Aetiological role of viral and bacterial infections in acute adult lower respiratory tract infection (LRTI) in primary care.

BACKGROUND: Lower respiratory tract infections (LRTI) are a common reason for consulting general practitioners (GPs). In most cases the aetiology is unknown, yet most result in an antibiotic prescription. The aetiology of LRTI was investigated in a prospective controlled study. METHODS: Eighty adults presenting to GPs with acute LRTI were recruited together with 49 controls over 12 months. Throat swabs, nasal aspirates (patients and controls), and sputum (patients) were obtained and polymerase chain reaction (PCR) and reverse transcriptase polymerase chain reaction (RT-PCR) assays were used to detect Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneumophila, influenza viruses (AH1, AH3 and B), parainfluenza viruses 1-3, coronaviruses, respiratory syncytial virus, adenoviruses, rhinoviruses, and enteroviruses. Standard sputum bacteriology was also performed. Outcome was recorded at a follow up visit. RESULTS: Potential pathogens were identified in 55 patients with LRTI (69%) and seven controls (14%; p<0.0001). The identification rate was 63% (viruses) and 26% (bacteria) for patients and 12% (p<0.0001) and 6% (p = 0.013), respectively, for controls. The most common organisms identified in the patients were rhinoviruses (33%), influenza viruses (24%), and Streptococcus pneumoniae (19%) compared with 2% (p<0.001), 6% (p = 0.013), and 4% (p = 0.034), respectively, in controls. Multiple pathogens were identified in 18 of the 80 LRTI patients (22.5%) and in two of the 49 controls (4%; p = 0.011). Atypical organisms were rarely identified. Cases with bacterial aetiology were clinically indistinguishable from those with viral aetiology. CONCLUSION: Patients presenting to GPs with acute adult LRTI predominantly have a viral illness which is most commonly caused by rhinoviruses and influenza viruses.

The community prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in older people living in their own homes: implications for treatment, screening and surveillance in the UK.

Methicillin-resistant Staphylococcus aureus (MRSA) predominantly affects those over 65 years old. There may be a substantial pool of older people with MRSA in the community. We studied the prevalence in one London general practice, screening 258 older people living in their own home. MRSA (E-MRSA 15) was found in two participants (0.78%). Past history of MRSA was the only significant risk factor. The results of this and other studies suggest that national guidelines recommending early discharge for MRSA carriers have not resulted in widespread community acquisition amongst elderly people living in their own home. Community antibiotic policies for skin and soft-tissue infection do not require amendment. Patients with previous MRSA should be isolated and screened on admission especially to high-risk units.

High-efficiency biolistic co-transformation and regeneration of 'Chardonnay' (Vitis vinifera L.) containing npt-II and antimicrobial peptide genes.

A reliable and efficient system for transformation and regeneration of 'Chardonnay' (Vitis vinifera L.) plants via microprojectile bombardment was developed. Improvements over the previous biolistic transformation system included: (1) the use of gold particles for bombardment; (2) step-wise selection at 10 then 15 mg/l kanamycin; and (3) embryo induction at 27 degrees C. Embryogenic cell cultures were either bombarded with pBI426, which contains the reporter gene gus (uidA) coding for beta-glucuronidase (GUS), or were co-bombarded with pSAN237 carrying the npt-II (neomycin phosphotransferase II) selectable marker gene, and a second plasmid with an antimicrobial peptide gene. A large number of transient (7,883 +/- 1,928) and stable (46 +/- 32) blue spots per plate at 2 and 95 days after bombardment, respectively, were obtained according to GUS expression analyses. A total of 447 putative transgenic embryos was harvested from 84 bombarded plates. From these embryos, 242 (54%) were regenerated into plants within the first year of the experiment. Southern blot analyses confirmed integration of the transgenes into the grape genome. Co-transformation was tested with four separate antimicrobial constructs. The co-transformation frequency of unlinked genes was 48% as measured by polymerase chain reaction (PCR), and 56% as estimated by dot blot hybridization. Expression of the gus gene, and PCR and Southern blot analyses of npt-II and antimicrobial genes from regenerated plants document stable transformation of 'Chardonnay' and establish the parameters for highly-efficient biolistic transformation in V. vinifera.

Design and performance of a multicentre, randomized controlled trial of teleconsulting.

We have designed and performed a multicentre, randomized controlled trial of teleconsulting. The trial investigated the effectiveness and cost implications in rural and inner-city settings of using videoconferencing as an alternative to general practitioner referral to a hospital specialist. The participating general practitioners referred a total of 3170 patients who satisfied the entry criteria. Of these, 1040 (33%) failed to provide consent or otherwise refused to participate in the trial. Of the patients recruited to the trial, a total of 1902 (91%) completed and returned the baseline questionnaire. Although the trial was successful in recruiting sufficient patients and in obtaining high questionnaire response rates, the findings will require careful interpretation to take account of the limits which the protocol placed on the ability of general practitioners to select patients for referral.

