Platelet reactivity and immature platelets in patients with Covid-19

Background

Coronavirus disease 2019 (Covid-19) is associated with high incidence of thromboembolic events, both venous and arterial. Currently, there are no clinical or laboratory markers to guide antithrombotic therapy in COVID-19 patients. Immature platelets represent a population of hyper-reactive platelets associated with arterial thrombotic events.

Objectives

To determine indices of immature platelets and platelet reactivity in Covid-19 patients.

Methods

This prospective study compared consecutive COVID-19 patients (n=47, median age = 56 years) to patients with acute myocardial infarction (AMI, n=100, median age = 59 years) and a group of stable patients with cardiovascular risk factors (n=64, median age=68 years). Immature platelet fraction (IPF) and immature platelet count (IPC) were determined by the Sysmex XN-3000 auto-analyzer on admission and at subsequent time-points.

Results

IPF% on admission was higher in the Covid-19 group than the stable group and similar to the AMI group (4.8% [IQR 3.4–6.9], 3.5% [2.7–5.1], 4.55% [3.0–6.75], respectively, p=0.005 for Covid-19 vs. stable). IPC on admission was also higher in the Covid-19 group than the stable group and similar to the AMI group (10.8×109/L [8.3–18.1], 7.35×109/L [5.3–10.5], 10.7×109/L [7.7–16.8], respectively, P<0.0001 for Covid-19 vs. stable). The maximal IPF% among the Covid-19 group was higher than the stable group and similar to the AMI group. The maximal IPC in the Covid-19 group was higher than the maximal IPC in both the stable and AMI groups (Covid-19: 14.4×109/L [9.4–20.9], AMI: 10.9×109/L [7.6–15.2], P=0.0035, Stable: 7.55×109/L [5.55–10.5], P<0.0001).

Conclusions

Patients with Covid-19 have increased immature platelets indices compared to stable patients with cardiovascular risk factors, and as the disease progresses also compared to AMI patients. Enhanced platelet turnover and reactivity may, therefore, have a role in the development of thrombotic events in Covid-19 patients.

Funding Acknowledgement

Type of funding sources: None. IPF in COVID-19, AMI and stable groups

Immature platelets in patients with Covid-19: association with disease severity

Background

Coronavirus disease 2019 (Covid-19) is associated with a high incidence of thromboembolic events, both venous and arterial. Currently, there are no clinical or laboratory markers to guide risk-stratification or antithrombotic therapy in Covid-19 patients. Circulating immature platelets represent a population of hyper-reactive platelets, which are associated with arterial thrombotic events.

Objectives

To assess whether the proportion of immature platelets in the circulation is associated with disease severity in patients with Covid-19

Methods

This prospective study evaluated consecutive patients with COVID-19 admitted with various degrees of disease severity, as determined by the standard Covid-19 severity Score. Disease severity was evaluated during hospitalization. Immature platelet fraction (IPF) absolute number and percentage were measured on admission and at additional time points during the hospital course using the SysmexXN-3000 auto-analyzer. The maximal values of IPF% and absolute IPF was analyzed according to disease severity.

Results

A total of 136 consecutive patients with Covid-19 were recruited. Mean age was 60±19 years for patients with mild and moderate disease and 69±14 years for patients with severe disease, 52% with mild and moderate disease and 48% with severe disease were woman, 11% with mild and moderate disease and 20% with severe disease with concurrent cardiovascular disease

The median of IPF% was higher in the severe COVID-19 group compared to patients with mild or moderate disease [4.2 (IQR 2.73–6.45) vs 5.8 (IQR 3.9–8.7), P=0.01, Figure 1)]. The median of IPF absolute number was also significantly higher in patients with severe disease comparing to patients with mild or moderate disease (4.2 (2.85–6.1) vs 5.1 (IQR 3.65–7.35), P<0.0001, Figure 2].

Conclusions

Patients with severe Covid-19 have a higher level of IPF in the circulation than patients with mild or moderate disease. IPF may serve as a reliable prognostic marker for in-hospital disease severity in patients with Covid-19

Funding Acknowledgement

Type of funding sources: None. Figure 1. IPF% (median, 95% confidence interval)Figure 2. IPF# (median, 95% confidence interval)

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

CHANGES IN IRISIN RELEASE IN RESPONSE TO PERIPHERAL KISSPEPTIN-10 ADMINISTRATION IN HEALTHY AND OBESE ADULT MEN

Context

Kisspeptin role in metabolism has been implicated recently. However, the nature of the signals that may connect body fat/muscle tissues with the central nervous system governing energy homeostasis remains to be elucidated.

