae Bdr protein family.

Here, we describe the molecular and immunological characterization of the bdr gene family of Borrelia turicatae, a relapsing-fever spirochete. Nine bdr alleles belonging to two different subfamilies were sequenced and localized to linear plasmids. Anti-Bdr antiserum was generated and used to analyze Bdr expression in pre- and postinfection isogenic populations. The analyses presented here provide a detailed characterization of the Bdr proteins in a relapsing-fever spirochete species, enhancing our understanding of these proteins at the genus-wide level.

A cohort mortality study among gas generator utility workers.

An earlier cohort study tracked the mortality experience through 1988 of male employees at five utility companies in the United States. Workers employed by the Pacific Gas and Electric Company (PG&E) were part of that study, but results for PG&E employees overall or for those involved in gas generator plant operations where hexavalent chromium compounds were used in open and closed systems from the 1950s to early 1980s were not reported. To evaluate risk of lung cancer and other diseases, a cohort of 51,899 PG&E male workers was followed for mortality from 1971 through 1997. Observed numbers of deaths were compared with those expected based on rates in the general California population, with standardized mortality ratios (SMR) and corresponding 95% confidence intervals (CI) calculated for the total cohort and for subsets defined by potential for gas generator plant exposure. A total of 10,591 deaths were observed, a number significantly less than expected (SMR, 0.89; 95% CI, 0.87 to 0.91). No significant excesses of total or specific cancers were observed, with SMR typically near or below 1.0. Lung cancer mortality in the entire cohort was close to expected (SMR, 0.98; 95% CI, 0.92 to 1.05), with no excess detected among persons who worked (SMR, 0.81; 95% CI, 0.35 to 1.60) or trained (SMR, 0.57; 95% CI, 0.12 to 1.67) at gas generator facilities. Furthermore, risk of lung cancer did not increase with increasing duration of employment or time since hire. The study thus provides no evidence that occupational exposures at PG&E facilities resulted in increased risk of lung cancer or any other cause of death. The results indicate that any chromium exposures were of insufficient magnitude to result in increased risk of lung cancer.