Comparison of clinical evaluation of genitourinary symptoms in female adolescents among primary care versus emergency department physicians.

OBJECTIVE: To compare clinical approaches to assessment and treatment of female adolescents with genitourinary symptoms among primary care and emergency department (ED) physicians. DESIGN: A chart review was performed of the evaluation and treatment of 472 patients presenting between July 1, 2005, and June 30, 2006. SETTING: Suburban and tertiary care EDs and primary care settings. PARTICIPANTS: Female patients age 13-21 years with genitourinary symptoms. INTERVENTIONS: None. OUTCOME MEASURES: Physician assessment of sexual history, performance of pelvic exam and sexually transmitted infection (STI) tests, empiric treatment of suspected STIs. RESULTS: Patients seen in primary care settings were more likely to be asked about sexual history, including contraceptive use, than patients in the ED (P<0.001). After adjustment for age and race, there was no statistically significant difference between the ED and primary care sites in performance of pelvic exams or gonorrhea and chlamydia tests. However, there was a higher likelihood that older adolescents would undergo pelvic exams (P=0.001), and STI testing (P=0.002) than younger patients. There was no significant difference in empiric treatment of patients with positive STI tests between ED and primary care sites or across the age spectrum. CONCLUSIONS: ED physicians should obtain sexual histories on patients with genitourinary symptoms. Both primary care and ED clinicians should consistently test for STIs in sexually active patients who have genitourinary symptoms. Physicians in both settings should have a low threshold for testing and empirically treating adolescents with symptoms or physical exam findings consistent with STIs.

Obesity and gestational diabetes among African-American women and Latinas in Detroit: implications for disparities in women's health.

OBJECTIVE: to estimate the prevalence of gestational diabetes mellitus (GDM), obesity, and excessive weight gain during pregnancy among Latinas and African-American women in a large Detroit health system and explore risk factors associated with GDM and its implications. METHODS: Descriptive statistics, chi2 tests, analysis of variance, and logistic regression analyses were used to describe the prevalence of obesity, excessive pregnancy weight gain, and GDM and to assess factors associated with GDM risk in a cohort of 552 African-American women and 653 Latinas in a large Detroit health system. RESULTS: Women ranged in age from 14 to 47 years. Almost 47% of African-American women and 37% of Latinas were overweight or obese, and 53% of African-American women and 38% of Latinas gained excessive weight during pregnancy. The prevalence of GDM was 5.4% among Latinas and 3.9% among African-American women. After adjusting for other risk factors, Latinas were 2.5 times more likely than African Americans to develop GDM. Other independent risk factors were family history of diabetes, age, body mass index, and gestational weight gain before 28 weeks. CONCLUSION: Because most women have repeated contact with the health care system during and immediately after pregnancy, care providers have unique opportunities to identify and assist those who are at risk of obesity and diabetes.

Effect of Fluosol DA 20% on antibody response to type 3 pneumococcal polysaccharide in rats.

Exchange transfusion with the oxygen-carrying resuscitation fluid, Fluosol DA 20% (FDA), interferes with the efficacy of penicillin therapy of pneumococcal infection in rats. Because this effect could not be attributed to an interaction between FDA and penicillin, the effect of FDA on the ability of rats to mount an antibody response to type 3 pneumococcal polysaccharide was tested. FDA (25 ml) was administered by isovolumetric exchange transfusion. Rats were immunized intravenously with 0.2 microgram of type 3 pneumococcal polysaccharide 3 days before, 1 day before, 1 day after, or 3 days after transfusion with FDA. IgM and IgG antibody responses were determined by ELISA 0, 3, 7, 10, 14, 21, and 28 days after immunization. When rats were immunized 3 days before or 1 day before transfusion with FDA, antibody levels were increased above control levels and remained relatively high through Day 28. When the animals were immunized 1 day after transfusion, antibody levels were approximately the same as in the control group. When the rats were immunized 3 days after transfusion, antibody levels were suppressed. These data suggest that FDA does not inhibit the humoral immune response when administered after or within 1 day before immunization, but does inhibit the response when immunization is given 3 days after transfusion.

Spurious elevation of automated leukocyte counts induced by Fluosol DA 20%.

During studies with Fluosol DA 20% (FDA) in rats, an artifactual leukocytosis was observed when an impedance type electronic cell counter was used. The effect was found to be directly related to the duration of the interval between addition of an erythrocyte lysing fluid and counting, observed up to 11 d after transfusion with FDA, blood cell associated, reproducible in vitro, FDA concentration dependent, temperature dependent, and present when human blood was used instead of rat blood. Microscopically, the effect appears to be the result of agglutination of lysed erythrocyte membranes due to the interaction of erythrocytes, the emulsion component of FDA, and the quaternary ammonium salt component of the lysing fluid. These data suggest that FDA causes subtle changes in erythrocytes and raises the possibility that other cells may be similarly affected.

Effect of exchange transfusion with Fluosol DA 20% on splenic distribution and immunocompetence of rat lymphocytes.

