Improving the detection of carbapenemase-producing organisms (CPO) in a low-prevalence setting: evaluation of four commercial methods and implementation of an algorithm of testing.

PURPOSE: Carbapenemase-producing organisms (CPOs) can be resistant to almost all ß-lactams and represent an increasing threat in healthcare facilities. Detection of these organisms in routine diagnostic laboratories is difficult; here we evaluate four commercially available CPO detection assays and assess their suitability for the clinical laboratory. METHODOLOGY: A panel of 95 clinical multidrug-resistant organisms (22 NDM, 24 OXA-48, 19 VIM, 4 OXA-23, 3 KPC, 4 NDM+OXA-48, 1 OXA23+NDM, 1 IMI, 1 IMP-1, 9 ESBL, 3 derepressed AmpC and 4 inducible AmpC producers) were tested by the RESIST-3 O.K.N., RapidEC CarbaNP, Acuitas Resistome and Xpert Carba-R assays.Results/Key Findings. The commercial assays performed well, with high sensitivities (96.2-100 %) and specificities (all, 100 %). The RapidEC CarbaNP and Acuitas Resistome were able to detect the broadest range of carbapenemase genotypes. The RESIST-3 O.K.N. and Xpert CarbaR had the shortest turnaround times, whilst the RapidEC CarbaNP was the only assay included in this study that could detect previously undescribed genotypes. CONCLUSION: Using an algorithm of the RapidEC CarbaNP, followed by either the RESIST-3 O.K.N. (Enterobacteriaceae) or the Xpert Carba-R (Pseudomonas aeruginosa and Acinetobacter spp.) on suspect CPOs allowed rapid in-house detection and genotyping of a high proportion of CPOs, reducing turnaround time by up to 7 days.

Vitamin D deficiency in pregnant women from a non-European ethnic minority population--an interventional study.

OBJECTIVE: To determine the vitamin D status of pregnant women from non-European ethnic minorities in South Wales. DESIGN: Prospective study. SETTING: Llandough Hospital, Cardiff, South Wales. SAMPLE: One hundred and sixty pregnant women from a non-European ethnic minority population in South Wales. METHODS: Biochemical screening of vitamin D status was carried out at the first antenatal visit. Women found to be deficient in vitamin D were subsequently supplemented and vitamin D status was rechecked at delivery. MAIN OUTCOME MEASURE: Vitamin D status at delivery. RESULTS: Eighty of 160 women had a vitamin D level below 8 ng/mL at their first antenatal visit and were treated with oral vitamin D. Factors that could influence vitamin D status such as religion, fluency in English and dressing habits did not appear to have any effect, although a higher proportion of women who had lived in Britain for longer than three years had subnormal vitamin D levels. In 58 of those checked at delivery, the mean plasma vitamin D level increased from 6 to 11 ng/mL although the mean parathyroid hormone level was unchanged. CONCLUSION: In view of the high incidence of subnormal vitamin D levels in women from ethnic minorities, we recommend biochemical screening of these women in early pregnancy, with subsequent supplementation where indicated.

Bone mineral density, collagen type 1 alpha 1 genotypes and bone turnover in premenopausal women with diabetes mellitus.

Osteopenia is a recognised complication of diabetes mellitus which could be due to abnormal bone turnover or disturbances in the calcium/parathyroid hormone/vitamin D axis or both. Genetic factors also play an important part in determining bone mass although this has not been studied in diabetes. Recently a polymorphism of the collagen type 1 alpha 1 (COL1A1) gene has been shown to be associated with low bone mass in British women. To identify subjects with diabetes who may be at risk of developing osteoporosis and fractures, we analysed bone mineral density in relation to the biochemical markers of bone turnover, calcium homeostasis and the COL1A1 genotype in a group of premenopausal women with Type I (insulin-dependent) diabetes mellitus (n = 31), Type II (non-insulin dependent) diabetes mellitus (n = 21) and control subjects (n = 20). Bone mineral density was lower at the femoral neck in the subjects with Type I diabetes (p = 0.08) as were serum 25-hydroxyvitamin D compared with control subjects (p = 0.023) and this was negatively correlated with serum collagen type 1 C-terminal propeptide (r = -0.56, p < 0.001). Bone mineral density in Type II diabetes was not different from control subjects, after correction for body mass index. Bone resorption was, however, raised in the Type II diabetic subjects as reflected by the higher urinary deoxypyridinoline values (p = 0.016) and lower collagen type 1 C-terminal propeptide:deoxypyridinoline ratio (p = 0.04). In the whole group studied, subjects with the COL1A1 's' genotype had lower bone mineral density at the femoral neck (p = 0.01) which was partly attributable to a lower body mass index. Following multiple regression analysis body mass index and collagen type 1 C-terminal propeptide concentrations remained determinants of bone mass at all three sites, whereas genotype appeared to be a predictor of bone mass at the femoral neck only. We conclude that measurement of these variables could prove useful in firstly identifying those diabetic women at risk of osteoporosis and secondly guiding therapeutic intervention.

