Low-dose and high-dose synacthen tests and the hemodynamic response to hydrocortisone in acute traumatic brain injury

INTRODUCTION

In order to identify whether low-dose (1 microg) tetracosactide (Synacthen) testing may be preferable to high-dose (250 microg) testing in the diagnosis of adrenal insufficiency in traumatic brain injury (TBI), as suggested by studies in other forms of critical illness.

METHODS

We retrospectively reviewed the results of modified tetracosactide tests (involving administration of both low-dose and high-dose tetracosactide) conducted for clinical indications in patients in a neurocritical care unit within 10 days of TBI. Sixty-three modified tests were included and cortisol concentrations before and after administration of tetracosactide were extracted from the hospital records. Data were also extracted regarding hemodynamic response to empirical corticosteroid therapy, based on rapid weaning from vasoactive drugs.

RESULTS

Cortisol increments at 30 and 60 min following tetracosactide correlated well in the low-dose test (r(2) = 0.875, P < 0.0001). The mean cortisol concentration was 581 nmol/l at 30 min and 556 nmol/l at 60 min in the low-dose test. Cortisol increments following low-dose and high-dose testing correlated well overall (r(2) = 0.839, P < 0.0001), but results were discordant in 27 of 63 cases (43%) when the same diagnostic threshold was used. ROC curve analysis showed that both tests performed poorly in identifying hemodynamic steroid responsiveness (AUC 0.553 and 0.502, respectively).

CONCLUSIONS

In the low-dose tetracosactide test, it is sufficient to determine cortisol concentrations at baseline and at 30 min. Low-dose and high-dose tests give discordant results in a significant proportion of cases when using the same diagnostic threshold. Neither test can be used to guide the initiation of corticosteroid therapy in acute TBI.

Socio-economic status and the risk of liver cancer mortality: a prospective study in Korean men

OBJECTIVE

To examine the association between socio-economic status (SES) and liver cancer mortality among Korean men.

STUDY DESIGN

Prospective cohort study

METHODS

Data were acquired from a large, prospective cohort study that included 548,530 civil service workers aged 30-59 years who had undergone health examination in 1998 provided by the Korean National Health Insurance System. Information on lifestyle and demographic characteristics was acquired through self-administered questionnaires. The main outcome event was mortality from liver cancer. Cox proportional hazards model was used to estimate relative risks (RRs) and 95% confidence intervals (95% CIs) after adjusting for age, body mass index, fasting serum glucose, alcohol consumption, smoking and hepatitis B surface antigen (HBsAg) status.

RESULTS

Liver cancer mortality differentials relating to SES were statistically significant and consistent in the fully adjusted model. Compared with the highest SES category, excess risk associated with liver cancer mortality was observed with decreasing SES levels: the RRs in the upper middle, lower middle and low SES categories were 1.35 (95% CI 1.13-1.61), 1.54 (95% CI 1.28-1.86) and 1.72 (95% CI 1.45-2.04), respectively. There was no effect modification by HBsAg status on the association between SES and liver cancer mortality.

CONCLUSIONS

This study demonstrated an inverse association between SES and liver cancer mortality, suggesting that SES is an independent predictor of liver cancer mortality. The policies and interventions regarding prevention of liver cancer need to focus on disadvantaged groups in order to reduce health disparities related to liver cancer.

Unusual mode of firearm injury from the recoiled rear end of a gun barrel

Atypical gunshot wounds are caused by a diverse set of parameters relating to weapons and ammunition. We report a previously-unreported and atypical mode of gunshot wound produced by a detached rear end of the barrel of a gun following accidental gun fire, and discuss the difficulties in the management. A 36-year-old man presented to the emergency department with an alleged history of injury on the forehead with the rear end of a gun barrel following accidental gunfire while cleaning the nozzle. Since the time of injury, the patient was in an altered sensorium and had weakness on the right side of the body. There was minimal but continuous bleeding from the wound, with extrusion of brain matter. Skull radiograph showed that the rear end of the barrel had entered the left frontal bone, with associated depressed fracture of the frontal bone. The patient underwent a bicoronal, bifrontal craniotomy with a T-shaped extension towards the barrel to facilitate the reflection of the scalp flap and to avoid any movement of the barrel as it might further injure the brain. Necrotic brain, dura and bone pieces were removed. The patient was doing well at follow-up except for mild residual motor deficits. This case illustrates that while working with limited facilities, particularly in underdeveloped countries, a careful clinical assessment, interpretation of available images and a judicious operative approach can help to save the patient.

