Accessibility and quality of secondary care rheumatology services for people with inflammatory arthritis: a regional survey.

Secondary care rheumatology services for patients with inflammatory arthritis (IA) in the West Midlands were audited using Arthritis and Musculoskeletal Alliance (ARMA) standards of care. Questionnaires were analysed from 1,715 patients in 11 rheumatology departments. ARMA standards recommend full multidisciplinary team assessment; referral rates to nurse specialists (52.3%), physiotherapists (48.7%) and occupational therapists (36.5%) were, however, lower than expected. Attendance at existing hospital-led education groups was rare (8.9%), awareness of existing helplines was moderate (59.2%) but the proportion of patients reporting satisfaction with advice about their disease was high (80.5%). Significant variations were found between departments. For patients with IA < 2 years (n = 236), 84.5% were seen by a rheumatologist within the ARMA standard of 12 weeks of referral; diagnosis of a type of IA was made at the first rheumatology appointment in 66.4%; 82.8% of rheumatoid arthritis patients had commenced disease-modifying drugs, although time to commencement varied across departments. This study raises issues regarding provision of rheumatology services, prioritisation of patient referral and patient education.

The impact of anti-tumour necrosis factor therapy for rheumatoid arthritis on the use of other drugs and hospital resources in a pragmatic setting.

BACKGROUND: Anti-tumour necrosis factor (anti-TNF) therapy has been an important development for the treatment of rheumatoid arthritis (RA) but the impact of its delivery on hospital resources in still emerging. AIMS: We audited the effect of starting anti-TNF on the use of other anti-rheumatic therapies and hospital resources in a routine secondary care setting. METHODS: A retrospective study of resource use before and after anti-TNF was conducted. Hospital records of 54 RA patients were studied and data taken from the time of commencing anti-TNF to 1 October 2004 and an equal time period prior to commencing anti-TNF. Identical data were collected for 54 controls not on anti-TNF. Relevant figures were extrapolated to per annum rates. Results were analysed using two-factor ANOVAs comparing the pre- versus post-anti-TNF period. Cases on intravenous (IV) versus subcutaneous (SC) anti-TNF were also compared in separate ANOVAs. RESULTS: Mean duration of anti-TNF therapy was 17.04 months (range 3.60-42.36). Mean pre- and 3-months post-anti-TNF Disease Activity Scores (DAS28) were 6.93 and 3.88, respectively. Cases were more likely than controls to be on oral prednisolone pre- and post-anti-TNF. Methylprednisolone requirement, number of disease-modifying anti-rheumatic drugs (DMARDs), telephone helpline contacts and duration as an inpatient reduced significantly post-anti-TNF. Day case admissions increased but outpatient appointments decreased only in cases on IV anti-TNF. CONCLUSIONS: In a pragmatic setting, anti-TNF therapy led to reduced need for steroid injections and other DMARDs, as well as reductions in use of several hospital resources. Wider replication of these findings will be important for planning delivery.

Measurement of endotracheal tube cuff leak to predict postextubation stridor and need for reintubation.