Mary J. Nielubowicz Award. Bringing nurses on-line: implementing nursing informatics.

Processing the vast amount of information required to provide quality nursing and health care today is an immense task. The Surgeon General of the Navy recently updated the Department's "Vision for the Future." He challenged Navy medicine to become a leader in technology integration. Shifting toward a managed-care environment makes it imperative for health care organizations and their personnel to integrate data, information, and systems at all levels. Implementation of a coordinator to assist nursing users with this technology is proving essential. This essay describes how one nursing directorate at a Naval hospital implemented a full-time staff member as Nursing Informatics Coordinator to serve in this role. Receiving and using data and information in the practice of nursing is vital to the profession. Specific factors identifying the reasons for development of this role, impact achieved, opportunities encountered, and the future of the position are addressed.

Parental ancestry and risk of multiple sclerosis in Alberta, Canada.

Self-reported population ancestry data for the 19 census divisions (CDs) of Alberta, Canada, were correlated with multiple sclerosis (MS) prevalence rates in those divisions, for men and women separately; and parental ancestry was compared between a group of MS patients and controls attending the University of Alberta MS Clinic. At the CD level, there was a positive correlation between single Scandinavian ancestry and MS prevalence in men, but this was not confirmed in the case-control comparison. The case-control comparison indicated an excess risk of MS associated with single non-specific European as opposed to British ancestry in men only. When paternal versus maternal ancestry was considered separately, there was an excess risk of MS associated with non-specific European as opposed to British ancestry for both men and women, but on the father's side only. Aboriginal ancestry was negatively associated with MS prevalence at the CD level in both men and women; and no MS patients with aboriginal origin were among cases assembled through the MS clinic.

Outcome study using an administrative database: terminal salpingostomy, physician case load and live birth rates.

Information on the outcome following salpingostomy performed for infertility in everyday practice is needed to counsel patients, determine the best approach to this condition and clarify whether the outcome is superior when surgery is performed by a physician who maintains a high volume of ongoing experience. A total of 547 consecutive subjects were identified over a 5 year period using the Alberta Health Care Claims Database. Their claims history was analysed over a follow-up of 2-7 years, to identify pregnancy-related events, loss to follow-up and events which would result in sterility. Pregnancies were cross-checked with the only in-vitro fertilization programme serving the region. The overall cumulative live birth and tubal pregnancy rates were 11.7 and 7.2% respectively. Live birth rates were significantly higher when practitioners had performed >10 procedures within the study period. Live birth rates would appear to be substantially lower in everyday practice than following surgery performed by acknowledged experts. A high volume of ongoing experience appears to be associated with superior live birth rates. It is unclear whether this association relates to case selection, surgical expertise or both variables.

Individuals with a chemical-dependent family member. Does their health care use increase?

