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BACKGROUND: Elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels at 20 weeks' gestation predict adverse cardiovascular (CV) complications during pregnancy in women with congenital heart disease (CHD). To improve early risk assessment in these women, we investigated the predictive value of first-trimester NT-proBNP for CV complications and its association with ventricular function during pregnancy. METHODS: Pregnant women with CHD, previously enrolled in a prospective national study or evaluated by an identical protocol, were included. Clinical data, echocardiographic evaluation and NT-proBNP measurements were obtained at 12, 20 and 32 weeks' gestation. Elevated NT-proBNP was defined as > 235 pg/ml (95th percentile reference value of healthy pregnant women in the literature). RESULTS: We examined 126 females (mean age 29 years). Elevated NT-proBNP at 12 weeks was associated with CV complications (n = 7, 5.6%, odds ratio 10.9, p = 0.004). Arrhythmias were the most common complication (71%). The negative predictive value of low NT-proBNP to exclude CV complications was 97.2%. In women with CV complications, NT-proBNP levels remained high throughout pregnancy, while a decrease was seen in women without CV complications (p < 0.001 for interaction between group and time). At 12 weeks, higher NT-proBNP levels were associated with impaired subpulmonary ventricular function (p < 0.001) and also with a decline in subpulmonary ventricular function later in pregnancy (p = 0.012). CONCLUSIONS: In this study, first-trimester NT-proBNP levels were associated with adverse CV complications and a decline in subpulmonary ventricular function later in pregnancy in women with CHD. Early NT-proBNP evaluation is useful for tailored care in pregnant women with CHD.

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We present a case of a 54-year-old woman with rapidly progressive renal failure of uncertain origin, who developed pleuropericarditis and livedo reticularis 6 weeks after initiation of hemodialysis (HD). The presentation with acute renal failure, the development of serositis, and the dramatic clinical response to empiric steroid therapy initially suggested the diagnosis of a systemic inflammatory disorder or vasculitis. Renal biopsy, performed 3 days after presentation, suggested crystal deposition disease, and subsequent investigations, using both dialysate oxalate concentrations and liver biopsy, led to the diagnosis of primary hyperoxaluria (PH). We discuss this atypical adult presentation of PH and propose a role for the use of steroids in the management of the acute inflammatory symptoms of oxalosis. We also briefly discuss the current medical management of patients with PH, including transplantation.

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The objective of this study was to correlate between macrophage inflammatory protein-1beta (MIP1beta) and viral loads in untreated, HIV-infected individuals. For that purpose, HIV-positive patients were tested for number of copies of HIV-RNA in plasma and for intracellular MIP1beta in freshly explanted CD8 and CD4 lymphocytes and monocytes. Results demonstrate that the levels of MIP1beta in the various cell populations were significantly higher in the HIV group than in age-matched healthy individuals. Moreover, patients with low CD4 cell counts (<500/microl) and relatively high viral loads exhibited much higher levels of intracellular MIP1beta than patients with lower viral loads and CD4 counts >500/microl. We conclude therefore that although MIP1beta is induced in the various cell populations as a result of HIV infection in vivo, a high intracellular level of MIP1beta appears to be linked to a deterioration in the immune status of the patients.

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Ethylene glycol poisoning is an important toxicological problem in medical practice because early diagnosis and treatment can prevent considerable morbidity and mortality. When ingested in the form of antifreeze or other automotive products, ethylene glycol results in central nervous system depression, cardiopulmonary compromise, and renal insufficiency. Metabolism of ethylene glycol to organic acids is required for metabolic derangement and organ damage. Laboratory features of ethylene glycol poisoning include increased anion gap metabolic acidosis, increased osmolal gap, calcium oxalate crystalluria, and detectable ethylene glycol in serum. This Case Conference integrates discussion of the toxicokinetic and analytical variables that affect the laboratory diagnosis of ethylene glycol intoxication.

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A 46-year-old man presented with shock and adult respiratory distress syndrome. Investigations revealed an adrenal mass that was diagnosed, by fine-needle aspiration biopsy, as pheochromocytoma. Because biopsy is contraindicated in patients with pheochromocytoma, this confusing presentation underscores the value of excluding this diagnosis by biochemical means before performing fine-needle aspiration of adrenal tumours.

