The microbiological analysis of Sahara dust and its association with asthma in Barbados

Sahara or African dust originates on the African continent and its transported across the North Atlantic to Barbados and other Caribbean Islands by the North East Trade Winds. The amount of dust deposited in Barbados has shown a steady increase over the years and so has the incidence of respiratory disease and asthma. This study investigated the monthly variation of the concentration of Sahara dust in the atmosphere the presence of micro-organisms in it. It also examined whether there was any association between these and asthmatic attendances at the Asthma Bay of the Accident and Emergency Department of the Queen Elizabeth Hospital (QEH). During the one year study period, dust deposition was lowest during February and March 1996 and heaviest during April to July 1996 with the peak in April. The peak in April did not coincide with any noticeable increase in asthma attendances during that month. A total of 289 dust samples were collected and cultured. The cultures grew mainly bacillus species and fungi, including several species of Aspergillus. 43 samples (14.8 percent) grew bacilli and fungi and 5 (1.7 percent) grew organisms other than bacilli and fungi, such as micrococci. More colonies of fungi were isolated during the early part of the year and more bacilli were found during the latter part of the year when there was the peak attendance at the QEH Asthma Bay. It is concluded that the content of Sahara dust may be of greater importance to the development of asthma than the concentration of the dust.(AU)

Methylene blue selectively stains intestinal metaplasia in Barrett's esophagus.

BACKGROUND: Specialized columnar epithelium in Barrett's esophagus resembles gastric intestinal metaplasia, which selectively stains with methylene blue. METHODS: We prospectively evaluated the safety, accuracy, reproducibility, cost, and diagnostic yield of methylene blue-directed biopsy in detecting specialized columnar epithelium and dysplasia in Barrett's esophagus. We performed upper endoscopy with methylene blue-directed biopsy and obtained 236 large cup biopsy specimens (145 stained, 91 unstained) from 14 patients with Barrett's esophagus of any length (Group 1) and 12 control patients. Biopsy specimens were independently examined by two pathologists unaware of the endoscopic results. RESULTS: Methylene blue stained specialized columnar epithelium in 18 of the 26 patients, including those with intramucosal carcinoma (1), high-grade dysplasia (1), and indefinite/low-grade dysplasia (6). Methylene blue staining pattern, which was focal in 72% and diffuse in 28% of patients, was reproduced in 8 patients who had repeat staining within 4 weeks. The overall accuracy of methylene blue staining for detecting specialized columnar epithelium was 95%. The diagnostic yield of methylene blue staining for specialized columnar epithelium in "control" patients was 42%. The risk for dysplasia in stained biopsy specimens was greater than in unstained ones (odds ratio 17.7, p = .0004). CONCLUSIONS: Methylene blue mucosal staining is a safe, inexpensive, reproducible, and highly accurate method of diagnosing specialized columnar epithelium in Barrett's esophagus.

Prospective assessment of colonoscopic intubation skills in trainees.

INTRODUCTION: The American Society for Gastrointestinal Endoscopy recommends a minimum of 100 supervised colonoscopies prior to assessment of technical competence. To establish a measurable standard for competence and to assess this recommendation, performance of colonoscopies at a university hospital was studied. METHODS: Colonoscopic preparation, surgical history, medication usage, technical maneuvers, extent of colon intubated, success rate, and cecal intubation time were prospectively monitored for first-year trainees, second-year trainees, and attendings. RESULTS: Excluding patients with poor preparations or colonic resections, 496 colonoscopies were studied. First-year trainees (n = 5) required attending assistance in 73 of 79 (92%) procedures. Second-year trainees (n = 7), who had performed a mean of 123 colonoscopies prior to the study, required attending assistance in 37 of 102 (36.3%) procedures. Attendings (n = 7) successfully intubated the cecum in 297 of 315 (94.3%) colonoscopies in a median time of 10.5 minutes. Second-year trainees were less successful than attendings in cecal intubation (success rate = 84%, p < 0.05), and required more time (median = 14.5 minutes, p < 0.01). More technical maneuvers were performed, and a lesser extent of colon was intubated, during trainee colonoscopies. CONCLUSIONS: We propose a 90% success rate and a median cecal intubation time of less than 15 minutes as reasonable standards for measuring technical competence. Trainees do not achieve this standard after the performance of 100 supervised colonoscopies.