OBJECTIVE: To examine health care utilization patterns of individuals who have a chemical-dependent family member (parent, spouse, or child). DESIGN: Morbidity and health care utilization patterns were examined for a 12-month period using the claims administrative data from the Alberta Health Care Insurance Plan (AHCIP). SETTING: General medical practice specializing in the treatment of addiction disorders. PARTICIPANTS: Two hundred seventy-eight (73 male, 205 female) subjects were identified between 1987 and 1990. No members of the subject group were Natives, and none were dependent on chemicals during the study period. A control group, matched for age, sex, and family size, was randomly selected from AHCIP records. MAIN OUTCOME MEASURES: Number and type of health care services and diagnoses listed in health care claims classified using the International Classification of Diseases. RESULTS: In 91% of cases, the chemical-dependent family member was male. Members of the subject group presented more often with mental disorders, digestive system problems, obstetrical problems, injuries, and poorly defined conditions. Also, they were more likely to have nonreferred visits, to have specialist visits, and to use laboratory services than population-matched controls. The subject group's use of specialists and laboratory services amounted to twice the cost of the control group's use of these services. CONCLUSIONS: Results show that individuals who have a chemical-dependent family member use more health care services than the general population. Morbidity among the subject group appears to be similar to that among chemical-dependent individuals; diagnoses related to stress and trauma are common.

Vitamin D deficiency: a concern in pregnant Asian women.

Vitamin D status of Asian mothers in Cardiff was investigated during early pregnancy and at the time of the birth of their babies, using serum parathyroid hormone (PTH). Median values in Asian (n 32) and Caucasian (n 63) mothers in early pregnancy were 1.56 and 0.81 pmol/l respectively. PTH levels from a separate sample of nineteen Asian and twenty-five Caucasian mothers at the time of birth were 3.0 and 2.20 pmol/l respectively. Altogether twelve Asian and two Caucasian women had elevated PTH. All Asian women who had high PTH values also had a very low serum 25-hydroxycholecalciferol level (25OHD). All samples were taken from women with no significant medical history and normal obstetric history. These findings suggest that subclinical vitamin D deficiency is still a cause for concern in Asian women. More active measures need to be taken to implement current recommendations to improve their vitamin D intake in pregnancy.

Regional variations in the prevalence rates of multiple sclerosis in the province of Alberta, Canada.

Multiple sclerosis (MS) prevalence rates were examined for the fiscal years 1984/1985-1988/1989, in the province of Alberta, Canada, by age, sex and census division. Data were derived from the health care records of individuals registered with the Alberta Health Care Insurance Plan which requires registration by all residents of the province (approximately 2.4 million). The overall crude prevalence rate was 216.7 per 100,000 (173.1 for males; 260.3 for females) population. Females had a significantly higher prevalence (p < 0.05) and the rates were highly correlated between the sexes (r = 0.94, p < 0.01). The present study confirms other studies finding a high prevalence rate within the province of Alberta. The prevalence rate for Alberta is among the highest reported in the world indicating that the province appears to be an excess risk area relative to other global locations. Also, the results indicate that MS is unevenly distributed throughout the province which offers support for the involvement of environmental factors related to the onset of this disorder.

Geographic variations in the prevalence rates of Parkinson's disease in Alberta.

Parkinson's disease prevalence rates were examined for the Province of Alberta by age, sex and census division. Using the claims administrative data from the Alberta Health Care Insurance Plan, a cohort of all registered individuals (2.4 million) was extracted and followed for the five year period, April 1, 1984 to March 31, 1989. No new members were added to the cohort and an attrition rate averaging 6% per year was observed. The overall crude prevalence rates of 248.9 and 239.8 per 100,000 population were noted for males and females respectively. Both sexes were found to have a statistically significant variation across Alberta's 19 census divisions. For males, examination of standardized morbidity ratios found a low risk of Parkinson's disease associated with five census divisions, of which two contained Alberta's two largest cities. An excess risk was associated with four primarily rural census divisions. Females, on the other hand, had a low risk associated with one rural census division and excess risk in four census divisions. The uneven distribution within Alberta offers support for an environmental theory of etiology which may be associated with rural living.

Coronary artery bypass grafting in Alberta from 1984 to 1989.

