Ladder fall injuries: patterns and cost of morbidity

Ladder fall injuries are associated with a wide spectrum of injury patterns. However, the healthcare cost of these injuries is unknown. The aim of this study was to determine the healthcare cost and duration of the morbidity associated with ladder fall injuries. A retrospective observational study involving patients with ladder injuries who presented to a Level 1 Trauma Centre over a 3-year period was performed. Patients then underwent a structured telephone interview to provide information about the duration of their disability and unemployment. There were 72 patients in the study, of whom 89% were male. Thirteen patients (18%) required hospital admission. The median length and cost of hospital stay was 1 week and 3555 (US$ 3950), respectively. The median duration of disability and unemployment was 6 weeks. The longest duration of disability was associated with foot fractures. The majority of patients fell between 5 and 10ft, and fell at work. The upper extremity was the most commonly injured anatomical region. There were no fatalities. Ladder injury falls are expensive to the health service and may warrant investment in their prevention.

The risk of complications of uveitis in a district hospital cohort

AIMS

To establish the frequency and risk factors for visual loss in a primary referral cohort of hospital patients with uveitis.

METHODS

561 consecutive uveitis patients attending three district hospitals were recruited and the acuity at the end of the study period recorded. A retrospective case-control study of risk factors for visual loss (permanent loss of acuity <6/9) was performed. Risk factors examined included type of uveitis, age at onset of uveitis, race, type of systemic inflammatory disease, length of follow up, and treatment variables.

RESULTS

Visual loss of at least 6/12 in one eye was found in 111 patients (19.9%). Only four patients (0.7%) suffered severe bilateral visual loss (6/36 or less). Visual loss was associated with age at onset >60 years (odds ratio 3.9, 95% confidence interval (CI) 2.2 to 7.0, long follow up 2.0 (1.2 to 3.3) and a history of cataract surgery 3.9 (2.1 to 7.2). It was less likely in patients with acute anterior uveitis 0.2 (0.1 to 0.3).

CONCLUSION

The frequency of visual loss associated with uveitis in a district hospital cohort is less than that found in referral centres and levels of legal blindness are low. Although acute anterior uveitis has a low frequency of visual loss it contributes significantly to the total burden. The ocular co-morbidity of the elderly may contribute to the increased visual loss of late onset uveitis.

Alterations in the post-translational modification and intracellular trafficking of clusterin in MCF-7 cells during apoptosis

Clusterin is a heterodimeric, disulfide-linked 70-80 kDa glycoprotein that is induced during regression of most, if not all, hormone-dependent epithelial tissues. These studies describe the biogenesis and intracellular trafficking of clusterin in MCF-7 cells before and after the initiation of apoptosis with antiestrogens and TNF alpha. Under physiological conditions, clusterin is modified in the endoplasmic reticulum (ER), and proteolytically cleaved in the Golgi to generate discrete alpha and beta chains prior to secretion. Treatment with TNFalpha or the antiestrogen, ICI 182,780, induces apoptosis in MCF-7 cells and leads to substantial changes in the activity of Golgi-resident enzymes, significantly altering the biogenesis of clusterin. This leads to the appearance of a 50-53 kDa uncleaved, nonglycosylated, disulfide-linked isoform of clusterin that accumulates in the nucleus. While clusterin contains a cryptic SV-40-like nuclear localization signal, mutation of this sequence does not affect the nuclear accumulation of the disulfide-linked nuclear isoform. Confocal microscopy demonstrates that the nuclear accumulation of clusterin is coincident with DNA fragmentation. These data suggest that, at least in secretory epithelial cells, retrograde transport from the Golgi to the ER of a nonglycosylated, uncleaved isoform and the subsequent translocation of clusterin to the nucleus occur in dying cells.

It can be a complicated life being an enzyme

It is becoming increasingly apparent that many well-known enzymes have alternative non-enzymic functions. Similarly, several proteins that were identified as having non-catalytic functions were subsequently found to have enzyme activities. Some examples are considered to illustrate the diversity of alternative functions. The semicarbazide-sensitive amine oxidase (EC 1.4.3.6) is considered in more depth as an example. It was originally believed to be a detoxifying enzyme, but the reaction products may have important signalling functions. Furthermore, this enzyme, from some sources, also behaves as a vascular-adhesion protein. Finally, the challenges posed by such multiplicity of functions for the interpretation of genetic deletion, in vivo inhibition and the development of functional protein databases are briefly considered.