The fate of glucose in strains S288C and S173-6B of the yeast Saccharomyces cerevisiae.

Intracellular metabolic flux has been investigated in two strains of Saccharomyces cerevisiae grown into stationary phase under both glucose-repressed and glucose-derepressed conditions. By employing a variety of simple methodologies (manometry, enzymatic analysis and colorimetric analysis) we have been able to identify and quantitate carbon flow from glucose without the need for isotopically labelled substrate. We can account for 88-98% (depending on strain and growth conditions) of the carbon products of glucose metabolism under both glycolytic and oxidative conditions as ethanol (27-40%), carbon dioxide (15-26%), acetate (2-3%), glycerol (5-11%), glycogen (5-13%) and trehalose (9-39%).

Transgenic plantlets of 'Chancellor' grapevine (Vitis sp.) from biolistic transformation of embryogenic cell suspensions.

Transgenic plantlets of 'Chancellor' grapevine (Vitis L. complex interspecific hybrid) were produced via biolistic transformation. Embryogenic cell suspensions were bombarded with 1 µm tungsten particles coated with pBI426 which encodes a fusion peptide between ß-glucuronidase (GUS) and neomycin phosphotransferase II (NPTII). The fusion peptide is under the control of a double 35S Cauliflower Mosaic Virus promoter and a leader sequence from Alfalfa Mosaic Virus. The cells were placed on kanamycin-containing media (10, 25 or 50 mg/l) 2 d after bombardment. Activated charcoal reduced cell browning. Embryos were first observed on selective media 14-29 weeks after bombardment. More than 1600 clusters of embryos were germinated and/or assayed for GUS. Of 621 embryos assayed for GUS expression, 182 (29.3%) were positive. PCR confirmed the presence of the NPTII gene in all 5 GUS-positive and 2 GUS-negative (bombarded) embryos tested. In germination experiments, 15% of the embryo clusters produced at least one plant with normal shoot growth. Of 164 normal plants assayed for GUS expression, 37 (22.6%) were positive. The NPTII gene was amplified by PCR in 1 (of 1) GUS-positive and 4 (of 5) GUS-negative bombarded plants, but not in non-bombarded control plants. Southern blotting confirmed integration of the NPTII gene in all 3 of the GUS and PCR-NPTII positive plants tested. Biolistics is an efficient method for transformation of 'Chancellor' and should be applicable to other important grape cultivars.

A method for the determination of the cellular phosphorylation potential and glycolytic intermediates in yeast.

A method is described for rapidly quenching metabolism in yeast and extracting metabolites for analysis. The saponin digitonin is used to permeabilize the yeast cell membrane, in conjunction with perchloric acid (PCA) to quench metabolism and extract metabolites. Using this digitonin-PCA quench and extraction procedure, we have determined ATP concentrations in Saccharomyces cerevisiae in the range 2.89-3.39 mM, [ATP]/[ADP] ratios of 4.5-6.6, and phosphorylation potentials of 48.7-49.9 kJ.mol-1. A direct comparison with the currently accepted freeze/grind PCA/thaw procedure for extraction of yeast cell metabolites shows that essentially the same values are obtained by both techniques. The digitonin-PCA quench extraction method, used in conjunction with automated enzymatic analyses of metabolites, allows rapid extraction and analysis of large numbers of samples and metabolites and hence permits detailed investigations of intermediary metabolism in yeast.

Studies in postoperative sequelae. Nausea and vomiting--still a problem.

We collected data on postoperative nausea and vomiting from 3850 patients aged 11-91 years. Thirty-seven percent of the 3244 patients who received a general anaesthetic reported nausea and 23.2% vomited. Twenty percent of the 606 patients who received a local anaesthetic reported nausea and 11.4% vomited. Of the general anaesthetic patients reporting nausea, 72.2% were women, and the mean age was lower than for those who did not (p < 0.001). Similarly for vomiting, 74.0% were women and again the mean age was lower (p < 0.001). Of the local anaesthetic patients reporting nausea, 62.0% were women and the mean age was lower than for those who did not (p < 0.001). Similarly for vomiting, 68.1% were women and again the mean age was lower (p < 0.001). Anxiety before general, but not local, anaesthesia was associated with postoperative nausea (p < 0.001) but not vomiting. Patients from the gynaecological, orthopaedic, ENT and general surgical wards had higher incidences of postoperative nausea and vomiting. Linear visual analogue pain scores were higher in patients with postoperative nausea and vomiting in both general and local anaesthesia groups (p < 0.001).

