Comparison of the urine-based ligase chain reaction test to culture for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in pediatric sexual abuse victims.

BACKGROUND: The urine-based ligase chain reaction (LCR) assay for Chlamydia trachomatis and Neisseria gonorrhoeae is an attractive alternative to culture because of the relative ease with which specimens may be collected, transported and processed. In addition LCR offers superior sensitivity while maintaining high specificity when compared with culture in various studies of adolescents and adults. A study comparing LCR to culture has not been published concerning children. METHODS: We conducted a prospective, comparison trial of the urine-based LCR test for Chlamydia trachomatis and Neisseria gonorrhoeae as compared with culture among children at a specialized referral center for evaluation for alleged sexual assault. Of the 1,010 children presenting to the center during the study period, 164 met the study requirements for risk of a sexually transmissible disease and collection of both culture and urine LCR specimens. RESULTS: Eight specimens tested positive by both methods for C. trachomatis. Another 10 specimens tested positive for C. trachomatis by LCR but were negative by culture. No patient with a negative LCR for C. trachomatis had a positive culture. For N. gonorrhoeae 2 specimens tested positive by both methods, and 3 specimens tested positive by LCR but negative by culture. No patient with a negative LCR for N. gonorrhoeae had a positive culture. CONCLUSIONS: The low prevalence of disease in the study population precluded statistical analysis. LCR may prove to be as specific and more sensitive than culture for the detection of C. trachomatis and N. gonorrhoeae in children. Further studies are needed.

Elevated cardiac troponin levels do not predict adverse outcomes in hospitalized patients without clinical manifestations of acute coronary syndromes.

The prognostic significance of elevated cardiac troponin levels (CTL) in hospitalized patients with no other evidence of myocardial ischemia or injury is largely unknown. Fifty patients (mean age 61 +/- 15 years, 15 women) out of 580 consecutive hospitalized patients were selected based on normal CK-MB and at least 3-fold increase of CTL. The medical charts of these patients were reviewed and a 1-year follow-up was performed. The most frequent admission diagnoses were exacerbation of congestive heart failure (22%), stroke (20%) followed by respiratory failure (6%), cirrhosis (6%), gastrointestinal bleeding (6%), end-stage renal disease (4%), atrial fibrillation (4%) and metastatic malignancies (4%). Abnormal CTL prompted a cardiology consult in 48% of patients, an echocardiogram in 44%, myocardial perfusion study in 10% and coronary angiography in 1 patient. Of 21 deaths, only 1 was related to an acute coronary event. The measurement of CTL in patients without definite clinical or electrocardiographic evidence of myocardial ischemia and with a wide spectrum of clinical diagnoses does not predict in-hospital and at 1 year cardiovascular complications and/or cardiac death.

The impact of elevated serum IgA and race on primary recipient renal allograft survival.

This study correlated overall serum IgA levels in pretransplant (preTx) sera with graft survival. IgA levels, determined by nephelometry, were normally distributed, with a mean level of 255 +/- 139 mg/dl and a median of 234 mg/dl in 631 adult primary kidney allograft recipients and a mean level of 213 +/- 123 mg/dl with a median of 196 mg/dl for 100 retransplant recipients. Improved 3-year survival was associated with a high preTx IgA serum level in primary recipients (Kaplan-Meier analysis, P = 0.01), but not in retransplant patients. After stratifying by race, IgA correlated with graft survival in Caucasian, Hispanic, and "other" (Middle Eastern, Indian subcontinent, and Asian) primary recipients (P < or = 0.04), but not in African Americans. Higher survival rates were not associated with IgA in primary recipients stratified for rejection episodes, blood transfusions, or HLA-DR mismatches. Graft survival was improved in patients with > 2 HLA-AB mismatches and serum IgA above the median. PreTx IgA level and IgA alpha-HLA activity were significantly associated in preTx sera of primary renal allograft recipients (chi 2 = 7.145, P = 0.01), although only 9% (12/133) of sera tested displayed IgA anti-HLA class I reactivity. Thus, enhanced graft survival mediated by elevated serum IgA levels may due in part to competition for allograft HLA class I binding with deleterious Ig subclasses or immune effector cells. Elevated serum IgA may also reflect an altered immunoregulatory state. The results suggest that, depending on the racial group, preTx serum IgA levels are a prognostic indicator of graft survival in primary renal allograft recipients.