An evaluation of the efficacy of vasoactive intestinal polypeptide antagonists in vivo in the anaesthetized dog

The effectiveness of competitive peptide vasoactive intestinal polypeptide (VIP) receptor antagonists was evaluated on heart rate in the anaesthetized dog. Two specific antagonists, VIP (6-28) and [D-p-Cl-Phe(6), Leu(17)]-VIP, and a nonspecific antagonist, pituitary adenylate cyclase activating peptide fragment (6-27) (PACAP), were studied. VIP (6-28) and [D-p-Cl-Phe(6), Leu(17)]-VIP (100 microg i.c.) increased the heart rate, whereas PACAP (100 microg i.c.) reduced the baseline heart rate. All three shifted the VIP dose-response curve to the right by two- to threefold for 30 min. In conclusion, PACAP, VIP (6-28), and [D-p-Cl-Phe(6), Leu(17)]-VIP have a direct effect on the heart rate, are equally effective, and the effects last approximately 30 min in vivo.

The effect of tezosentan, a non-selective endothelin receptor antagonist, on shear stress-induced changes in arterial diameter of the anaesthetized dog

The effects of changes in the mean (S(m)) and pulsatile (S(p)) components of arterial wall shear stress on arterial dilatation of the iliac artery of the anaesthetized dog were examined in the absence and presence of the endothelin receptor antagonist tezosentan (10 mg kg(-1) I.V.; Ro 61-0612; [5-isopropyl-pyridine-2-sulphonic acid 6-(2-hydroxy-ethoxy)-5-(2-methoxy-phenoxy)-2-(2-1H-tetrazol-5-yl-pyridin-4-yl)-pyrimidin-4-ylamide]). Changes in shear stress were brought about by varying local peripheral resistance and stroke volume using a distal infusion of acetylcholine and stimulation of the left ansa subclavia. An increase in S(m) from 1.81 +/- 0.3 to 7.29 +/- 0.7 N m(-2) (means +/- S.E.M.) before tezosentan caused an endothelium-dependent arterial dilatation which was unaffected by administration of tezosentan for a similar increase in S(m) from 1.34 +/- 0.6 to 5.76 +/- 1.4 N m(-2) (means +/- S.E.M.). In contrast, increasing the S(p) from 7.1 +/- 0.8 to a maximum of 11.5 +/- 1.1 N m(-2) (means +/- S.E.M.) before tezosentan reduced arterial diameter significantly. Importantly, after administration of tezosentan subsequent increases in S(p) caused arterial dilatation for the same increase in S(p) achieved prior to tezosentan, increasing from a baseline of 4.23 +/- 0.4 to a maximum of 9.03 +/- 0.9 N m(-2) (means +/- S.E.M.; P < 0.001). In conclusion, the results of this study provide the first in vivo evidence that pulsatile shear stress is a stimulus for the release of endothelin from the vascular endothelium.

Reverse arterial wall shear stress causes nitric oxide-dependent vasodilatation in the anaesthetised dog

The effects of a maintained increase in mean arterial wall shear stress (SS(m)) caused by blood flow in the normal and reverse direction on dilatation of the iliac artery were examined in the anaesthetised dog. Blood flow in the left iliac artery was varied in both the forwards and reverse directions by a perfusion pump connecting the right and left femoral arteries. An increase in blood flow, and therefore SS(m) in either direction, caused an increase in arterial diameter. However, an increase in forwards SS(m) (control 4.1+/-0.11 mm) caused a significantly greater change in arterial diameter than an equivalent increase in the reverse direction (control 4.3+/-0.08), 0.198+/-0.02 mm vs. 0.132+/-0.02 mm (mean+/-SEM) respectively, for the same increase in SS(m) (3.23 N/m(2)). The increase in arterial diameter in response to an increase in forwards or reverse SS(m) was attenuated by L-NAME (80 mg/kg i.v.), indicating that the arterial dilatation was mediated by nitric oxide (NO). These findings confirm that endothelial NO release is dependent on the steady-state SS(m) and that the response occurs irrespective of the direction in which this force is applied, but is attenuated in the reverse direction.

