Is it ethical to withdraw low-burden interventions in chronically ill patients?
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Critical Illness↗
Biomedical subjects
D J Lane
Publications and source records attributed to D J Lane.
Analysis of expiratory tidal flow patterns as a diagnostic tool in airflow obstruction.
An index obtained from tidal expiration, the ratio of time to peak tidal expiratory flow (tPTEF) to expiratory time (tE), discriminates between groups with and without airflow obstruction in infants and children and correlates with other measurements of airflow obstruction in adults. The aim of this study was to determine whether the diagnosis of airflow obstruction could be made from an analysis of the later part of the expiratory tidal flow time curve, i.e beyond the maximum flow. One hundred and eighteen patients attending the lung function laboratory with a putative diagnosis of airflow obstruction were studied. From uncoached tidal breathing, measurements were made of the average time constant of the respiratory system (Trs) and extrapolated volume (EV). Forced expiratory spirometry and whole-body plethysmography were performed. In this cross-sectional study, Trs correlated with inspiratory airways resistance and forced expiratory volume in one second (FEV1), according to the linear regression equations, airway resistance (Raw)=3.03 Trs+1.2, r=0.65, p<0.001, and FEV1% predicted = 87.8-23.7 Trs, r=058, p<0.001. EV correlated positively with overinflation, functional residual capacity (FRC) % pred = 152 EV+103, r=0.68, p<0.001. This study shows that there is a relationship between these measurements made from analysis of tidal breathing and recognized measurements of airflow obstruction and overinflation.
Adolescent↗
Rapid and sensitive detection of Chlamydia trachomatis using a ligatable binary RNA probe and Q beta replicase.
A simple assay format was developed for the direct detection of C. trachomatis rRNA utilizing ligation of recombinant MDV-1 probe RNA fragments hybridized to 23S rRNA after capture and release from a solid support. Assay background (equivalent to 10(4) targets) was suppressed by blocking sequences in the 5' MDV reporter probe fragment complementary to the 3' fragment by prehybridization of a DNA oligonucleotide. A pair of reporter fragments bearing a deletion within the region, obtained by a hydrid-selection-amplification protocol, yielded a low level of assay background which was reduced to < 2% with a blocker directed against the remaining pairing sequence. This probe set showed a sensitivity of 10(3) molecules of 23S rRNA (> 95% responding) and could detect a single elementary body (EB) of Chlamydia trachomatis or 1-10 EB added to a clinical matrix of pooled negative human cervical swab samples. The time of first appearance of amplification products by real-time fluorescence detection showed a linear response to log increases in the target level over a 10(5)-fold range, permitting the determination of target level within an order of magnitude. The assay showed approximately 10(9)-fold discrimination over Chlamydia pneumonae (TWAR) rRNA. High levels of cultured C. albicans, E. coli, S. aureus, or N. gonorrhoeae had no detectable effect on assay background or the ability to detect a single elementary body.
Bacteriological Techniques↗
A placebo-controlled study of liposome-mediated gene transfer to the nasal epithelium of patients with cystic fibrosis.
Cystic fibrosis (CF) is a common, serious, inherited disease. The major cause of mortality in CF is lung disease, due to the failure of airway epithelial cells to express a functional product of the cystic fibrosis transmembrane conductance regulator (CFTR) gene. A potential treatment for CF lung disease is the expression of CFTR in the airways following gene transfer. We have undertaken a double-blinded, placebo-controlled, clinical study of the transfer of the CFTR cDNA to the nasal epithelium of 12 CF patients. Cationic liposomes complexed with plasmid containing the human CFTR cDNA were administered to eight patients, whilst four patients received placebo. Biopsies of the nasal epithelium taken 7 days after dosing were normal. No significant changes in clinical parameters were observed. Functional expression of CFTR assessed by in vivo nasal potential difference measurements showed transient correction of the CF chloride transport abnormality in two patients (15 days after dosing in one patient). Fluorescence microscopy demonstrated CFTR function ex vivo. In cells from nasal brushings. In total, evidence of functional CFTR gene transfer was obtained in six out of the eight treated patients. These results provide proof of concept for liposome-mediated CF gene transfer.