BACKGROUND: The purpose of this study was to determine the predictive value of an endotracheal tube cuff leak for the development of postextubation stridor and the need for reintubation. STUDY DESIGN: Consecutive trauma patients who required intubation at a level I trauma center from July 1997 to July 1998 were studied prospectively. Pediatric patients and those who did not meet the standard weaning protocol criteria established by the Division of Trauma and Surgical Critical Care were excluded. Injury Severity Score, endotracheal tube size, reason for intubation, and the number of days intubated before the initial extubation attempt were recorded. At the time of extubation, the difference in exhaled tidal volume from before to after endotracheal tube cuff deflation was calculated. This number was then divided by the exhaled tidal volume before cuff deflation and was recorded as the percent cuff leak. Patients were followed for 24 hours after extubation for the development of stridor or need for reintubation. Statistical analysis to compare subgroups of patients was performed using ANOVA with Scheffé post hoc analysis. RESULTS: Among the 110 patients analyzed, the most common reason for intubation was closed-head injury. Seven patients (6.4%) developed stridor alone and had a mean cuff leak of 5 8 mL (8.4% of tidal volume before cuff deflation). Six patients (5.5%) experienced stridor that required reintubation and had a mean cuff leak of 68 mL (9.2% of tidal volume before cuff deflation). Patients who developed stridor or needed reintubation had been intubated for a significantly greater length of time than those not developing stridor or requiring reintubation (2.6 versus 3.0 days, p < 0.001). There were no differences in Injury Severity Score, endotracheal tube size, or reason for intubation between these groups. CONCLUSIONS: A cuff leak of less than 10% of tidal volume before cuff deflation is useful in identifying patients at risk for stridor or reintubation (96% specificity). It appears that the amount of cuff leak decreases after intubation for more than 3 days, increasing the risk of stridor and need for reintubation. This information may be helpful in identifying those patients who need treatment for laryngotracheal edema, ie, use of steroids or anesthesia during extubation, the efficacy of which remains to be determined.

Prevalence of pulmonary nocardiosis in a tuberculosis hospital in Amritsar, Punjab.

The prevalence of pulmonary nocardiosis in a tuberculosis and chest diseases hospital in Amritsar is reported. Of 1510 sputum samples cultured from 1016 patients, 67 sputa originating from 16 patients were found to be positive for the Nocardia asteroides species complex. Based upon repeated isolation of N. asteroides from the respiratory tract, its microscopic demonstration in KOH wet mounts or stained smears of sputum and clinical evaluation of patients, 14 cases of pulmonary nocardiosis were diagnosed. This gave a prevalence of 1.4% pulmonary nocardiosis in the tuberculosis hospital. The prevalence of the disease was found to be 1.3% in the males as against 1.5% in the females. Of the various clinical categories of patients investigated, pulmonary tuberculosis with sputum negative for acid-fast bacilli (AFB) yielded the highest prevalence of 3.2%, followed by 1.3%, 1.2%, 1.1% and 0.5% in pneumonia, chronic obstructive pulmonary disease (COPD), bronchiectasis and pulmonary tuberculosis with sputum positive for AFB, respectively. Type IV cutaneous hypersensitivity to nocardin was observed in 19 of 908 (2%) patients tested, whereas only a solitary positive reactor was found among 260 healthy volunteers. Twelve of 19 nocardin positive reactors (63%) had unequivocally proven pulmonary nocardiosis. The nocardin skin test gave false negative results in two nocardiosis patients. More comprehensive investigations are warranted in order to evaluate the nocardin skin test as an additional aid for the diagnosis of nocardiosis. Barring a solitary exception, the nocardiosis patients were successfully treated with sulphadiazine or trimethoprim-sulphamethoxazole (TMP-SMZ) combination. To the best of our knowledge, this is the largest series of pulmonary nocardiosis patients in a prospective study as yet reported from India. The observations underscore the point that nocardiosis warrants greater attention in the differential diagnosis of bronchopulmonary diseases.

Follow-up screening of lead-poisoned children near an auto battery recycling plant, Haina, Dominican Republic.

