Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study.

Anatomical abnormalities of the cervical spine at the level of the Atlas vertebra are associated with relative ischaemia of the brainstem circulation and increased blood pressure (BP). Manual correction of this mal-alignment has been associated with reduced arterial pressure. This pilot study tests the hypothesis that correcting mal-alignment of the Atlas vertebra reduces and maintains a lower BP. Using a double blind, placebo-controlled design at a single center, 50 drug naïve (n=26) or washed out (n=24) patients with Stage 1 hypertension were randomized to receive a National Upper Cervical Chiropractic (NUCCA) procedure or a sham procedure. Patients received no antihypertensive meds during the 8-week study duration. The primary end point was changed in systolic and diastolic BP comparing baseline and week 8, with a 90% power to detect an 8/5 mm Hg difference at week 8 over the placebo group. The study cohort had a mean age 52.7+/-9.6 years, consisted of 70% males. At week 8, there were differences in systolic BP (-17+/-9 mm Hg, NUCCA versus -3+/-11 mm Hg, placebo; P<0.0001) and diastolic BP (-10+/-11 mm Hg, NUCCA versus -2+/-7 mm Hg; P=0.002). Lateral displacement of Atlas vertebra (1.0, baseline versus 0.04 degrees week 8, NUCCA versus 0.6, baseline versus 0.5 degrees , placebo; P=0.002). Heart rate was not reduced in the NUCCA group (-0.3 beats per minute, NUCCA, versus 0.5 beats per minute, placebo). No adverse effects were recorded. We conclude that restoration of Atlas alignment is associated with marked and sustained reductions in BP similar to the use of two-drug combination therapy.

Acute polyosteal osteomyelitis in a patient with congenital ichthyosis and acute lymphoblastic leukemia.

Osteomyelitis can develop after bacteremia in children and is a rare complication of chemotherapy for acute lymphoblastic leukemia. A child with congenital ichthyosis, acute lymphoblastic leukemia and multifocal hematogenous osteomyelitis is described herein. A breached skin barrier secondary to ichthyosis during induction chemotherapy, coupled with impaired immunity, likely provided the opportunity for bacterial seeding, leading to an extensive multifocal osteomyelitis.

Pharmacological treatments for alcoholism: revisiting lithium and considering buspirone.

OBJECTIVE: Previous research has suggested that both lithium and buspirone could lessen alcoholics' desire to drink as well as reduce the actual amounts of alcohol consumed. The purpose of this study was to compare lithium and buspirone monotherapy with placebo on outcomes of abstinence, alcohol quantity consumed, treatment retention and compliance, and medication side effects. METHODS: We conducted a randomized, double-blind, placebo-controlled, three-arm parallel group, clinical trial that compared lithium and buspirone with placebo in 156 alcohol-dependent men. RESULTS: Study retention rates for the three treatment groups at 3 and 6 months, respectively, were 61% and 46% for lithium, 44% and 27% for buspirone, and 52% and 38% for placebo (p = NS, for 3 and 6 months). Overall abstinence rates were 28% and 19% at 3 and 6 months, respectively. However, mean daily quantities of alcohol consumed and percentage of drinking days decreased significantly (p < 0.0001) over time in all treatment groups. Differential improvement was seen only for the decrement in quantity consumed in the buspirone group, compared with the placebo group, but only at a trend level (p = 0.07). According to pill counts, compliance did not differ significantly among the treatment groups. CONCLUSIONS: These results do not support the hypothesis that either lithium or buspirone, compared with placebo, produces differential reductions in alcohol consumption. The results suggest the need to enhance treatment retention to maximize outcomes.

Treatment attrition among alcohol-dependent men: is it related to novelty seeking personality traits?

"Dropouts" are a major concern when monitoring treatment efficacy in clinical trials. Alcohol-dependent patients are especially prone to discontinuing treatment, perhaps because of impulsive behavior. The Tridimensional Personality Questionnaire (TPQ) measures a trait-like quality, novelty seeking, which may reflect impulsiveness. We tested the hypotheses that higher TPQ Novelty Seeking subscale scores would be associated with increased rates of treatment dropout and increased risk for dropping out earlier. A total of 170 alcohol-dependent men who participated in a double-blind, placebo-controlled pharmacotherapeutic trial for decreasing relapse drinking completed the TPQ and were monitored until treatment dropout. Logistic regression and Cox proportional hazards models were used to (1) describe the relationship between the TPQ Novelty Seeking score and the dichotomous outcome variable, treatment dropout; and (2) assess the effects of a number of potential confounding covariates on the relationship between the risk factor, novelty seeking, and the time to the outcome event. The mean Novelty Seeking score was significantly higher among study dropouts compared with nondropouts (p = 0.003). Higher Novelty Seeking scores were associated with a higher adjusted odds ratio for dropping out (adjusted odds ratio = 1.07, 95% confidence interval [CI] = 1.00-1.15) and a higher adjusted hazard rate for dropping out earlier (adjusted hazard rate = 1.05, 95% CI = 1.00-1.09). The TPQ Novelty Seeking subscale score may identify a subgroup of alcohol-dependent men who are at risk for dropping out of treatment. This information may be useful for developing treatment plans to encourage these high-risk patients to remain in treatment.

Outpatient parenteral antibiotic therapy. Management of serious infections. Part I: Medical, socioeconomic, and legal issues. Advances in i.v. delivery.