OBJECTIVE: To examine the geographic and temporal trends in the performance of coronary artery bypass grafting (CABG) in the province of Alberta. This examination was designed to improve understanding of the geographic distribution and temporal changes in the incidence of the procedure. DESIGN: A cohort of all individuals (2.4 million) registered with the Alberta Health Care Insurance Plan (AHCIP) was followed for the five-year period from April 1, 1984 to March 31, 1989. No new members were admitted to the cohort and an attrition rate averaging 6% per year was observed. SETTING: Data from the claims administrative database of the AHCIP were used. The AHCIP includes the records of all registered residents of the province and is virtually complete. PARTICIPANTS: Participants included all 2963 members of the cohort (2413 males, 550 females) who underwent CABG over the study period. MAIN RESULTS: The overall mean surgical rate was 28.8 per 100,000 (46.7 for males, 10.8 for females; chi 2 = 1172.8, df = 1, P < 0.0001). The mean age at surgery was 59.6 years (57.9 for males, 61.4 for females), with 70 and 76% of procedures occurring between the ages of 60 and 70 years for males and females, respectively. The largest increases in incidence were in males (223%) and females (148%) aged 70 years or older. Both males (chi 2 linearity = 25.95, df = 3, P < 0.01) and females (chi 2 linearity = 8.34, df = 3, P < 0.05) displayed an increasing trend over the study period. Data were aggregated across the five-year study period to assess geographic variations. No difference was noted across census divisions for either sex. CONCLUSIONS: The similarity in rates across census divisions implies consistent use of criteria for the performance of this procedure. Also, the results imply that research, in Alberta, should focus more on indications for the procedure and its outcomes, than on geographic disparities.

Accuracy of growth hormone measurements.

The availability of high quality reagents and new methodology have contributed to overall improvements in the performance of immunoassays of human growth hormone in recent years. Discrepancies between superficially similar methods do occur as a result of the heterogeneous nature of the hormone itself. However, there is also evidence of incorrect standardisation in widely used, commercially available assays. Careful interpretation of growth hormone assays is still required, therefore, especially when results from different laboratories are being compared.

Epidemiological studies using monoclonal antibodies to Legionella pneumophila serogroup 1.

Legionella pneumophila serogroup 1 can be subgrouped by panels of monoclonal antibodies. The Oxford panel divides serogroup 1 strains into three major subgroups, provisionally named Pontiac, Olda and Bellingham. Strains causing outbreaks tend to be in the Pontiac subgroup, with strains from the other subgroups appearing also in sporadic cases. Isolates from sources in the UK unassociated with outbreaks are mainly the Olda and Bellingham strains; only 10% are Pontiac, yet this strain has caused 80 to 90% of the cases of Legionnaires' Disease so far studied. We compared our method with other methods of subgrouping serogroup 1 strains.

Vitamin D status in Crohn's disease: association with nutrition and disease activity.

Forty patients with Crohn's disease were divided into undernourished (18) and well nourished (22) groups depending on whether their midarm circumference was below or above 90% of the ideal standard. Plasma 25-(OH)D3 and the dihydroxylated metabolites, 24,25-(OH)2D3 and 1,25-(OH)2D3 were measured in the summer. Results were related to clinical and biochemical parameters and also compared with results from patients with ulcerative colitis and healthy subjects who served as controls. Plasma 25-(OH)D3 was reduced in the undernourished Crohn's group compared with the well nourished Crohn's group, who did not differ from the controls. Over 50% of the undernourished Crohn's group had evidence of secondary hyperparathyroidism and raised alkaline phosphatase concentrations, although concentrations of 1,25-(OH)2D3 were normal. The low 25-(OH)D3 concentrations related to disease activity. It is suggested that undernourished Crohn's patients who have high levels of disease activity are at risk of vitamin D deficiency, and attempts should be made to improve their vitamin D nutrition.

Differential effects of acute DA receptor blockade with domperidone on LH and TSH release in patients with hyperprolactinemia.

Since dopamine (DA) has been implicated in the inhibitory control of both TSH and LH, we have compared TSH and LH levels following dopamine (DA) receptor blockade with domperidone in patients with hyperprolactinemia due to presumed prolactinomas. Eight euthyroid patients (aged 19-37 yr) with presumed prolactinomas each received domperidone (10 mg iv) at 11:00 and 23:00 h and tests were separated by at least one week. Basal TSH levels were significantly greater at 23:00 than at 11:00 h (2.7 +/- 0.5 vs 1.7 +/- 0.4 mU/l, mean +/- SE, p less than 0.01) whereas basal LH levels did not differ. All subjects showed clear rises in basal TSH levels following drug administration and these were significantly greater at 23:00 than at 11:00 h (p less than 0.02 at each time point). In contrast there was no alteration in LH levels following drug administration at either time of day. These data suggest that the mechanisms underlying the dopaminergic control of TSH and LH are different in these patients. Furthermore the data argue against an anterior pituitary or median eminence site of action of DA in the inhibition of LH release in hyperprolactinemia since domperidone does not penetrate the blood brain barrier to any appreciable extent.