Single-nucleotide polymorphism alleles in the insulin receptor gene are associated with typical migraine

We have identified a migraine locus on chromosome 19p13.3/2 using linkage and association analysis. We isolated 48 single-nucleotide polymorphisms within the locus, of which we genotyped 24 in a Caucasian population comprising 827 unrelated cases and 765 controls. Five single-nucleotide polymorphisms within the insulin receptor gene showed significant association with migraine. This association was independently replicated in a case-control population collected separately. We used experiments with insulin receptor RNA and protein to investigate functionality for the migraine-associated single-nucleotide polymorphisms. We suggest possible functions for the insulin receptor in migraine pathogenesis.

The transcription factor onecut-2 controls the microphthalmia-associated transcription factor gene

Microphthalmia-associated transcription factor (MITF) is essential for melanocyte differentiation. MITF mutations are associated with some cases of Waardenburg syndrome (WS) type 2. WS is a dominantly inherited disease characterized by auditory-pigmentary defects that result from the absence of melanocytes. The lack of mutation in MITF coding sequences in some WS2 patients suggests that unidentified factors controlling MITF expression might be involved. We show here that the cut-homeodomain transcription factor Onecut-2 (OC-2) is expressed in melanocytes and binds to the MITF gene promoter. Overexpression of OC-2 in transfected cells stimulates MITF promoter activity. Mutations that prevent OC-2 binding decrease MITF promoter activity by 75%. Based on these results, we searched in 56 WS2 patients for mutations in the OC2 gene or in OC-2 binding sites in the MITF promoter, but none was found. These results show that OC-2 stimulates MITF expression and that OC2 is a candidate gene, but not a common cause, of WS.

Trauma-induced coagulopathy and treatment in Kosovo

The 67th Combat Support Hospital at Camp Bondsteel, Kosovo, treated victims of trauma on an almost daily basis at the beginning of U.S. peacekeeping efforts in the region. Military health care personnel must respond quickly and efficiently when confronted with patient wounds resulting in massive blood losses. The limited medical resources of a field hospital often complicate efforts to treat the most severe injuries. One such case involved a young farmer riddled with gunshot wounds. Early volume/blood resuscitation before, during, and after surgery led to a massive blood coagulopathy. This case study describes the actions the physicians and nurses initiated to save this victim of violence. The subsequent discussion delineates methods to reduce intraoperative blood losses, blood transfusion alternatives, and technological advances in trauma resuscitation.

A clinical study of the Korotkoff phases of blood pressure in children

BACKGROUND

Five Korotkoff phases are described in adults, but there are no studies of the Korotkoff phase distribution in children. This study determines the presence and length of Korotkoff phases in children, providing data on the repeatability of these measurements, the relationship between the phases, and finally the relationship between the phases and heart rate, blood pressure and arm circumference.

METHODS

Seventy, 11-year-old children were studied. The Korotkoff sounds were recorded from the bell of a stethoscope to a MiniDisc system and each sound described twice on separate occasions as phase I, II, III or IV, with phase V meaning disappearance of the sound.

RESULTS

Phases I, II, III, IV and V were present in 97% (68/70), 61% (43/70), 51% (36/70), 88% (62/70) and 80% (56/70) respectively. When the recordings were blindly re-assessed there was no significant difference in the phase distribution of the sounds. All five phases were present in 40% (28/70). Phase III only occurred in the presence of phase II (P < 0.0001). There was no significant relationship between the presence of the different phases and heart rate or blood pressure. Arm circumference was significantly larger in children with phase V present (P < 0.02).

CONCLUSIONS

The Korotkoff sounds and phase distribution present in normal children is described. Korotkoff sounds were consistently allocated to the various Korotkoff phases. This study provides insights into the problems of accurate diastolic blood pressure measurement. Phase V was more likely to be present with increasing arm circumference, but the variation in the occurrence of phases II and III remains unexplained.