Objective

The present study was designed to investigate the effects of peripheral kisspeptin-10 administration on irisin release in human males.

Subjects and methods

Kisspeptin-10 was administered to normal weight (n=8) and obese (n=8) men. Sequential blood sampling was performed for 30 minutes pre and 210 minutes post kisspeptin injection at 30 minutes interval. ELISA kit was used to detect plasma irisin levels.

Results

There is a significant (P<0.0001) effect of Kisspeptin-10 administration on irisin release in both normal weight and obese participants. Mean irisin levels (96.24 ± 1.351 ng/mL) at 210 minutes were significantly (P<0.0001) enhanced as compared to pre-kisspeptin (59.18 ± 4.815 ng/mL) in normal weight subjects. In obese subjects mean irisin levels (75.76 ± 4.06 ng/mL) were significantly (P<0.0001) elevated at 180 minutes post-kisspeptin when compared with pre-kisspeptin irisin levels (41.28 ± 2.89 ng/mL).

Conclusion

Our findings suggest that kisspeptin may have a novel therapeutic potential to induce irisin release in humans which may have anti-obesity effects.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Can older adults improve the identification of moderate intensity using walking cadence?

BACKGROUND

The majority of older adults do not reach the physical activity guidelines. One possible explanation for this may be that older adults overestimate their physical activity levels, because they are unable to identify exercise intensity.

METHODS

Forty-four older adults were recruited and randomly assigned into two walking groups lasting 6 weeks. The intervention group was asked to walk a minimum of 150 min per week at moderate intensity using walking cadence indicated with a pedometer. The control group did not get any feedback on walking intensity.

RESULTS

The ability to identify moderate intensity while walking did not significantly improve in neither groups (p = 0.530). However, participants in the intervention group increased significantly the time spent at moderate intensity, in 10 min bouts (p < 0.01).

DISCUSSION

A pedometer providing walking cadence to reach moderate intensity is a good tool for increasing time walked at the recommended intensity, but not because participants know more what is considered moderate intensity.

Walking Cadence to Exercise at Moderate Intensity for Adults: A Systematic Review

Background. Most adults choose walking as a leisure activity. However, many do not reach the international physical activity guidelines for adults, which recommend moderate intensity aerobic activity for at least 150 minutes/week in bouts of 10 minutes. Purpose. This systematic review provides an update on the walking cadence required to reach moderate intensity in adults and older adults, identifies variables associated with reaching moderate intensity, and evaluates how walking cadence intensity should be measured, but the main purpose is to report the interventions that have been attempted to prescribe walking cadence to increase time spent at moderate intensity or other outcomes for adults and older adults. Methods. SportDISCUS, Scopus, and PubMed databases were searched. We identified 3,917 articles and 31 were retained for this systematic review. Only articles written in English were included. Results. In general, 100 steps/minute is prescribed for adults to achieve moderate intensity, but older adults may require a higher cadence. Currently, few studies have explored using walking cadence prescription as an intervention to increase physical activity levels. Conclusion. Prescribing walking cadence as a way to increase physical activity levels has potential as a practical and useful strategy, but more evidence is required to assess its ability to increase physical activity levels at moderate intensity.

Terror Bombing-Mechanisms, Consequences and Implications

Our objective in this review is to describe the unique features of bombing injury and to outline some special elements of their management. This is to allow the timely improvement and adjustment of existing mass casualty protocols.

Forensic studies, detonation and explosion, mechanisms of injury in explosion and their bodily effects, chemical effects of the explosive, site of the explosion and the wounding potential, the Multidimensional Injury Pattern, diagnostic evaluation of Multidimensional Injury Pattern, and surgical and treatment dilemmas associated with it are described and discussed.

Coeliac screening in a Scottish cohort of children with type 1 diabetes mellitus: is DQ typing the way forward?

BACKGROUND

Children with type 1 diabetes mellitus (T1DM) are at increased risk of coeliac disease (CD). Recent guidelines indicate coeliac screening should include HLA typing for CD predisposing (DQ2/DQ8) alleles and those negative for these alleles require no further coeliac screening.