Operation and energy dependence of the reducing-equivalent shuttles during lactate metabolism by isolated hepatocytes.

The participation and energy dependence of the malate-aspartate shuttle in transporting reducing equivalents generated from cytoplasmic lactate oxidation was studied in isolated hepatocytes of fasted rats. Both lactate removal and glucose synthesis were inhibited by butylmalonate, aminooxyacetate or cycloserine confirming the involvement of malate and aspartate in the transfer of reducing equivalents from the cytoplasm to mitochondria. In the presence of ammonium ions the inhibition of lactate utilization by butylmalonate was considerably reduced, yet the transfer of reducing equivalents into the mitochondria was unaffected, indicating a substantially lesser role for butylmalonate-sensitive malate transport in reducing-equivalent transfer when ammonium ions were present. Ammonium ions had no stimulatory effect on uptake of sorbitol, a substrate whose oxidation principally involves the alpha-glycerophosphate shuttle. The role of cellular energy status (reflected in the mitochondrial membrane electrical potential (delta psi) and redox state), in lactate oxidation and operation of the malate-aspartate shuttle, was studied using a graded concentration range of valinomycin (0-100 nM). Lactate oxidation was strongly inhibited when delta psi fell from 130 to 105 mV whereas O2 consumption and pyruvate removal were only minimally affected over the valinomycin range, suggesting that the oxidation of lactate to pyruvate is an energy-dependent step of lactate metabolism. Our results confirm that the operation of the malate-aspartate shuttle is energy-dependent, driven by delta psi. In the presence of added ammonium ions the removal of lactate was much less impaired by valinomycin, suggesting an energy-independent utilization of lactate under these conditions. The oxidizing effect of ammonium ions on the mitochondrial matrix apparently alleviates the need for energy input for the transfer of reducing equivalents between the cytoplasm and mitochondria. It is concluded that, in the presence of ammonium ions, the transport of lactate hydrogen to the mitochondria is accomplished by malate transfer that is not linked to the electrogenic transport of glutamate across the inner membrane, and, hence, is clearly distinct from the butylmalonate-sensitive, energy-dependent, malate-aspartate shuttle.

Preparation of the critically ill for interhospital transfer.

Changes in monitoring and therapy during the preparation of 100 critically ill patients for interhospital transfer by a specialist team were documented prospectively with the aim of providing guidelines for nonspecialists. Severity of illness scores were recorded before and after preparation. Median duration of preparation for ambulance journeys was 50 min and for aeroplane journeys was 82 min. During preparation, a portable electrocardiogram and pulse oximeter were attached to 21 and 76 patients respectively and intra-arterial pressure monitoring was continued or instituted in 88 patients. Supplemental oxygen and intravenous fluids were the therapies most commonly increased or instituted by the transport team; mechanical ventilation, positive end-expiratory pressure and inotropic drugs were increased or instituted less frequently. Median therapeutic intervention scores before and after preparation were 21 and 23 respectively, highlighting the need to increase rather than withdraw support for transfer.

Post-viral fatigue syndrome. Epidemiology: a critical review.

Numerous reports in medical journals, lay magazines, and newspapers bear witness to the level of interest in the postviral fatigue syndrome and the heated controversy about the true nature of this condition. For many, it represents a 'rag bag' diagnosis into which unsolved diagnostic problems are discarded. Others are in no doubt that there is a discrete syndrome, probably with a specific causation. The real answer almost certainly lies somewhere in between, but the truth can only be established through epidemiological studies designed to answer key questions. Does it exist at all, and, if so, how frequently does it occur? Who is most likely to get it and what is its cause? What is the nature of its implied association with viral infections and what is the role of other frequently postulated factors, such as psychiatric morbidity? What is its natural history and is there any evidence that any of the treatment/management regimes on offer can effectively lead to symptomatic relief or improve prognosis? In this chapter, we consider the evidence on these key questions, identify some of the deficiencies in our current knowledge and highlight the kind of research which is still required.

Quality of life after intensive care.

An important aspect of effectiveness of intensive care services is change in the quality of life of survivors after critical illness. A questionnaire was complied using established methods for assessment of quality of life and sent to all known survivors of a regional intensive care unit. Each patient's quality of life was then quantified using disability categories. The results show that patients with a good premorbid quality of life suffered a significant decline after critical illness. Similar important decreases in quality of life were found in younger patients and trauma victims. Quality of life may be a valuable consideration in determining the appropriateness of intensive care management.