Marfan's syndrome: a review

Marfan's syndrome is an inherited disorder of connective tissue, in which the most pronounced abnormalities occur in the musculoskeletal, cardiovascular and ocular systems. Aortic dilatation and dissection are the major causes of morbidity and mortality. Recent advances in surgical techniques and earlier intervention have reduced postoperative mortality and morbidity.

The application of ICP-SMS, GF-AAS and HG-AFS to the analysis of water and sediment samples from a temperate stratified estuary

Three atomic spectrometry techniques, namely sector field inductively coupled plasma mass spectroscopy, graphite furnace atomic absorption spectrometry and hydride generation atomic fluorescence spectroscopy (ICP-SMS, GF-AAS and HG-AFS, respectively), housed at separate independent laboratories, were used to analyse water and sediment samples collected from the Huon River Estuary, SE Tasmania (Australia) in the Austral spring 1998. A dithiocarbamate-chelation/back-extraction technique was used to separate and preconcentrate Co, Ni, Cu, Zn, Cd and Pb from eight collected water samples prior to analysis by ICP-SMS and GF-AAS. A number of other elements in the waters were analysed directly (Mn, Fe and Zn by GF-AAS; As by HG-AFS), or following sample dilution (1 + 19: V, Mn, Fe, As, Mo, Ba and U by ICP-SMS). Where possible, previously corroborated GF-AAS and HG-AFS techniques were used to verify obtained ICP-SMS results. From the analysis of four reference waters (SLEW-1 and -2, SLRS-3 and NASS-5), good agreement, to within +/- 10-20%, was typically found between certified (or information only values) and measured results (irrespective of analytical technique). Exceptions included Zn (and sometimes Fe) that could not be quantified by ICP-SMS due to elevated blank signals, and As which was found to lie below ICP-SMS detection limits. For Huon Estuary water samples, inter-method agreement was within +/- 10-20% (for those elements amenable to analysis by more than one technique). Nitric acid extracts of two certified reference materials (Buffalo River Sediment and BCSS-1) and six Huon Estuary sediments were analysed by ICP-SMS (for Al, Sc, V, Cr, Mn, Fe, Co, Ni, Cu, Zn, As, Cd and Pb) and HG-AFS (for As). Results from the certified reference materials indicated extraction efficiencies of 60 70% (for most elements). A close correlation between ICP-SMS and HG-AFS was obtained for leachable As in the sediments. In terms of potential inorganic contaminants, the Huon Estuary was found to be a relatively 'clean' water system. The elemental concentrations measured in water and sediment samples from this region were found to lie within current Australian guidelines for estuaries. In general, no one analytical technique was able to accurately determine all elements in all samples from this relatively pristine estuarine environment. A combination of all three analytical techniques was necessary for the successful analysis of the elements considered in this study.

Drooling in Parkinson's disease: a novel speech and language therapy intervention

Drooling and difficulty swallowing saliva are commonly reported in people with Parkinson's disease (PD). Drooling in PD is the result of swallowing difficulties rather than excessive saliva production. Currently, there is little research into the effectiveness of treatments to reduce drooling. The aims of the study were to develop objective measures of saliva volume and drooling for PD and to assess the efficacy of two therapeutic strategies to control drooling, i.e. specific speech and language therapy (SLT) including a portable metronome brooch to cue swallowing and injections of botulinum toxin into both parotid glands to reduce the amount of saliva produced. This paper will describe the assessments used, including the measurement of saliva, swallowing and drooling. The main focus will be the strategies used in the SLT intervention. The preliminary results are presented.

Investigation of a cluster of children with Down's syndrome born to mothers who had attended a school in Dundalk, Ireland

OBJECTIVES

To investigate a reported cluster of Down's syndrome in offspring of former pupils of a girls' school in Ireland, to establish the prevalence of Down's syndrome among live births in the area around the school, and to review the literature on the possible causes of reported clusters of Down's syndrome.