METHODS

Children (n=176) with T1DM attending clinics across two Scottish regions were screened for HLA DQ2/DQ8 as part of routine screening. Data collected included the frequency of DQ2/DQ8 genotypes and the additional cost of HLA screening.

RESULTS

Overall, DQ2/DQ8 alleles were identified in 94% of patients. The additional cost of HLA typing was £3699.52 (£21.02 per patient). All patients with known CD (11/176) were positive for DQ2/DQ8 and all were diagnosed with CD within 5 years of T1DM diagnosis.

CONCLUSIONS

The vast majority of children with T1DM have CD-predisposing HLA genotypes limiting the number of patients that can be excluded from further screening. We conclude that HLA genotyping is not currently indicated for CD screening in this population.

Carfilzomib and the cardiorenal system in myeloma: an endothelial effect?

Carfilzomib (Cfz) has been associated with an ~5% incidence of unexplained and unpredictable cardiovascular toxicity in clinical trials. We therefore implemented a detailed, prospective, clinical cardiac and renal evaluation of 62 Cfz-treated myeloma patients, including serial blood pressure (BP), creatinine, troponin, NT-proBNP and pre- and post-treatment echocardiograms, including ejection fraction (EF), average global longitudinal strain and compliance. Pre-treatment elevations in NT-proBNP and BP, as well as abnormal cardiac strain were common. A rise in NT-proBNP occurred frequently post-treatment often without corresponding cardiopulmonary symptoms. A rise in creatinine was common, lessened with hydration and often reversible. All patients had a normal EF pre-treatment. Five patients experienced a significant cardiac event (four decline in EF and one myocardial infarction), of which 2 (3.2%) were considered probably attributable to Cfz. None were rechallenged with Cfz. The ideal strategy for identifying patients at risk for cardiac events, and parameters by which to monitor for early toxicity have not been established; however, it appears baseline echocardiographic testing is not consistently predictive of toxicity. The toxicities observed suggest an endothelial mechanism and further clinical trials are needed to determine whether or not this represents a class effect or is Cfz specific.

Factors that influence the decision to perform a karyotype in suspected disorders of sex development: lessons from the Scottish genital anomaly network register

BACKGROUND

Although a karyotype represents the first objective evidence of investigating a case of suspected disorder of sex development (DSD), the factors that influence the clinician's decision to initiate investigations are unclear.

METHODS

Cases of suspected DSD in Scotland were identified through the Scottish Genital Anomaly Network (SGAN) Register. The timing as well as other factors that influence the decision to perform a karyotype were subsequently studied.

RESULTS

Out of the 572 cases on the register, 383 (67%) were classified as having a non-specific disorder of under-masculinisation. In 463 (81%) cases, the sex of rearing was male, in 71 (12%) female, and in 38 (7%) cases data regarding sex of rearing were unavailable. A karyotype was reported to have been performed in 153/572 (27%) cases. Infants in Scotland with suspected DSD are more likely to have a karyotype performed in the presence of a low external masculinisation score, bilateral impalpable testes, proximal hypospadias, or associated malformations.

DISCUSSION

These data represent the first attempt at benchmarking the decision to check a karyotype and investigate infants with suspected DSD. Whilst this decision may be related to the complexity of the genital anomaly, there are other factors that may influence this decision, and these require further exploration through more rigorous systems for data collection.

Exaggerated adrenarche in a cohort of Scottish children: clinical features and biochemistry

OBJECTIVE

To investigate the reported association between exaggerated adrenarche (EA) and reduced foetal growth and to identify possible risk factors for future morbidity in Scottish children with clinical features of EA.

DESIGN

Three-year prospective study.

MEASUREMENTS

Auxology, blood pressure (BP), biochemical analysis of blood and urine, pelvic ultrasound in girls.

RESULTS

Fifty-two patients were recruited of whom one girl had nonclassical congenital adrenal hyperplasia (17-OHP 17 nmol/l) and one had insufficient blood for analysis. The final cohort comprised 42 girls of mean (SD) age 7.7 (0.99) and eight boys of 8.8 (0.67) years. Mean (SD) birth weight was 3.27 (0.49) and 3.10 (0.76) kg in girls and boys respectively. Height/weight SDS were 1.13/1.69 in girls and 1.69/1.88 in boys. Mean systolic/diastolic BP was 107.8/60.4 (50th-75th centile) in girls and 115.5/63.9 (75th-91st centile) in boys. Uterine and ovarian development was prepubertal. Median serum dehydroepiandrosterone sulphate (DHEAS) was 2.1 and 4.1 mumol/l, androstenedione 3.1 and 3.8 nmol/l in girls and boys respectively, with DHEAS within the reference range/undetectable in 18/2 and androstenedione in 12/6 patients. Fasting insulin was 9.0 and 15.0 mU/l in girls and boys respectively, with concomitant low normal SHBG. Anti-Mullerian hormone (AMH) was 15.7 pmol/l in 27 girls, compared with 5.0 pmol/l in normal girls aged 5-8 years.