Adolescent↗
Detection of Mycobacterium tuberculosis directly from sputum by using a prototype automated Q-beta replicase assay.
We have adapted an assay for the direct detection of Mycobacterium tuberculosis using a prototype automated instrument platform in which probes are amplified with Q-beta replicase. The assay was based on amplification of specific detector probe following four cycles of background reduction (reversible target capture) in a closed disposable pack. The assay signal was the time required for fluorescence to exceed background levels (response time [RT]). RT was inversely related to the number of M. tuberculosis rRNA target molecules in the sample. Equivalent signals and noises were observed in assays containing either sputum or buffer. All mock samples containing > or = 10 CFU of M. tuberculosis responded in the assay (average RT, 13.91 min), while most (83%) samples containing as many as 10(7) CFU of Mycobacterium avium gave no response during a 25-min amplification reaction. The samples containing M. avium which did respond had an average RT of 17.04 min. Seventy-five percent (167 of 223) of samples containing no target gave no responses; the remaining 25% had an average RT of 15.53 min. Eighty-three frozen sputum samples were tested to develop a candidate cutoff RT for the assay prior to more extensive clinical testing. After resolution of discrepant results and with a 14-min RT cutoff, 30 of 38 M. tuberculosis-positive samples were positive by the assay; 1 of 45 negative samples responded within 14 min. Assay sensitivity, specificity, and positive and negatives predictive values in this pilot study were 79, 98, 97, and 85%, respectively.
DNA Probes↗
Performance of an automated Q-beta replicase amplification assay for Mycobacterium tuberculosis in a clinical trial.
We present data from a clinical trial study in which an automated version (Galileo) of a previously described Q-Beta replicase-amplified probe assay (J. S. Shah et al., J. Clin. Microbiol. 33:1435-1441, 1995) was used for the direct detection of Mycobacterium tuberculosis complex in sputum. The assay was designed to target specific regions of 23S rRNA found in M. tuberculosis, Mycobacterium bovis, Mycobacterium africanum, and Mycobacterium microti and had a sensitivity ranging from approximately <10 to 300 CFU. The assay was tested for cross-hybridization by using large numbers (e.g., 10(5)to 10(10) CFU/assay) of 133 other organisms commonly found in respiratory tract samples, including non-M. tuberculosis Mycobacterium spp., other bacteria, fungi, and viruses. All of these competitors tested negative by the assay. Automated assay results for 780 respiratory tract samples (sputum or bronchoalveolar lavage specimens) collected and tested at three trial sites in the United States) were compared with the results of culture and acid-fast microscopy. Aliquots of conventionally digested and decontaminated sputum pellets were heated at 100 degrees C and mechanically disrupted prior to hybridization and background reduction, amplification, and detection in a closed disposable test pack. Pertinent elements of individual patient histories relating to tuberculosis exposure, previous active disease, antituberculosis therapy status, etc., were considered in the resolution of discrepant results for 48 (assay false-positive) samples. Seventy-one of 90 (78.9%) culture-positive samples were positive when tested in the Galileo assay, while 7% of culture-negative samples were assay positive, corresponding to a sensitivity of 79% and a specificity of 93%. Following resolution of discrepant results by chart review, the sensitivity and specificity for the Q-Beta replicase amplification assay with the Galileo analyzer were 84 and 97%, respectively. A total of 69.2% of smear-negative (culture positive) samples were detected by the assay. Ten test packs at a time were automatically processed by the Galileo analyzer without operator intervention following loading of samples. The first result was reported in approximately 3 h, and the last result was available in 6.5 h. To our knowledge, this is the first report of a clinical study with a fully automated amplification probe hybridization assay for the detection of pathogens directly from a clinical specimen.
Bronchoalveolar Lavage Fluid↗
Diversity of host species and strains of Pneumocystis carinii is based on rRNA sequences.