Maternal and fetal colloid osmotic pressure following fluid expansion during cesarean section.

OBJECTIVES: To characterize the changes in colloid osmotic pressure during delivery and to determine the relationship between maternal and fetal colloid osmotic pressures. DESIGN: Clinical, prospective study. SETTING: Obstetrical operating theater in a tertiary care university hospital. PATIENTS: Thirty healthy parturient patients, at term gestation receiving spinal anesthesia for elective cesarean section. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Maternal colloid osmotic pressure samples were obtained at the time of intravenous insertion and delivery. Fetal umbilical vein and umbilical artery colloid osmotic pressure samples were measured from the umbilical cord at delivery. The volume of intravenous infusion and dose of ephedrine were recorded for each patient. Maternal colloid osmotic pressure at delivery was significantly less than that value measured at the time of intravenous catheter insertion in each patient (15.8 +/- 0.3 vs. 23.1 +/- 0.3 mm Hg; p < .0001). Umbilical artery colloid osmotic pressure was consistently higher than umbilical vein colloid osmotic pressure (21.0 +/- 0.4 vs. 19.4 +/- 0.3 mm Hg; p < .0001). Both umbilical artery colloid osmotic pressure and umbilical vein colloid osmotic pressure were significantly higher than maternal colloid osmotic pressure at delivery (p < .0001). The volume of intravenous infusion and the dose of ephedrine both correlated inversely with maternal colloid osmotic pressure measured at delivery (p < .05). CONCLUSIONS: The reduction in maternal colloid osmotic pressure during delivery is, in part, related to intravenous fluid expansion and the amount of vasopressor administered. Despite the significant fluctuations in maternal colloid osmotic pressure, the placenta and fetus possess the capability to alter colloid osmotic pressure.

Perioperative analgesia with subarachnoid sufentanil administration.

BACKGROUND AND OBJECTIVES: Thirty-seven ASA Physical Status I parturients undergoing elective cesarean delivery were evaluated to determine the effects of subarachnoid sufentanil administration. METHODS: This study was carried out in a randomized, double-blind fashion. All patients received 1.4 ml 0.75% bupivacaine with 8.25% dextrose following 10 micrograms, 15 micrograms, or 20 micrograms sufentanil, or 1 ml of normal saline containing no sufentanil. Onset and duration of sensory and motor anesthesia, duration of complete analgesia, duration of effective analgesia, and intraoperative parenteral opioid requirements were evaluated. Incidence of side effects such as respiratory depression, pruritus, nausea, and vomiting were evaluated. RESULTS: Duration of complete analgesia and duration of effective analgesia were prolonged significantly in all patient groups receiving sufentanil as compared to control groups receiving no narcotic. Pruritus was significantly increased in patient groups receiving subarachnoid sufentanil. Respiratory depression was not observed in any patient studied. One- and five-minute Apgar scores; umbilical, venous, and arterial blood gas results; and Early Neonatal Neurobehavioral Scale results were all within normal limits and were not significantly different among the groups.

Vertebral column length and spread of hyperbaric subarachnoid bupivacaine in the term parturient.

Patient height is considered an important determinant of the dose of spinal anesthesia. However, the relationship between body height and the level of sensory anesthesia with a fixed dose of spinal anesthetic has not been clearly documented. Recent evidence suggests no correlation between height or weight of parturients and spread of spinal anesthesia. Vertebral column length rather than body height may be more important in determining anesthetic spread. We studied the correlation between vertebral length measured from C7 to the level of the iliac crest (IC) and to the sacral hiatus (SH) and the sensory anesthetic level after the subarachnoid administration of 12 mg hyperbaric bupivacaine in term pregnant patients. There was no correlation between patient height, weight or body mass index and sensory anesthesia level. However, a significant correlation existed between vertebral length measured from C7 to IC (r = 0.32, p = 0.025) or to SH (r = 0.38, p = 0.006) and the level of anesthesia.