CONCLUSIONS

Our Scottish EA cohort showed female predominance, no evidence of reduced foetal growth, a tendency to overweight with commensurate mild hyperinsulinaemia and modest elevation of serum androgens in some patients. We have found raised AMH levels in the girls, indicating advanced ovarian follicular development.

Microcycle conidiation and medusa head conidiophores of aspergilli on indoor construction materials and air filters from hospitals

Microcycle conidiation and microniche colonization by aspergilli was observed in-situ on various indoor construction and finishing materials. Microcycle conidiation, direct conidiogenesis from a conidium or spore with minimal intervening hyphal development, for several decades has been considered a survival mechanism during stress for a variety of moulds. Adhesive transparent tape mounts and bulk materials from various indoor materials, including air filters from hospitals and healthcare institutions, were transported to the laboratory for light microscopic and scanning electron microscopic observations. Additional materials were held in moist chambers over nonsterile soils and examined periodically for fungal development. Microcycle conidiation was observed usually in areas of sparse fungal development, mostly in association with isolations of members of the Aspergillus flavus-, A. versicolor-, A. niger groups. Branched conidiophores and medusa heads, more often associated with colonization by Eurotium spp., were observed on some preserved woods. These conidiogenesis processes might be factors in the survival and blooms of indoor aspergilli.

Recombinant activated factor VII (NovoSeventm): addition to replacement therapy in acute, uncontrolled and life-threatening bleeding

BACKGROUND AND OBJECTIVES

Recombinant activated factor VII (rFVIIa, NovoSeven) has been used off-label for various conditions. A protocol for its use in acute, uncontrolled life-threatening bleeding, was devised and employed. A haematologist/transfusion specialist was assigned as a member of the team.

MATERIALS AND METHODS

The clinical data were reviewed and summarized. A scoring system for the assessment and monitoring of coagulopathy was employed. Each parameter of prothrombin time (PT), activated partial thromboplastin time (aPTT), platelet number and fibrinogen level was allocated points according to the degree of abnormality. Three scoring levels emerged.

RESULTS

Between April 2001 and April 2003, 13 patients received rFVIIa for acute, uncontrolled life-threatening bleeding. Nine of 13 patients remained alive for 15 days or longer after rFVIIa infusion. All patients who experienced a reduction or cessation of bleeding after rFVIIa infusion, also had a lower coagulopathy score after replacement therapy, prior to rFVIIa infusion, compared with their score at rFVIIa request. There was a reduction in the average use of blood products after rFVIIa infusion. The coagulopathy score was statistically predictive of response to rFVIIa and survival.

CONCLUSIONS

In an area where very little data exists, we report the usefulness of rFVIIa. We propose that transfusion replacement should aim to correct coagulopathy before infusion of rFVIIa and that a haematologist/transfusion specialist should be involved in the management of these patients. A prognostically significant coagulopathy scoring system is offered.

Randomized, crossover comparison study of the short-term effect of oral testosterone undecanoate and intramuscular testosterone depot on linear growth and serum bone alkaline phosphatase

AIM

To compare the effects of oral testosterone undecanoate (TU) 40 mg daily and intramuscular depot sustanon 50 (SUS), 4 weekly, on short-term growth and bone turnover.

METHOD

Prospective, randomised, cross-over study over 26 weeks with 4 weeks of run-in, 8 weeks of treatment I (TU/SUS), 4 weeks of wash-out, 8 weeks of treatment II (SUS/TU) and 4 weeks of final wash-out.

MAIN OUTCOME MEASURES

Weekly change in lower leg length (LLL) as measured by knemometry, i.e. LLL velocity (LLLV) and absolute bone alkaline phosphatase levels (bALP), as well as percentage change in bALP (%bALP).