Drug treatment of primary hyperparathyroidism: use of clodronate disodium.

Clodronate disodium (dichloromethylene diphosphonate), a specific inhibitor of bone resorption, was given by mouth (1.0-3.2 g daily) to nine patients with primary hyperparathyroidism for two to 32 weeks so that its clinical and metabolic effects could be evaluated. Bone resorption decreased in all patients as judged by a fall in the fasting urinary calcium to creatinine and hydroxyproline to creatinine ratios. Serum calcium concentration was increased in all patients before treatment and fell in response to treatment to values near the upper end of the normal range. Hypercalcaemia and hypercalciuria recurred when treatment was stopped. In three patients treated for longer than 19 weeks clodronate failed to sustain the reduction in serum calcium concentration but the concentration remained below pretreatment values. These results suggest that clodronate may be of use in the medical management of primary hyperparathyroidism, particularly in patients in whom suppression of bone disease is desirable before surgery or in whom surgery is contraindicated.

Plant phenols utilized as nutrients by a phytophagous insect.

Phenols are commonly regarded as feeding deterrents for phytophagous insects, but the tree locust Anacridium melanorhodon survives better and grows faster when certain phenols are added to a food plant that is relatively low in both protein and phenols. The phenols are at high concentration in the common host plants. Much of the phenol retained by the insect becomes bound in the cuticle where it probably stabilizes the protein.

Effects of prosomatostatin on growth hormone and prolactin response to arginine in man. Comparison with somatostatin.

The effects of the hypothalamic 28 aminoacid peptide prosomatostatin (Pro-SS) on arginine-induced growth hormone (GH) and prolactin (PRL) release and blood glucose levels in man are compared with those obtained after an equimolar dose of somatostatin (SS). In comparison with SS, Pro-SS caused greater and more prolonged inhibition of GH release, a more marked reduction of the PRL response to arginine, and greater enhancement of the hyperglycaemic action of arginine. The greater potency and prolonged action of Pro-SS make it an interesting tool to study hormonal control mechanisms in a variety of physiological and pathological conditions.

Biochemical markers of bone turnover in Paget's disease.

The two most commonly used biochemical markers of bone turnover are the serum alkaline phosphatase and the urinary excretion of peptide-bound hydroxyproline, both of which are increased in Paget's disease. Serum alkaline phosphatase is assumed to be derived from osteoblasts during the process of bone formation, whereas small peptides containing hydroxyproline are excreted in the urine following the degradation of bone collagen. The alkaline phosphatase is probably the more useful measurement for diagnosis and for following response to treatment, whereas hydroxyproline, although very sensitive, presents technical difficulties in collection and measurement. Several other biochemical changes in Paget's disease indicate abnormal bone metabolism. These include increased urinary excretion of hydroxylysine and its glycosides derived from collagen, as well as the release into the circulation and subsequent urinary excretion of fragments of pro-collagen indicative of increased collagen formation. Proteins specific to bone, such as osteocalcin, are increased in serum, bone, such as osteocalcin, are increased in serum, as are various enzymes possibly derived from bone cells, including acid phosphatase and proline imino-peptidase. Treatment of Paget's disease results in a fall in urinary hydroxyproline before alkaline phosphatase. This indicates that drug treatment, whether with diphosphonates, calcitonin or mithramycin, has a primary action to inhibit bone resorption, with a subsequent adaptive reduction in bone formation rate.

Environmental and biotic factors affecting the phenolic content of different cultivars ofSorghum bicolor.

Levels of phenolic acids in healthy plants ofSorghum bicolor differ considerably with cultivar and always decrease as the plant matures. Laboratory- and field-grown plants show significant differences in phenolics. Environmental factors, particularly light intensity, influence the concentration of phenolics in sorghum. Attack by insects and pathogenic fungi also increase the phenolic content of the plants to varying degrees dependent on the cultivar and the stage of growth of the plant.