Comparative effects of subarachnoid hyperbaric bupivacaine and tetracaine-procaine for cesarean delivery.

Hyperbaric solutions of 0.75% bupivacaine (8.25% dextrose), and 1% tetracaine mixed with an equal volume of 10% procaine were compared in a double-blind study of 22 parturients undergoing elective cesarean delivery and spinal anesthesia. The onset of sensory anesthesia and motor block was similar in the two groups. The maximal level of sensory anesthesia to pinprick was significantly higher after the use of the tetracaine-procaine mixture. The adequacy of anesthesia was similar in both groups as indicated by the lack of differences with regard to anesthetic supplementation between the groups. However, a significantly shorter duration of sensory anesthesia and motor blockade occurred in the group in which bupivacaine was employed. The incidence of hypotension was higher in those patients receiving the tetracaine-procaine mixture as indicated by the use of significantly higher total doses of ephedrine to maintain baseline blood pressure in this group. No differences in Apgar scores or blood gases were noted between the two groups of patients. This study suggests that hyperbaric 0.75% bupivacaine offers certain advantages over hyperbaric tetracaine-procaine when used in equal volumes for spinal anesthesia cesarean delivery.

Continuous noninvasive monitoring of cardiac output with esophageal Doppler ultrasound during cardiac surgery.

Esophageal Doppler ultrasonography offers a continuous and noninvasive alternative to standard thermodilution cardiac output monitoring. A total of 372 simultaneous measurements of Doppler and thermodilution cardiac output were compared in 16 patients undergoing cardiac surgery. In addition, echocardiographic aortic diameter measurement, necessary for Doppler calibration, was compared with direct surgical measurement in 23 patients. Echocardiographic aortic measurement was often time consuming and correlated poorly (r = 0.31) with surgical measurement. On the other hand, Doppler cardiac output was determined easily and accurately tracked thermodilution cardiac output (R2 = 0.95, common slope coefficient 1.050, by multiple linear regression). Furthermore, Doppler cardiac output was more reproducible, showing less short-term variability than thermodilution cardiac output. The esophageal Doppler technique allows cardiac output monitoring in patients for whom invasive monitoring is not warranted.

A potential mechanism in medroxyprogesterone acetate teratogenesis.

PIP: MPA (medroxyprogeste)rone acetate) has been shown to be te)ratogenic in rabbits but not in rats or mice (Andrew and Staples 1977). Since normal steroid action appears to be mediated, in large part, through interaction with specific steroid receptors, it was postulated that the species difference in teratogenicity might be due to a difference in the interaction of MPA with target cells. A primary event in steroid-cell interaction is the binding of a steroid to intracellular receptors. Studies were initiated to measure the specific nature of MPA binding to glucocorticoid and progestin receptors in appropriate rat and rabbit target tissues. The competition of MPA with 3H-dexamethasone binding in liver cytosol (glucocorticoid receptor) and with 3H-progesterone binding in uterine cytosol (progesterone receptor) was determined. In rabbit liver cytosol, MPA was as effective at competing for specific dexamethasone binding as the natural glucocorticoids and considerably more effective than the nonspecific steroids. In rat liver cytosol MPA was only 10% as effective as the natural glucocorticoids and the competition could not be distinguished from that of nonspecific steroids. A similar species difference was not seen in uterine cytosol; MPA competed with progesterone in a similar fashion in both rat and rabbit. These data demonstrate a distinct species difference in the competitive nature of MPA for the glucocorticoid receptor but not for the progestin receptor. The results suggest that MPA, or possibly a metabolite, may be teratogenic in rabbits by binding with specific glucocorticoid receptors to inhibit or alter normal steroidal function in embryo-fetal development.^ieng