Properties of the tobacco mosaic virus intermediate length RNA-2 and its translation

The existence of subgenomic RNAs is well established in the case of plant viruses such as tobacco mosaic virus (TMV). However, except for the subgenomic coat protein mRNA, it is not known whether the other subgenomic RNAs have a function in the life cycle of the virus. In search of more information about one of the major subgenomic RNAs-intermediate length RNA-2 or I2 RNA-of TMV, in vitro and in vivo translational studies were performed. The I2 RNA, which codes in vitro for the synthesis of a 30K (K = kilodalton) protein, appears to be uncapped as judged by the need of different in vitro translation conditions for the synthesis of this protein, compared to the conditions required for the synthesis of the 126K and 183K proteins coded by the capped genomic RNA. In vivo a protein migrating in the same position as the 30K protein synthesized in vitro can be detected in infected tobacco leaves. Since this protein occurs transiently early upon infection, whether it is virus-coded or virus-induced, it could have an early function during infection.

Quantifying the accuracy of automated structure segmentation in 4D CT images using a deformable image registration algorithm

Four-dimensional (4D) radiotherapy is the explicit inclusion of the temporal changes in anatomy during the imaging, planning, and delivery of radiotherapy. One key component of 4D radiotherapy planning is the ability to automatically ("auto") create contours on all of the respiratory phase computed tomography (CT) datasets comprising a 4D CT scan, based on contours manually drawn on one CT image set from one phase. A tool that can be used to automatically propagate manually drawn contours to CT scans of other respiratory phases is deformable image registration. The purpose of the current study was to geometrically quantify the difference between automatically generated contours with manually drawn contours. Four-DCT data sets of 13 patients consisting of ten three-dimensional CT image sets acquired at different respiratory phases were used for this study. Tumor and normal tissue structures [gross tumor volume (GTV), esophagus, right lung, left lung, heart and cord] were manually drawn on each respiratory phase of each patient. Large deformable diffeomorphic image registration was performed to map each CT set from the peak-inhale respiration phase to the CT image sets corresponding with subsequent respiration phases. The calculated displacement vector fields were used to deform contours automatically drawn on the inhale phase to the other respiratory phase CT image sets. The code was interfaced to a treatment planning system to view the resulting images and to obtain the volumetric, displacement, and surface congruence information; 692 automatically generated structures were compared with 692 manually drawn structures. The auto- and manual methods showed similar trends, with a smaller difference observed between the GTVs than other structures. The auto-contoured structures agree with the manually drawn structures, especially in the case of the GTV, to within published interobserver variations. For the GTV, fractional volumes agree to within 0.2+/-0.1, center of mass displacements agree to within 0.5+/-1.5 mm, and agreement of surface congruence is 0.0+/-1.1 mm. The surface congruence between automatic and manual contours for the GTV, heart, left lung, right lung and esophagus was less than 5 mm in 99%, 94%, 94%, 91% and 89%, respectively. Careful assessment of the performance of automatic algorithms is needed in the presence of 4D CT artifacts.

Separating the vibrationally resolved Auger decay channels for a CO core hole state

The K-VV Auger spectrum of carbon monoxide (CO) excited by C 1s photoionization has been investigated with a novel electron-electron coincidence setup. The energy resolution is sufficiently high to resolve the vibrational energy levels of the core-ionized intermediate state and of most dicationic final states in the two-dimensional electron energy map. We demonstrate how the influence of vibrational states on a molecular Auger spectrum can be accessed experimentally without the constraint of averaging over all intermediate state energies.