T- and B-splenic lymphocyte frequency, immune response 4 days after immunization with sheep red blood cells (SRBC), and proliferative response to concanavalin A (Con A) were determined 1, 3, and 5 days after exchange transfusion with Fluosol DA 20% (FDA) in adult, male Sprague-Dawley rats vs sham transfused rats. T-cell, T-helper, T-suppressor, and B-lymphocyte were reduced 1 day after transfusion (P less than or equal to 0.001). T- and B-lymphocyte frequencies were still reduced at day 3 (P = 0.0372). By day 5, there were no significant reductions in T-cell, T-helper, T-suppressor, and B-cell frequencies in the FDA-transfused rats. The frequency of cells with cytoplasmic IgG was reduced (P less than or equal to 0.025) in cells harvested from spleens of FDA-transfused rats and tested fresh. Proliferative response of splenic lymphocytes to Con A was unaffected by transfusion with FDA (P greater than or equal to 0.078). Splenic hemolytic plaques in response to SRBC were unaffected if rats were transfused 3 days after immunization with SRBC and 1 day prior to study (P = 0.941), enhanced if rats were transfused 1 day after SRBC immunization and 3 days prior to study (P = 0.0015), and suppressed if rats were transfused 1 day before SRBC immunization and 5 days before study (P less than 0.0001). Transfusion with FDA causes transient decreases in identifiable T and B lymphocytes, depresses cytoplasmic IgG-positive B cells, does not affect proliferative response to Con A, does not affect an ongoing specific immune response, enhances an early specific immune response, and inhibits the induction of a specific immune response.

Ototoxicity of intraventricularly administered gentamicin in adult rabbits.

To determine whether daily intraventricular injection of gentamicin sulfate is ototoxic, adult male rabbits were given 0.2 ml of saline (group 1; n = 8) or 0.25 mg/kg of gentamicin sulfate in 0.2 ml of saline (group 2; n = 7) by intraventricular infusion once a day for 21 d. All rabbits were also given intramuscular gentamicin sulfate, 2 mg/kg, twice daily. Before and after antibiotic treatment, brainstem auditory evoked responses (BAERs) were recorded. During the experimental period, neurologic examinations were performed on all rabbits. After treatment, the animals were euthanized; brain tissue and cochleas were then removed for histopathologic examination. The ratios of neurologic abnormalities observed in group 1 and 2 animals, respectively, were 0/8 and 5/7; of abnormal BAERs, 0/8 and 5/7; of abnormal brain morphology, 2/5 and 6/6; and of abnormal cochlear morphology, 0/6 and 7/7. The electrophysiologic evidence of auditory deficit and the structural evidence of ototoxic insult are significantly associated (p less than or equal to 0.006) with intraventricularly administered gentamicin sulfate. These data suggest that intraventricular gentamicin should be used with caution.

Effect of exchange transfusion with an oxygen-carrying resuscitation fluid on the efficacy of penicillin therapy of pneumococcal infection in rats.

The effects of exchange transfusion with Fluosol DA (FDA) or stroma-free hemoglobin on the outcome of pneumococcal infection in rats were determined. Rats were sham transfused or exchange transfused with 25 ml of FDA or stroma-free hemoglobin. They were then challenged intraperitoneally with Streptococcus pneumoniae type 3 and treated with penicillin for 120 h. Only 2 of 15 (13.3%) FDA-transfused rats were alive at 312 h compared with 11 of 15 (73.3%) concurrently studied sham-transfused control rats (P = 0.0016). Of 10 stroma-free hemoglobin-transfused rats and 10 concurrently studied sham-transfused control rats (P = 0.98), 8 from each group (80%) were alive at 312 h. Penicillin therapy only suppressed pneumococcal infection in FDA-transfused rats, and relapse occurred after therapy was stopped. This effect could not be attributed to interference with the bactericidal activity of penicillin against pneumococci, to an alteration in the pneumococcal burden before penicillin therapy or to an alteration of the leukocyte and polymorphonuclear leukocyte response by FDA. In contrast, pneumococcal infection in stroma-free hemoglobin-transfused rats was cured with penicillin therapy. These data showed that FDA altered the ability of rats to respond to pneumococcal infection.

Effect of oxygen-carrying resuscitation fluids on the pharmacokinetics of antipyrine, diazepam, penicillin, and sulfamethazine in rats.

The effects of exchange transfusion with an oxygen-carrying resuscitation fluid, Fluosol DA 20% or stroma-free hemoglobin, on the pharmacokinetics of antipyrine, diazepam, penicillin, and sulfamethazine were studied in rats. After transfusion with Fluosol DA 20% or stroma-free hemoglobin the pharmacokinetics of antipyrine, diazepam, and penicillin were unchanged when compared to control animals. After transfusion with Fluosol DA 20%, the t 1/2 of sulfamethazine was increased from 3.15 +/- 0.56 to 7.65 +/- 2.41 hr (p less than 0.05) and the Vd was increased from 60.7 +/- 17.5 to 152 +/- 16 ml (p less than 0.05). In contrast, after transfusion with stroma-free hemoglobin, the AUC of sulfamethazine was decreased from 129 +/- 28 to 80.5 +/- 27.7 micrograms X h X ml-1 (p less than 0.05) and there was an increase in Cl from 12.2 +/- 3.4 to 20.2 +/- 6.0 ml X h-1 (p less than 0.05) and Vd from 60.1 +/- 11.8 to 132 +/- 49 ml (p less than 0.05). The reason for these alterations is not clear. Fluosol DA 20% and stroma-free hemoglobin may alter the acetylation of sulfamethazine.