We have amplified by PCR Pneumocystis carinii cytoplasmic small-subunit rRNA (variously referred to as 16S-like or 18S-like rRNA) genes from DNA extracted from bronchoalveolar lavage and induced sputum specimens from patients positive for P. carinii and from infected ferret lung tissue. The amplification products were cloned into pUC18, and individual clones were sequenced. Comparison of the determined sequences with each other and with published rat and partial human P.carinii small-subunit rRNA gene sequences reveals that, although all P. carinii small-subunit rRNAs are closely related (approximately 96% identity), small-subunit rRNA genes isolated from different host species (human, rat, and ferret) exhibit distinctive patterns of sequence variation. Two types of sequences were isolated from the infected ferret lung tissue, one as a predominant species and the other as a minor species. There was 96% identity between the two types. In situ hybridization of the infected ferret lung tissue with oligonucleotide probes specific for each type revealed that there were two distinct strains of P. carinii present in the ferret lung tissue. Unlike the ferret P. carinii isolates, the small-subunit rRNA gene sequences from different human P. carinii isolates have greater than 99% identity and are distinct from all rat and ferret sequences so far inspected or reported in the literature. Southern blot hybridization analysis of PCR amplification products from several additional bronchoalveolar lavage or induced sputum specimens from P. carinii-infected patients, using a 32P-labeled oligonucleotide probe specific for human P. carinii, also suggests that all of the human P. carinii isolates are identical. These findings indicate that human P. carinii isolates may represent a distinct species of P. carinii distinguishable from rat and ferret P. carinii on the basis of characterization of small-subunit rRNA gene sequences.
Animals↗
Difference between functional residual capacity and elastic equilibrium volume in patients with chronic obstructive pulmonary disease.
BACKGROUND: A study was performed to determine the elastic equilibrium volume (Vr) of the respiratory system in patients with chronic obstructive pulmonary disease (COPD). METHODS: Voluntary relaxed expiration from total lung capacity (TLC) was studied in three groups of subjects: seven patients with severe chronic airways obstruction (COPD), 10 normal subjects, and 15 subjects with restrictive disease. RESULTS: In the normal subjects and the patients with restrictive disease voluntary relaxed expiration from TLC stopped close to end tidal volume (FRC) and the volume expired in this manoeuvre was less than that expired in a slow vital capacity manoeuvre (SVC). In the patients with COPD the voluntary relaxed expiration continued beyond the end tidal volume (FRC) and the volume expired was not different from the SVC. Oesophageal (pleural) pressures and surface diaphragmatic EMG recordings in the patients with COPD supported the premise that relaxation was achieved. CONCLUSIONS: In patients with COPD, end tidal volume (FRC) is higher than the elastic equilibrium volume, Vr, of the respiratory system. This is in contrast to patients with restrictive disease and normal subjects in whom end tidal volume (FRC) is close to Vr. This study shows that, in patients with severe chronic obstructive pulmonary disease, Vr is at least as small as residual volume (RV).
Functional Residual Capacity↗
Analysis of tidal expiratory flow pattern in the assessment of histamine-induced bronchoconstriction.
BACKGROUND: There are times in clinical practice when it would be useful to be able to assess the severity of airways obstruction from tidal breathing. Three indices of airways obstruction derived from analysis of resting tidal expiratory flow have previously been described: (1) Tme/TE = time to reach maximum expiratory flow/expiratory time; (2) Krs = decay constant of exponential fitted to tidal expiratory flow versus time curve; and (3) EV = extrapolated volume--that is, area under the curve when the fitted exponential is extrapolated to zero flow. In this paper a further index--dtr/TE, time from the beginning of expiration till the rapid decay of flow begins/expiratory time--is evaluated. The aim of this study was to assess the ability of these indices to detect mild airways obstruction. METHODS: A histamine bronchial provocation test was performed in 20 adult patients with a diagnosis of asthma or symptoms of cough and/or shortness of breath. Baseline forced expiratory volume in one second (FEV1), functional residual capacity (FRC), and specific inspiratory conductance (sGaw) were measured and the measurements repeated after the final inhalation of histamine. Expiratory flow patterns during quiet breathing over five consecutive representative breaths were analysed before and after histamine. The test was concluded in 12 subjects when FEV1 had decreased by 20% of the post saline value, and in the remaining eight after inhalation of 16 or 32 mg/ml histamine. RESULTS: FEV1, sGaw, FRC, Krs, EV, and dtr/TE were all different after histamine (paired t test). For Tme/TE no difference was shown. Change in EV detected change in end tidal volume but underestimated it compared with the change measured by body plethysmography. Percentage fall in Krs after histamine correlated with percentage fall in FEV1 (r = 0.527, Pearson correlation coefficient). This was of a similar order to the correlation between the percentage fall in sGaw and in FEV1 (r = 0.543). CONCLUSIONS: Analysis of expiratory tidal flow-time patterns predicted a decrease in FEV1 following histamine challenge as did measurement of sGaw. This analysis of tidal breathing would be useful in circumstances where forced expiratory manoeuvres are unreliable or inapplicable.