METHODS

Questionnaire survey of obstetric and personal histories of women who had attended the girls' school at Dundalk, County Louth, Republic of Ireland, at some time during 1956-7, and also of women who had attended another, nearby, girls' school during the same period. Comparison of observed numbers of cases of Down's syndrome identified by these surveys with maternal age adjusted expected numbers for the reported live births. Laboratory tests were conducted to verify and characterise the cases of Down's syndrome constituting the cluster. Retrospective collection and collation of data on Down's syndrome occurring among live births, and the compilation of maternal age specific incidences, in County Louth and in Newry and Mourne District in neighbouring Northern Ireland, during 1961-80. These rates were compared with reference rates and rates for other areas of Ireland.

RESULTS

Six children with Down's syndrome were confirmed among 387 reported live births to women who had been pupils at the girls' school in Dundalk during 1956-7, compared with 0.69 expected (nominal p<10(-4)). Five of the affected births were to mothers under 30 years of age, against 0.15 expected (nominal p<10(-6)), although only four of these mothers were attending the school at any one time. The origin of the non-disjunction was found to be maternal first meiotic in four children, mitotic after fertilisation in another (with the youngest mother), and in the remaining one could not be determined. The marked excess of Down's syndrome in births to young mothers did not extend to offspring of former pupils of the other Dundalk girls' school surveyed, or to live births in County Louth generally or in adjacent Newry and Mourne District.

CONCLUSION

A striking, highly localised, excess of Down's syndrome in births to young mothers who had attended a girls' school in Dundalk during 1956-57 has been confirmed. However, not all of the mothers of the affected children attended the school concurrently and the origin of non-disjunction in one child was an error occurring after conception. Some exposure essentially confined to girls attending the school at this time is a possible, although unlikely, explanation, but a review of potential risk factors does not suggest what this could be. Previous suggestions that an influenza epidemic or contamination from the Windscale nuclear reactor fire might be implicated, both of which occurred in October 1957, can be effectively dismissed because three of the women with affected offspring had left the school by then and had moved away from Dundalk, and Down's syndrome in the child of another mother originated in an error after fertilisation. Owing to the retrospective nature of the investigation and the characteristics of the cases, chance is the most likely explanation for the cluster.

Natural and unnatural history of pulmonary atresia

OBJECTIVE

To investigate mortality, cause of death, survival, and quality of life in all types of cardiac malformation with congenital pulmonary atresia.

DESIGN

Retrospective analysis.

SETTING

The resident population of one health region with a single tertiary referral centre.

PATIENTS

All babies with pulmonary atresia live born in 1980 to 1995.

MAIN OUTCOME MEASURES

Anatomical classification, total mortality, cause of death, duration of survival, exercise ability. All cases were classified as pulmonary atresia with intact septum (PA-IVS), pulmonary atresia with ventricular septal defect (PA-VSD), or pulmonary atresia with complex cardiac malformation (complex pulmonary atresia).

RESULTS

129 cardiac malformations with congenital pulmonary atresia were identified from 601 635 live births (21.4/100 000): 29 had PA-IVS, 60 had PA-VSD, and 40 had complex pulmonary atresia. Total mortality was 72/129 (56%), with 15 deaths in the first week and 49 in the first year. There were 23 surgical deaths, 33 hospital deaths (not related to surgery), and 16 sudden deaths, 12 of which remained unexplained. The sudden death rate was 29/1000 patient years of follow up. Of the 57 survivors, 39% have exercise ability I or II and 61% III or IV. Definitive surgical repair produced better exercise ability.

CONCLUSIONS

Early mortality is high in all types of pulmonary atresia, although survival has improved in recent years. Most children who have not undergone definitive repair have significant exercise limitation.

L-dopa-resistant parkinsonism syndrome following cerebral radiation therapy for neoplasm

A bradykinetic form of parkinsonism, unresponsive to levo-dopa therapy developed in four patients two to eight weeks after completion of external beam irradiation (39.2 Gy to 59.4 Gy) of their intracranial neoplasm. In the absence of other causative factors, we relate the movement disorder to radiation-induced changes within the basal ganglia. At post-mortem examination one patient had putamenal gliosis and thickened vessels with loss of nigral neurons.