Interaction of oxygen-carrying resuscitation fluids with morphine.

The oxygen-carrying resuscitation fluids, Fluosol DA 20% and stroma-free hemoglobin, are currently being evaluated for efficacy and effects in vivo. Because these fluids may be administered to trauma victims, the pharmacokinetics of morphine was studied in rats after transfusion with one of these fluids. During development of high-performance liquid chromatography assay for morphine in plasma, an in vitro interaction between plasma, Fluosol DA, or stroma-free hemoglobin and morphine was observed at pH greater than 10.5. This interaction was dependent on pH and was specific to morphine, compared with codeine. The interaction between stroma-free hemoglobin and morphine appeared to be covalent in nature. The t1/2 of morphine was significantly prolonged from 1.02 +/- 0.50 hours (mean +/- SD) to 2.46 +/- 2.68 hours (p = 0.03) after transfusion with stroma-free hemoglobin, and to 2.05 +/- 0.95 hours (p = 0.006) after transfusion with Fluosol DA. The volume of distribution was increased from 1.35 +/- 0.81 L X kg-1 to 2.99 +/- 1.45 L X kg-1 (p = 0.004) after transfusion with stroma-free hemoglobin; no such difference was observed after transfusion with fluosol DA (p = 0.86). The area under the time-concentration curve was increased from 2.37 +/- 1.78 mg X hr X L-1 to 6.02 +/- 6.61 mg X hr X L-1 (p = 0.02), and total body clearance was decreased from 1.02 +/- 0.53 L X hr-1 X kg-1 to 0.55 +/- 0.36 L X hr-1 X kg-1 (p = 0.01) after transfusion with Fluosol DA. No significant differences were observed in these parameters after transfusion with stroma-free hemoglobin (p = 0.48 and p = 0.81, respectively). These data show that stroma-free hemoglobin prolongs the t1/2 of morphine by altering the volume of distribution. In contrast, Fluosol DA prolongs the t1/2 of morphine by altering the total body clearance. These data may have important therapeutic implications.

Comparative penetration of azlocillin and mezlocillin into cerebrospinal fluid of normal rabbits and rabbits with experimentally induced Pseudomonas aeruginosa meningitis.

The impacts of meningeal infection with Pseudomonas aeruginosa and route of drug administration on the penetration of azlocillin and mezlocillin into the cerebrospinal fluid of rabbits were evaluated. The penetration of both agents was increased to a similar degree in rabbits with meningitis compared with normal rabbits. The increase in penetration was greater after intravenous administration than after intramuscular administration.

Central nervous system toxicity of intraventricularly administered gentamicin in adult rabbits.

To determine whether daily intraventricular injection of gentamicin sulfate would cause neurologic or morphologic abnormalities of the central nervous system, adult male rabbits were given gentamicin sulfate, 2 mg/kg, intramuscularly twice a day plus saline, 0.2 ml (group 1), or gentamicin, 0.05 mg/kg (group 2), 0.25 mg/kg (group 3), or 0.5 mg/kg (group 4), given as the sulfate intraventricularly once a day. The majority of the animals in group 4 developed neurologic abnormalities which progressed to death in animals that were not euthanized; neuropathologic studies revealed chemical ventriculitis and meningitis that were associated with high levels of gentamicin in the cerebrospinal fluid and tissue of the central nervous system. Similar neurologic and morphologic changes were seen in most animals of group 3 but not in rabbits of groups 1 and 2. The ototoxicity and nephrotoxicity of gentamicin are well known; these data indicate that it may be toxic to the central nervous system as well.

Antigenicity and protective effects of type 3 pneumococcal polysaccharide in rats.

The response to type 3 pneumococcal polysaccharide vaccination, the protective effect of type 3 pneumococcal polysaccharide vaccination, and the ability of hemagglutinating antibody to type 3 pneumococcal polysaccharide to cross the blood-brain barrier were studied in rats. Hemagglutinating antibody response to vaccination with type 3 pneumococcal polysaccharide was found to be dependent on the dose and route of inoculation. Intraperitoneal vaccination with type 3 pneumococcal polysaccharide protected the rats from subsequent intraperitoneal challenge with type 3 Streptococcus pneumoniae but had no effect after intracisternal challenge with type 3 S. pneumoniae. In the presence or absence of sterile meningeal inflammation, hemagglutinating antibody could not be found in cerebrospinal fluid of animals vaccinated intraperitoneally with type 3 pneumococcal polysaccharide. These results suggest that type 3 pneumococcal polysaccharide is antigenic in rats and intraperitoneal vaccination with type 3 pneumococcal polysaccharide does not protect against experimental meningitis because antibodies do not cross the blood-brain barrier.