Physicians who prescribe outpatient parenteral antibiotic therapy must remain abreast of advances in intravenous catheters and infusion pumps so they can select equipment that realizes the full potential of therapy and suits the patient's needs for comfort, reliability, and safety. The cost of equipment and installation can vary greatly and is thus another important consideration when choosing these devices.

Marked hyperbilirubinemia in infectious mononucleosis. Analysis of laboratory data in seven patients.

While mild to moderate hepatic dysfunction is commonly encountered in infectious mononucleosis induced by Epstein-Barr virus (EBV), clinical jaundice with high bilirubin levels (greater than or equal to 6.0 mg/dL [greater than or equal to 103 mumol/L] is only occasionally encountered. In this study, seven patients with primary EBV infections had peak bilirubin levels of 10.2 to 23.0 mg/dL (174 to 393 mumol/L) and, for the most part, presented initial diagnostic problems. Complications included the virus-associated hemophagocytic syndrome and acute respiratory distress syndrome in one patient and transient renal failure in another. The laboratory data suggested that a combination of hemolysis and viral-induced cholestasis was responsible for the intense hyperbilirubinemia in at least five patients. Physicians should be aware that marked hyperbilirubinemia can occur with EBV-induced infectious mononucleosis and, thereby, obviate the need for costly diagnostic laboratory tests and, occasionally, invasive procedures.

Nosocomial transmission of a strain of Staphylococcus aureus causing toxic shock syndrome.

A strain of Staphylococcus aureus producing toxic shock syndrome toxin-1 was repeatedly isolated from the nares of a neurosurgeon. This strain was identical to strains cultured from two of his patients who developed toxic shock syndrome after laminectomy. The relatedness of the isolates was shown by Southern blot hybridization analyses using chromosomal transposons as probes. This approach should be considered, in addition to standard bacteriologic techniques, as an effective method to analyze the relatedness of nosocomial isolates.

Pharmacological modulation of suppressor cell activity in mice with disseminated histoplasmosis.

Indomethacin and cyclophosphamide (CY) were used in an attempt to modify the suppressive effects of spleen cell populations from mice with disseminated histoplasmosis at 1 week of infection. In vitro addition of indomethacin did not alter the depressed plaque-forming cell response to sheep erythrocytes of normal spleen cells cocultured with unfractionated or nylon wool-fractionated spleen cells from infected mice. Likewise, indomethacin given intraperitoneally did not enhance the subnormal in vivo plaque-forming cell response of spleen cells from infected mice. Conversely, 20 mg of CY per kg given intraperitoneally 2 days before or 6 h after the inoculation with Histoplasma capsulatum partially reversed the suppression effected by splenic T cells (nylon wool passed) in vitro, whereas 50 mg of CY per kg given intraperitoneally 6 h after the injection of H. capsulatum ablated suppressor T cell activity in vitro; neither dosage of CY altered the suppression mediated by unseparated or nylon wool-adherent spleen cells. Furthermore, the administration of 50 mg of CY per kg failed to improve the depressed footpad responses of mice infected for 1 week to sheep erythrocytes in sheep erythrocyte-sensitized mice or to histoplasmin. These findings indicate that in experimental disseminated histoplasmosis, suppression effected by splenic T cells can be alleviated by CY; however, there is a persistent immunosuppressor mechanism(s) that cannot be counteracted by either indomethacin or CY.

Effect of method of administration on extravascular penetration of four antibiotics.

The effect of both method of drug administration and serum protein binding on antibiotic penetration into subcutaneous Visking chambers was studied in rabbits. Ampicillin and oxacillin were administered by either repeated intramuscular injection of 30 mg/kg every 4 h or by constant infusion of 7.5 mg/kg per h for 24 h. Gentamicin was given by intramuscular injection of 4 mg/kg every 4 h for 28 h and by constant infusion of 1 mg/kg per h for 24 h. Amikacin was given by intramuscular injection of 8 mg/kg every 4 h for 12 h and by constant intravenous infusion of 2 mg/kg per h for 12 h. Protein binding to rabbit serum was 73% for oxacillin, 9% for ampicillin, 19% for gentamicin, and 0% for amikacin. Chamber concentrations achieved for oxacillin, gentamicin, and amikacin were not significantly different for constant infusion versus intermittent administration. For ampicillin, chamber concentration was slightly higher by constant infusion than by intermittent administration (P less than 0.02). Fluctuations in drug concentration from peak to trough values in the chambers during the intermittent administration studies were markedly dampened when compared with serum fluctuations. This study demonstrates that whereas steady state is reached more rapidly by intermittent administration, the mean steady-state concentration of an antibiotic achieved at an extravascular site is the same or greater by constant infusion than by intermittent dosing. This is true for highly protein bound antibiotics as well as those with low serum protein binding.

Chronic blastomycotic meningitis.

Three cases of blastomycosis which presented as chronic meningitis are reported. Blastomycotic meningitis is an uncommon form of chronic fungal meningitis and is difficult to diagnose during life unless the patient has obvious systemic blastomycosis elsewhere. Evaluation of cerebrospinal fluid obtained by lumbar tap is usually not diagnostic. Obstructive hydrocephalus developed in all three patients during the course of their fungal meningitis. Culture of ventricular fluid yielded the fungus in all three patients (although only after death in one case). One patient received only minimal therapy before death whereas the third patient received a full course of amphotericin B with restoration to his premorbid state. Blastomycosis should be included in the differential diagnosis of chronic meningitis and, when suspected, the cisternal or ventricular fluid should be sampled.