In August 1997 we performed a follow-up survey of 146 lead-poisoned children from a community near a previously active auto battery recycling smelter in Haina near Santo Domingo, Dominican Republic. Our follow-up survey confirmed a severe incidence of elevated blood lead (BPb) and erythrocyte protoporphyrin/zinc protoporphyrin (EP-ZnPP) levels. The mean BPb level was 32 micrograms/dL and the mean EP-ZnPP level was 128 micrograms/dL. The frequency distribution of BPb showed that only 9% of the children had BPb levels below the currently acceptable 10 micrograms/dL threshold level, 23% had between 10 and 19 micrograms/dL, 40% had between 20 and 39 micrograms/dL, 27% had between 40 and 99 micrograms/dL, and the remainder had > 100 micrograms/dL. These findings are significantly greater than the mean BPb and EP-ZnPP levels of 14 and 35 micrograms/dL, respectively, in a comparison group of 63 children in Barsequillo, 4 miles away. BPb frequency distributions for these groups were < 10 micrograms/dL (42%), 10-19 micrograms/dL (32%), and 20-39 micrograms/dL (16%); in the remaining 10%, BPb levels were between 40 and 99 micrograms/dL. Similarly, the corresponding frequency distribution of EP-ZnPP levels in Haina children were proportional to the severity of lead poisoning and significantly higher than those of the Barsequillo comparison group. This study reveals that at least 28% of Haina children require immediate treatment; of these, 5% with lead levels > 70 micrograms/dL are also at risk for severe neurologic sequelae, and urgent action is imperative.

A new high molecular weight agglutinin from garlic (Allium sativum).

Erythrocyte agglutination by lectins from Allium sativum was inhibited only by mannose of the sugars tested. However, asialofetuin was more effective inhibitor of agglutination as compared to mannose. This led to the use of an asialofetuin-silica affinity column to isolate agglutinins of 110 and 25 kDa (ASA110 and ASA25). While ASA25 is a dimeric protein comprising of subunits of 12.5 and 13.0 kDa, ASA110 is a glycoprotein of two identical subunits of 47 kDa. ASA110 revealed to have a high content of aspartic acid, glycine, leucine and serine but low content of cysteine and methionine. It contains 14 residues of neutral sugars in addition to 43 residues of hexosamines per mole of lectin and requires metal ions for its functional conformation. Serological cross-reactions with other species showed some common epitopes of ASA110 and ASA25 present in A. porrum, A. ascalonicum, Narcissus alba, PHA and Con A but not in A. cepa. ASA110 with CHO cells indicated it to be weakly cytotoxic with LD50 of 160 microg/ml.

New lymphocyte stimulating monocot lectins from family Araceae. II.

Two lectins purified from the tubers of Arisaema consanguineum Schott (ACA) and A. curvatum Kunth (ACmA) belonging to the monocot family Araceae were mitogenic for human peripheral blood mononuclear cells (PBMC) in the [3H]-thymidine uptake assay. ACA and ACmA had an optimum stimulatory concentration of 10-25 micrograms/ml and 50-100 micrograms/ml, respectively, as observed in PBMC from five different individuals. The mitogenic response of PBMC was inhibitable in a dose-dependent manner by asialofetuin. The lectins were T-cell specific, and stimulation kinetic studies using ACA and ACmA showed that they induce maximum thymidine uptake in PBMC at day 4 and 3, respectively.

Purification and properties of four monocot lectins from the family Araceae.

Four new monocot lectins from the tubers of araceous plants, namely, Arisaema consanguineum Schott (ACA), A. curvatum Kunth (ACmA) and Sauromatum guttatum Schott (SGA) from the tribe Areae, and Gonatanthus pumilus D. Don (GPA) from the tribe Colocasieae have been purified by affinity chromatography on asialofetuin-linked amino activated silica beads. These lectins possess similar physicochemical and biological properties. All the lectins gave a single peak on HPLC size exclusion and cation exchange columns, and a single band on PAGE, (pH 4.5). In SDS-PAGE, all the lectins gave a single band corresponding to a subunit of M(r) 1,3000. All the lectins yielded multiple peaks on anion-exchange column, multiple bands on non-denatured PAGE (pH 8.3) and a family of bands on isoelectric focusing. The lectins agglutinate rabbit, rat and sheep red blood cells (RBCs) but are inactive towards human ABO erythrocytes. The haemagglutination activity of these lectins is inhibited by asialofetuin only, while simple sugars/derivatives including chitin, porcine mucin and fetuin did not react. In serological studies against rabbit anti-SGA serum, all four lectins produced immunoprecipitin lines. The lectins within each tribe were identical but the lectins belonging to the tribe Areae were only partially identical to the lectins from the tribe Colocasieae.

