Identification of Cryptococcus gattii by use of L-canavanine glycine bromothymol blue medium and DNA sequencing.

Cryptococcus neoformans and Cryptococcus gattii are closely related pathogenic fungi. Cryptococcus neoformans is ecologically widespread and affects primarily immunocompromised patients, while C. gattii is traditionally found in tropical climates and has been reported to cause disease in immunocompetent patients. l-Canavanine glycine bromothymol blue (CGB) agar can be used to differentiate C. neoformans and C. gattii, but there are few reports of its performance in routine clinical practice. Growth of C. gattii on CGB agar produces a blue color, indicating the assimilation of glycine, while C. neoformans fails to cause a color change. Using reference and clinical strains, we evaluated the ability of CGB agar and D2 large ribosomal subunit DNA sequencing (D2 LSU) to differentiate C. neoformans and C. gattii. One hundred two yeast isolates were screened for urease activity, melanin production, and glycine assimilation on CGB agar as well as by D2 sequencing. Seventeen of 17 (100%) C. gattii isolates were CGB positive, and 54 of 54 C. neoformans isolates were CGB negative. Several yeast isolates other than the C. gattii isolates were CGB agar positive, indicating that CGB agar cannot be used alone for identification of C. gattii. D2 correctly identified and differentiated all C. gattii and C. neoformans isolates. This study demonstrates that the use of CGB agar, in conjunction with urea hydrolysis and Niger seed agar, or D2 LSU sequencing can be reliably used in the clinical laboratory to distinguish C. gattii from C. neoformans. We describe how CGB agar and D2 sequencing have been incorporated into the yeast identification algorithm in our laboratory.

Effects of on-line medical control in the prehospital treatment of atraumatic illness.

OBJECTIVE: On-line medical control (OLMC) is costly and time-consuming, yet little is known about the direct effect of OLMC on the quality of care provided. The objective of this study was to analyze the effect of OLMC on adherence to protocol and quality of care provided. METHODS: Retrospective review of trip sheets completed by out-of-hospital personnel in an urban/suburban/rural emergency medical services system with a volume of 144,000 calls/year; approximately 15,000/year are ALS calls. Two levels of provider--paramedics and critical care technicians (CCTs)--work under single standard protocols and a single medical director. Prehospital trip sheets of 774 sequential patients with atraumatic illnesses for whom an ALS crew was dispatched were reviewed for adherence to standard protocol and for appropriateness of deviations from protocol, with and without the use of OLMC. RESULTS: Adherence to protocols occurred in 78.3% of all patient encounters. OLMC was utilized in 61.5% of patient encounters. The CCTs were more likely to utilize OLMC than were the paramedics, 72% vs 56% (p < 0.001). There was a trend towards paramedics' adhering to protocol more frequently than did the CCTs, 80% vs 74%, which did not reach statistical significance (p = 0.057). Adherence to protocol was significantly less likely to occur with OLMC than without OLMC, regardless of the training of the provider, 72.8% vs 86.5% (95% CI 8.1-19.3%, p < 0.001). Adherence to protocol was significantly less likely to occur as the acuity of the patient's condition increased (p < 0.001). Nonadherence was more likely to be judged appropriate rather than inappropriate (p < 0.05) as the acuity level increased. When there was nonadherence to protocol, the use of OLMC did not improve the care provided. CONCLUSIONS: OLMC does not improve adherence to protocol or the quality of care provided in the treatment of atraumatic illness.

Effects of decreasing sedentary behavior and increasing activity on weight change in obese children.

Obese children 8-12 years old from 61 families were randomized to treatment groups that targeted increased exercise, decreased sedentary behaviors, or both (combined group) to test the influence of reinforcing children to be more active or less sedentary on child weight change. Significant decreases in percentage overweight were observed after 4 months between the sedentary and the exercise groups (-19.9 vs. -13.2). At 1 year, the sedentary group had a greater decrease in percentage overweight than did the combined and the exercise groups (-18.7 vs. -10.3 and -8.7) and greater decrease in percentage of body fat (-4.7 vs. -1.3). All groups improved fitness during treatment and follow-up. Children in the sedentary group increased their liking for high-intensity activity and reported lower caloric intake than did children in the exercise group. These results support the goal of reducing time spent in sedentary activities to improve weight loss.

Effects of mastery criteria and contingent reinforcement for family-based child weight control.

This study tested the effects of mastery criteria and contingent reinforcement in a family-based behavioral weight control program for obese children and their parents over two years. Families with obese children were randomized to one of two groups. The experimental group was targeted and reinforced for mastery of diet, exercise, weight loss, and parenting skills. The control group was taught behavior-change strategies and provided noncontingent reinforcement at a pace yoked to the experimental group. Both groups received the same behavioral family-based educational components over 6 months of weekly meetings and six monthly follow-up meetings. Results showed significantly better relative weight change at 6 months and 1 year for children in the experimental compared to the control group, but these effects were not maintained at 2 years. These results suggest the introduction of mastery criteria and contingent reinforcement for mastery can improve outcome during treatment in behavioral treatments for childhood obesity.

Child and parent factors that influence psychological problems in obese children.

This study assessed the influence of child and parental obesity and parental psychiatric symptoms on psychological problems in obese 8-11-year-old children. Child psychological problems were measured using the Child Behavior Checklist/4-18, whereas adult psychiatric symptoms were measured using the Cornell Medical Index. Multiple linear regression analyses showed parental psychiatric symptoms were related to child psychological problems for six of eight problem behavior scales. Child obesity made no independent contribution to child psychological problems, and parental obesity was related to child problems on only one scale. The most prevalent problems were Anxiety/Depression for 15% of the boys and Social Problems for 20% of the boys and 12.8% of the girls. These results suggest a broader conceptualization of factors that influence behavior problems of obese children than their degree of obesity.