Adult↗
What can alternative medicine offer for the treatment of asthma?
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Asthma↗
Evolutionary relationships within the fungi: analyses of nuclear small subunit rRNA sequences.
Nucleotide sequences of the small subunit ribosomal RNA (18S) gene were used to investigate evolutionary relationships within the Fungi. The inferred tree topologies are in general agreement with traditional classifications in the following ways: (1) the Chytridiomycota and Zygomycota appear to be basal groups within the Fungi. (2) The Ascomycota and Basidiomycota are a derived monophyletic group. (3) Relationships within the Ascomycota are concordant with traditional orders and divide the hemi- and euascomycetes into distinct lineages. (4) The Basidiomycota is divided between the holobasidiomycetes and phragmobasidiomycetes. Conflicts with traditional classification were limited to weakly supported branches of the tree. Strongly supported relationships were robust to minor changes in alignment, method of analysis, and various weighting schemes. Weighting, either of transversions or by site, did not convincingly improve the status of poorly supported portions of the tree. The rate of variation at particular sites does not appear to be independent of lineage, suggesting that covariation of sites may be an important phenomenon in these genes.
Animals↗
Evolutionary relationships among sulfur- and iron-oxidizing eubacteria.
Some 37 reverse transcriptase, partial 16S rRNA sequences from sulfur- and/or iron-oxidizing eubacteria, including sequences from species of the genera Thiobacillus, Thiothrix, Thiomicrospira, Acidophilium, "Leptospirillum," Thiovulum, and Chlorobium, have been determined. In addition, 16S sequences from a number of unnamed sulfur- and/or iron-oxidizing bacteria from hydrothermal vent sites, from invertebrate-bacterial endosymbioses, and from various mineral recovery operations also have been determined. The majority of sequences place their bacterial donors in one or another of the subdivisions of the Proteobacteria. However, three unnamed facultatively thermophilic iron-oxidizing isolates, Alv, BC, and TH3, are affiliated with the gram-positive division. One H2S-oxidizer, from the genus Thiovulum, is affiliated with Campylobacter, Wolinella, and other genera in what appears to be a new subdivision of the Proteobacteria. Three "Leptospirillum"-helical vibrioid isolates, BU-1, LfLa, and Z-2, exhibit no clear phylum level affiliation at all, other than their strong relationship to each other. A picture is emerging of an evolutionary widespread capacity for sulfur and/or iron oxidation among the eubacteria.
Bacteria↗
Precipitins and specific IgG antibody to Aspergillus fumigatus in a chest unit population.