Clusterin biogenesis is altered during apoptosis in the regressing rat ventral prostate

Clusterin was first characterized as an apoptosis-associated transcript after it was identified as testosterone-repressed prostate message (TRPM-2) that is expressed in the epithelial cells of the regressing rat ventral prostate. Increases in clusterin mRNA and protein have been consistently detected in apoptotic cell death paradigms, establishing clusterin gene expression as a prominent marker of apoptotic cell loss. However, enhanced protein expression has also been reported in surviving cells. This ambiguity makes it difficult to define the contribution of clusterin to apoptosis. To address this problem, a panel of polyclonal and monoclonal antibodies were raised against the clusterin alpha-chain, beta-chain, and mixed alpha/beta epitopes. These antibodies detect changes in the biogenesis of clusterin during apoptosis by Western analysis and immunohistochemistry. A 42-kDa glyco/isoform of clusterin appears to be up-regulated in dying epithelial cells. This glyco/isoform is apparently generated as a result of apoptosis-induced stimulation of a normal but under-utilized, synthetic pathway. These data demonstrate that clusterin synthesized by apoptotic cells can be immunologically distinguished from clusterin synthesized by surviving cells in damaged tissue.

Expanded phase II trial of paclitaxel in metastatic breast cancer: a Southwest Oncology Group study

BACKGROUND

The study was designed to evaluate the efficacy of paclitaxel in metastatic breast cancer patients. The design was motivated by a report from FDA and NCI staff proposing assessment of pre- and post-treatment symptoms as a means of evaluating treatment effectiveness [1].

METHODS

Patients with symptomatic and/or measurable metastatic breast cancer with prior treatment received paclitaxel 210 mg/m2 as a 3 hour infusion every three weeks until toxicity or progression. A unique endpoint was subjective symptomatic response, defined as an improvement in the Symptom Distress Scale score by > or = 3 points at two successive evaluations before treatment failure. Patients were also evaluated for objective response and toxicity.

RESULTS

Of 135 patients registered, 123 were eligible and treated. The subjective symptomatic response rate for 93 symptomatic patients who completed forms was 40%, 95% confidence interval 29-51%. The objective response rate in 77 patients with measurable disease was 19%, 95% confidence interval 11-30%. In patients with both measurable and symptomatic disease, 37% had symptomatic and 13% had objective responses. Median times to treatment failure and death were 4 and 11 months, respectively. Toxicity was greater than anticipated: 12% discontinued treatment due to toxicity, 29% developed at least one Grade 3 neuromuscular toxicity, and two patients died of sepsis while neutropenic.

CONCLUSION

Paclitaxel by 3 hour infusion at a dose of 210 mg/m2 produced excessive neurotoxicity in patients with previously treated metastatic breast cancer. Both sustained subjective symptom reduction and objective responses were demonstrated, but dose reduction for routine practice is recommended.

Primary care screening for prostate cancer

Prostate cancer is second only to lung cancer among killers of men in the United States. Researchers continue to develop tests that are more sensitive for diagnosing prostate cancer. At present, primary care assessment and evaluation of the disease are determined by physical evidence that may not be apparent and by laboratory values that may not be truly reflective of the underlying disease process. Men over the age of 40 need an annual evaluation for increased prostate-specific antigen (PSA) along with a digital rectal examination. Some data suggest that the digital rectal exam and PSA levels may be insensitive indicators of prostate cancer in men with low total or free testosterone levels. The synergistic effect of testosterone on PSA could mask indicators for evaluation of prostate cancer.

Alzheimer testing at Silver Years

Early last year, the GenEthics Consortium (GEC) of the Washington Metropolitan Area convened at George Washington University to consider a complex case about genetic testing for Alzheimer disease (AD). The GEC consists of scientists, bioethicists, lawyers, genetic counselors, and consumers from a variety of institutions and affiliations. Four of the 8 co-authors of this paper delivered presentations on the case. Supplemented by additional ethical and legal observations, these presentations form the basis for the following discussion.