Central nervous system Whipple's disease: relapse during therapy with trimethoprim-sulfamethoxazole and remission with cefixime.

The central nervous system (CNS) is frequently involved in patients with Whipple's disease and is the most common site of disease relapse. Antibiotics such as trimethoprim-sulfamethoxazole (TMP-SMX) that have reliable CNS penetration, are therefore recommended as first-line therapy. We report a patient with Whipple's disease who was treated with TMP-SMX and presented 14 months after initiation of therapy with visual decline and severe headaches. The patient was also treated concurrently with low-dose weekly methotrexate for severe psoriasis. Evaluation by magnetic resonance imaging revealed bilateral posterior white matter abnormalities that pathologically were consistent with Whipple's disease. He was ultimately treated with cefixime, an orally administered third-generation cephalosporin. Visual function improved on this regimen and follow-up magnetic resonance imaging showed regression of the lesions. This case represents the first report of both CNS relapse during therapy with TMP-SMX and successful treatment with cefixime. We also speculate that methotrexate, which impairs cell-mediated immunity, may have contributed to the relapse.

Restoration of exocrine pancreatic function following pancreas-liver-kidney transplantation in a cystic fibrosis patient.

Pancreatic transplantation for endocrine replacement is well-established for insulin-dependent diabetes mellitus. Exocrine pancreatic function after pancreas transplantation has been maintained after orthotopic cluster transplants for malignancy, and restoration of adequate exocrine function in a previously deficient patient has been reported in a patient with chronic pancreatitis who developed labile diabetes and steatorrhea after pancreatectomy. We performed a triple organ transplant (pancreas, liver and kidney) in a patient with exocrine pancreatic insufficiency and insulin-dependent diabetes related to cystic fibrosis (CF) after he developed hepatic and renal failure. Pancreatic exocrine secretions were drained enterically to the jejunum. At 24-month follow-up, malabsorption is absent. The 3-day stool fat, stool trypsin and chymotrypsin are normal. Serum carotene is within the normal range. Exocrine pancreatic insufficiency in CF patients can be corrected by pancreas transplantation. However, routine use in CF is precluded by the risks of surgery and immunosuppression. For diabetic patients with pancreatic exocrine insufficiency who require another organ transplant (e.g., lung, liver, or kidney), simultaneous pancreas transplantation with the exocrine secretions directed into the upper gastrointestinal tract should be considered.

Role of upper endoscopy in evaluation of upper gastrointestinal symptoms in patients undergoing bone marrow transplantation.

We reviewed our upper endoscopy (esophagogastroduodenoscopy, EGD) experience in a group of 65 consecutive patients receiving carmustine (BCNU) 600 mg/m2, cisplatin 200 mg/m2, VP-16 2400 mg/m2, and autologous bone marrow transplantation (BMT) for relapsed or refractory non-Hodgkin's lymphoma or Hodgkin's disease. Forty-one patients (33 with chest irradiation) underwent 48 EGDs for the following symptoms: upper gastrointestinal bleeding (melena and/or hematemesis) (12/48); persistent nausea and vomiting (7/48); odynophagia (25/48); and dysphagia (14/48). All patients who had dysphagia or odynophagia had endoscopic evidence of severe esophagitis, with confluent erosions or ulcerations. Gastrointestinal bleeding, which presented as melena or hematemesis, was caused by severe esophagitis in 11 of 12 patients. Yeasts were detected in 11/42 histological, or cytological specimens and were isolated in 4/26 cultures. No bleeding or infectious complications occurred in any patient as a result of the EGD procedure. We conclude that severe esophagitis documented by EGD is common in lymphoma patients receiving autologous BMT. Use of EGD, however, did not affect the decision to initiate empirical therapy with amphotericin B for persistent fever.