BACKGROUND: The enzyme linked immunosorbent assay (ELISA) for detecting IgG antibodies to Aspergillus fumigatus is more sensitive than the measurement of Aspergillus precipitins. The relation of the results from both techniques to the clinical pattern of disease in a large unselected group of patients from a large referral centre is unknown. METHODS: The clinical relation of precipitins to Aspergillus fumigatus to clinical disease was determined retrospectively in 98 patients attending a primary referral centre. Precipitin results were compared with the specific IgG antibody to A fumigatus in 88 of the sera. Precipitins were determined by the agar gel double diffusion test and specific IgG antibody to A fumigatus by a quantitative ELISA. RESULTS: Precipitins were detected in the unconcentrated serum of 51 patients. Thirty nine of these had a mycetoma or allergic bronchopulmonary aspergillosis, 34 having specific IgG antibody to A fumigatus more than the control range. Forty seven patients had precipitins only after threefold concentration of serum or to only one of the four A fumigatus antigen extracts. Most of these had specific IgG in or near the control range. Thirty of these had A fumigatus skin test negative asthma or bronchiectasis, in which aspergillus was probably not pathogenic. There was a close relation between the level of antibody detected by the ELISA and the number of precipitin lines. CONCLUSIONS: This study reaffirmed the supportive role of aspergillus precipitins in the diagnosis of pulmonary aspergillosis. No additional benefit in the routine use of the ELISA was seen. It also showed that care should be taken in interpreting positive precipitin results from concentrated serum and that using several rather than one A fumigatus antigen extract is helpful for identifying allergic aspergillosis.
Antibodies, Fungal↗
Chronic persistent asthma: nebulizers and therapy additional to inhaled beta-agonists and steroids.
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Asthma↗
Phylogenetic analysis of the genus Listeria based on reverse transcriptase sequencing of 16S rRNA.
The phylogenetic interrelationships of members of the genus Listeria were investigated by using reverse transcriptase sequencing of 16S rRNA. The sequence data indicate that at the intrageneric level the genus Listeria consists of the following two closely related but distinct lines of descent: (i) the Listeria monocytogenes group of species (including Listeria innocua, Listeria ivanovii, Listeria seeligeri, and Listeria welshimeri) and (ii) the species Listeria grayi and Listeria murrayi. At the intergeneric level a specific phylogenetic relationship between the genera Listeria and Brochothrix was evident. The sequence data clearly demonstrated that the genus Listeria is phylogenetically remote from the genus Lactobacillus and should not be included in an extended family Lactobacillaceae.
Base Sequence↗
16S ribosomal DNA amplification for phylogenetic study.
A set of oligonucleotide primers capable of initiating enzymatic amplification (polymerase chain reaction) on a phylogenetically and taxonomically wide range of bacteria is described along with methods for their use and examples. One pair of primers is capable of amplifying nearly full-length 16S ribosomal DNA (rDNA) from many bacterial genera; the additional primers are useful for various exceptional sequences. Methods for purification of amplified material, direct sequencing, cloning, sequencing, and transcription are outlined. An obligate intracellular parasite of bovine erythrocytes, Anaplasma marginale, is used as an example; its 16S rDNA was amplified, cloned, sequenced, and phylogenetically placed. Anaplasmas are related to the genera Rickettsia and Ehrlichia. In addition, 16S rDNAs from several species were readily amplified from material found in lyophilized ampoules from the American Type Culture Collection. By use of this method, the phylogenetic study of extremely fastidious or highly pathogenic bacterial species can be carried out without the need to culture them. In theory, any gene segment for which polymerase chain reaction primer design is possible can be derived from a readily obtainable lyophilized bacterial culture.
Bacteria↗
Evolutionary relationships among pathogenic Candida species and relatives.
Small subunit rRNA sequences have been determined for 10 of the most clinically important pathogenic species of the yeast genus Candida (including Torulopsis [Candida] glabrata and Yarrowia [Candida] lipolytica) and for Hansenula polymorpha. Phylogenetic analyses of these sequences and those of Saccharomyces cerevisiae, Kluyveromyces marxianus var. lactis, and Aspergillus fumigatus indicate that Candida albicans, C. tropicalis, C. parapsilosis, and C. viswanathii form a subgroup within the genus. The remaining significant pathogen, T. glabrata, falls into a second, distinct subgroup and is specifically related to S. cerevisiae and more distantly related to C. kefyr (psuedotropicalis) and K. marxianus var. lactis. The 18S rRNA sequence of Y. lipolytica has evolved rapidly in relation to the other Candida sequences examined and appears to be only distantly related to them. As anticipated, species of several other genera appear to bear specific relationships to members of the genus Candida.
Aspergillus fumigatus↗
Alternative and complementary medicine for asthma.
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Acupuncture Therapy↗