New lymphocyte stimulating monocot lectins from family Araceae.

Three monocot lectins from underground tubers of plants belonging to the family Araceae were investigated for their mitogenic potential towards human peripheral blood lymphocytes. All the three lectins turned out to be potent mitogens in the [3H]-thymidine uptake assay. Gonatanthus pumilus lectin was mitogenic at an optimum concentration of 25 micrograms/ml while Alocasia indica and Sauromatum guttatum lectins were most effective at a concentration of 50 micrograms/ml. [3H]-thymidine incorporation studies further revealed that the lectins were T-cell mitogens and did not induce any appreciable DNA synthesis in B-enriched lymphocytes. The proliferation kinetic studies detected maximum incorporation on day 3 and the mitogenic response was shown to be inhibited by asialofetuin in a concentration-dependent manner.

Amaranthus hypochondriacus and A. tricolor lectins: isolation and characterization.

Asialofetuin-linked amino activated silica was used for the affinity purification of lectins from Amaranthus hypochondriacus Linn (AHL) and A. tricolor Linn (ATL). Like a few other Amaranthus lectins, these lectins were also inhibited by N-acetyl-D-galactosamine, fetuin and asialofetuin; they agglutinated human and different animal erythrocytes. The purified lectins yielded a single band on PAGE pH 8.3, pH 4.5 and SDS-PAGE, pH 8.3. These also gave a single peak in gel exclusion on Biogel P-200, HPLC 300 SW and cation exchange columns. However, both lectins gave multiple peaks in anion exchange column and multiple bands in isoelectric focusing. AHL and ATL are dimeric proteins in which the subunits having M(r) 29,000 and 39,000, respectively, are not held together by disulphide linkages. The pure lectins are glycoproteins and do not require Ca2+, Mn2+ and Mg2+ for their agglutination activity.

Screening of azo dyes for mutagenicity with Ames/Salmonella assay.

Azo dyes, the largest portion of manufactured dyestuffs, are primarily used as colouring substances in food, textiles, and the plastic industry. It has been estimated that 128 tonnes per annum of dyes are released into the environment worldwide [Anliker, 1977]. Certain azo compounds are known to be mutagenic in bacterial tests [Yahagi et al., 1975; Venitt and Bushell, 1976; Brown et al., 1978]. Watersoluble dyes are biotransformed by intestinal micro-organisms in the gastro intestinal tract, and the toxicity, mutagenicity, and carcinogenicity of these dyes in the gut or liver may be attributed to their metabolites. Since it is desirable to have a genotoxic evaluation of a chemical being released into the environment in order to check their indiscriminate use, a project has been initiated to determine the mutagenicity of the azo dyes being used commercially. The present report deals with the results of 13 dyes tested in Salmonella typhimurium with and without metabolic activation.

Comparison of paraffin baiting and conventional culture techniques for isolation of Nocardia asteroides from sputum.

Of 1,510 sputum samples examined from 1,016 patients with bronchopulmonary disorders, Nocardia asteroides was isolated from 67 samples by paraffin baiting, as compared with only 30 isolations by the conventional technique of culturing on Sabouraud dextrose agar. This higher efficacy of the paraffin bait technique was found to be statistically significant (P less than 0.001).

Occurrence and characterization of lympho-agglutinins in Indian plants.

Lympho-agglutinins have been detected and characterized in 31 plant species. Out of these, 14 agglutinated only the neuraminidase-treated cells. The lectin-rich genera included Crotalaria and Erythrina (Fabaceae), Amaranthus (Amaranthaceae), Artocarpus (Moraceae) and Clerodendron (Verbenaceae). The new lectins varied in their potency and biological action spectra. The 3 Artocarpus species were found to be exceptionally potent and specific for melibiose, an alpha-D-galactoside. Among the most effective sugar inhibitors for other lectins were N-acetyl-galactosamine, lactose, galactose and asialofetuin/fetuin.