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OBJECTIVE: To test the hypothesis that implementation of a practice guideline for blood gas measurement would decrease numbers and increase appropriateness of tests (according to criteria in the guideline) for up to 1 yr after introduction of the guideline. DESIGN: Numbers of tests and appropriateness of each test were measured retrospectively during each of five periods: two baseline periods 2 yrs and 1 yr before introduction of the guideline and three follow-up periods 2 to 3 months, 6 to 7 months, and 12 to 13 months after introduction of the guideline. SETTING: A ten-bed multidisciplinary intensive care unit (ICU) within a 500-bed tertiary teaching hospital. PATIENTS: A random sample of 30 patients admitted to the ICU during each of the periods specified above. INTERVENTIONS: The nominal group process was used to develop a new guideline and a multipronged educational approach was used to facilitate implementation of the guideline. MEASUREMENTS AND MAIN RESULTS: At 2 to 3 months, test numbers decreased from 4.9 +/- 1.6 to 3.1 +/- 1.8 (SD) tests/patient/day and to 2.4 +/- 1.2 tests/patient/day at 12 to 13 months. Appropriateness increased from a mean of 44% at baseline to 78% at 2 to 3 months and 79% at 12 to 13 months. There were no differences in Acute Physiology and Chronic Health Evaluation scores or ICU mortality among the patient groups and no differences in number of ventilator days or time to wean from ventilation. Cost-minimization analysis showed that the incremental cost-saving 1 yr after introduction of the guideline was $19.18 per patient per day. CONCLUSIONS: Implementation of this guideline for arterial blood gas measurement increases efficiency of test utilization without prolonging mechanical ventilation or affecting outcome.

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Many atypical manifestations that can be inaugural in giant cell arteritis are well known. Three cases with facial edema as the first manifestation are described. Similar cases reported to date are reviewed.

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Five unrelated children are described with a rare autoimmune lymphoproliferative syndrome (ALPS) characterized by massive nonmalignant lymphadenopathy, autoimmune phenomena, and expanded populations of TCR-CD3+CD4-CD8- lymphocytes. These findings, suggesting a genetic defect in the ability of T lymphocytes to respond to normal immunoregulatory mechanisms, prompted an evaluation of lymphocyte apoptosis. Each child had defective Fas-mediated T lymphocyte apoptosis associated with a unique, deleterious Fas gene mutation. One mutation appeared to cause a simple loss of function; however, four others had a dominant negative phenotype when coexpressed with normal Fas. Family studies demonstrated the inheritance of the mutant Fas alleles. The occurrence of Fas mutations together with abnormal T cell apoptosis in ALPS patients suggests an involvement of Fas in this recently recognized disorder of lymphocyte homeostasis and peripheral self-tolerance.

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The authors report the case of a man 49 years of age with near-fatal ethylene glycol poisoning. Detection of calcium oxalate monohydrate crystals in the urine was the only real-time confirmation of the diagnosis. The case illustrates that, if the toxin has already been metabolized, familiarity with the appearance and significance of this unusual form of calcium oxalate crystal may be the key to an accurate diagnosis.

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Plasma ionized calcium [Ca++] concentrations are decreased in patients having lactic acidosis. To further investigate this observation, we prospectively studied nine critically ill patients who had lactic acidosis and measured arterial pH, PCO2, [Ca++], lactate, and albumin concentrations. We found a strong association between decreased [Ca++] and increased plasma lactate concentrations (r2 = 0.78, p less than or equal to 0.001). This unexpected association--[Ca++] usually increases with increasing acidosis--might be clinically important and the mechanism deserves further investigation.

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The authors analyse the relationships which exist, in terms of programmes, sectors and institutions, between animal health, animal production and veterinary public health on the one hand, and between each of these three sectors and public health in general on the other. The most important common factor is food safety. Undernutrition, which affects some 60 million inhabitants of Latin America and the Caribbean, is still the most important public health problem in this part of the world. While it is known that the major cause of undernutrition is the low gross domestic product and uneven distribution of wealth, increased animal production and productivity would provide the key to an improvement in the situation. The concept of animal health, in its broadest sense, implies optimum animal production in a given region and during a specified period of time. Veterinary public health has functions and objectives which are crucial for food safety: protection and hygiene of foods, and control of the use in animal production of substances toxic to human beings (such as heavy metals, hormones and insecticides). Within the area of transmissible diseases, the authors discuss control measures for zoonoses. Besides the specific subject of interdisciplinary relationships in regard to zoonoses, the authors stress the importance of joint work conducted in the research, development and implementation of laboratory diagnostic activities and the production and quality control of antigens and vaccines. The production of laboratory animals is another sphere of common activity and research, and it cannot be said that such work is specific to any one of the three disciplines. Moreover, the fields of health, animal health and veterinary public health share the same methods and strategies, and reciprocal benefits could be more significant than the objectives of individual programmes. Reference is made to the organisation of state services and their adaptation to administrative de-centralisation, particularly at the local level.

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Tradicionalmente a saúde animal está vinculada exclusivamente aos modelos biomédicos das enfermidades dos animais, principalmente as transmissíveis. A influência microbiologicista, sempre associada à técnica de diangóstico e a procedimentos imunoprofiláticos, apesar de produzir avanços notórios, também produz metodologicamente uma visäo reducional, parcial e desintegradora da saúde animal. As alternativas de soluçäo dos problemas de saúde animal na América Latina têm que levar em consideraçäo as características destas sociedades, considerando que nestas há grupos de atores sociais com distintas visöes, objetivos e interesses

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The postantibiotic effect of oxacillin on Staphylococcus aureus ATCC 6538P was determined under different test conditions by reference (viability counting) and semiautomated (electronic counting) methods. Differences in durations of the postantibiotic effect obtained with the two counting methods were not statistically significant. The semiautomated method provided a more rapid and convenient alternative to viability counting.

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