Molecular cloning and characterization of Brugia malayi hexokinase

5' EST from filarial gene database has been subjected to 3' rapid amplification of cDNA ends (RACE), semi-nested PCR and PCR to obtain full-length cDNA of Brugia malayi. Full-length hexokinase gene was obtained from cDNA using gene specific primers. The elicited PCR product was cloned, sequenced and expressed as an active enzyme in Escherichia coli. Sequence analysis of B. malayi hexokinase (BmHk) revealed 59% identity with nematode Caenorhabditis elegans but low similarity with all other available hexokinases including human. BmHk, an apparent tetramer with subunit molecular mass of 72 kDa, was able to phosphorylate glucose, fructose, mannose, maltose and galactose. The Km values for glucose, fructose and ATP were found to be 0.035+/-0.005, 75+/-0.3 and 1.09+/-0.5 mM respectively. BmHk was strongly inhibited by ADP, glucosamine, N-acetyl glucosamine and mannoheptulose. The recombinant enzyme was found to be activated by glucose-6-phosphate. ADP exhibited noncompetitive inhibition with the substrate glucose (Ki=0.55 mM) while, mixed type of inhibition was observed with inorganic pyrophosphate (PPi) when ATP was used as substrate (Ki=9.92 microM). The enzyme activity is highly dependent on maintenance of free sulfhydryl groups. CD analysis indicated that BmHk is composed of 37% alpha-helices and 26% beta-sheets. The observed differences in kinetic properties of BmHk as compared to host enzyme may facilitate designing of specific inhibitors against BmHk.

First Order Decision Diagrams for Relational MDPs

Markov decision processes capture sequential decision making under uncertainty, where an agent must choose actions so as to optimize long term reward. The paper studies efficient reasoning mechanisms for Relational Markov Decision Processes (RMDP) where world states have an internal relational structure that can be naturally described in terms of objects and relations among them. Two contributions are presented. First, the paper develops First Order Decision Diagrams (FODD), a new compact representation for functions over relational structures, together with a set of operators to combine FODDs, and novel reduction techniques to keep the representation small. Second, the paper shows how FODDs can be used to develop solutions for RMDPs, where reasoning is performed at the abstract level and the resulting optimal policy is independent of domain size (number of objects) or instantiation. In particular, a variant of the value iteration algorithm is developed by using special operations over FODDs, and the algorithm is shown to converge to the optimal policy.

Molecular cloning and characterization of Plasmodium falciparum transketolase

The pentose phosphate pathway (PPP) is an important metabolic pathway for yielding reducing power in the form of NADPH and production of pentose sugar needed for nucleic acid synthesis. Transketolase, the key enzyme of non-oxidative arm of PPP, plays a vital role in the survival/replication of the malarial parasite. This enzyme in Plasmodium falciparum is a novel drug target as it has least homology with the human host. In the present study, the P. falciparum transketolase (PfTk) was expressed, localized and biochemically characterized. The recombinant PfTk harboring transketolase activity catalyzed the oxidation of donor substrates, fructose-6-phosphate (F6P) and hydroxypyruvate (HP), with K(m)(app) values of 2.25 and 4.78 mM, respectively. p-Hydroxyphenylpyruvate (HPP) was a potent inhibitor of PfTk, when hydroxypyruvate was used as a substrate, exhibiting a K(i) value of 305 microM. At the same time, noncompetitive inhibition was observed with F6P. The native PfTk is a hexamer with subunit molecular weight of 70kDa, which on treatment with low concentrations of guanidine hydrochloride (GdmCl) dissociated into functionally active dimers. This protein was localized in the cytosol and nucleus of the parasite as studied by confocal microscopy. A model structure of PfTk was constructed based on the crystal structure of the transketolases of Saccharomyces cerevisae, Leishmania mexicana and Escherichia coli to assess the structural homology. Consistent with the homology modeling predictions, CD analysis indicated that PfTk is composed of 39% alpha-helices and 26% beta-sheets. The availability of a structural model of PfTk and the observed differences in its kinetic properties compared to the host enzyme may facilitate designing of novel inhibitors of PfTk with potential anti-malarial activity.

Posture and performance: sitting vs. standing for security screening

A classification of the literature on the effects of workplace posture on performance of different mental tasks showed few consistent patterns. A parallel classification of the complementary effect of performance on postural variables gave similar results. Because of a lack of data for signal detection tasks, an experiment was performed using 12 experienced security operators performing an X-ray baggage-screening task with three different workplace arrangements. The current workplace, sitting on a high chair viewing a screen placed on top of the X-ray machine, was compared to a standing workplace and a conventional desk-sitting workplace. No performance effects of workplace posture were found, although the experiment was able to measure performance effects of learning and body part discomfort effects of workplace posture. There are implications for the classification of posture and performance and for the justification of ergonomics improvements based on performance increases.