PATIENTS

Fourteen boys with delayed growth and puberty; two declined and one boy with sickle cell trait dropped out with priapism a week after SUS. The remainder had a median age of 14.3 years (range 12.5-17.4), testicular volume of 2 ml each (2-6), HtSDS of -2.1 (-3.3 to -1.0) and BA delay of 2.4 years (0.7-4.4).

RESULTS

Median LLLV in the treatment blocks was 0.7 mm/wk (-0.27 to 2.2) and LLLV during the run-in and wash-out periods was 0.27 mm/wk (-0.3 to 0.6) (p <0.005). LLLV during treatment with TU and SUS was 0.51 mm/wk (-0.22 to 2.17) and 0.67 mm/wk (-0.27 to 2.2), respectively (NS). Median LLLV during the washout phases that followed the TU block and the SUS block was similar at 0.28 mm/wk (-0.1 to 0.6) and 0.3 mm/wk (-0.2 to 0.6), respectively. LLLV peaks and troughs that were related to the timing of the injection were more evident during SUS therapy. Median bALP during the run-in period was 94.2 U/l (16-282) and the median %bALP during this period was 1.2% (-57, 16). The main rise in bALP occurred during the treatment blocks with a %bALP of 19.3% (-28.8, 121.7) (p <0.005). Median bALP at the beginning and end of the SUS block was 99.7 U/l (51.7, 225) and 170 U/l (64.8, 273), respectively (p <0.05). Median bALP at the beginning and end of the TU block was 111 U/l (51, 287) and 127.6 U/l (66.4, 298) (NS). Median %bALP during SUS was higher than during TU at 28.1% (4.4, 121.7) and 11.8% (-28.8, 83.6) (p = 0.07).

CONCLUSION

At the doses studied, testosterone undecanoate was as effective as sustanon at promoting short-term growth but changes in bone alkaline phosphatase were more marked during sustanon therapy.

Transdermal testosterone application: pharmacokinetics and effects on pubertal status, short-term growth, and bone turnover

The aim of the study was to assess the effect of transdermal testosterone on free testosterone concentrations in saliva and on short-term growth and bone turnover in boys with growth or pubertal delay. A prospective, randomized, crossover study was conducted over 26 wk with 4 wk of run-in, 8 wk of treatment I (8 or 12 h), 4 wk of washout, 8 wk of treatment II (8 or 12 h), and 4 wk of final washout. The main outcome measures were salivary testosterone profiles during the different study periods; weekly change in lower leg length (LLL) as measured by knemometry, i.e. LLL velocity; absolute and percentage change in bone alkaline phosphatase (bALP) levels; and deoxypyridinoline cross-links measured in urine. Eight boys who took part in the study had a median age of 13.5 yr (range, 12.4-14.9 yr), testicular volume of 3 ml (range, 2-6 ml), height SD score of -2.4 (range, -1.44 to -3.35), and bone age delay of 2 yr (range, 1-3.2 yr). Median salivary testosterone during 8- and 12-h treatments [179 pg/ml (range, 7-3579 pg/ml) and 150 pg/ml (range, 12-3472 pg/ml) (not significant)] was significantly higher than during the run-in and washout blocks (P < 0.0001) [9 pg/ml (range, <7 to 122 pg/ml) and 13 pg/ml (range, <7 to 285 pg/ml) (not significant)]. LLL velocity in the treatment blocks (median, 0.64 mm/wk; range, 0.1-1.08 mm/wk) was significantly higher than during the run-in and washout periods (median, 0.48 mm/wk; range, -0.06 to 0.92 mm/wk) (P < 0.001). The main rise in bALP occurred during the first treatment block with a median percentage change in bALP of 44.2% (range, -4 to 87%) and a smaller percentage change in bALP at the end of the second treatment block of 9.8% (range, -4 to 55%). The increases in bALP were not significantly different between the 8- and 12-h treatment periods, and there was no significant decline during the washout periods. Overnight transdermal testosterone application, as Virormone (5 mg), may be a potentially acceptable method of induction of puberty and stimulates short-term growth and bone turnover.

Levels of mucin gene expression in normal human conjunctival epithelium in vivo

PURPOSE

Conjunctival impression cytology (CIC) samples were used to determine the mean and normal range of mRNA levels of human MUC1, MUC2, MUC4, MUC5AC, and MUC7 mucin genes.

METHODS

Real time PCR was performed to determine normal mRNA levels in CIC samples of 24 male and 19 female healthy donors. Correlation coefficients between gene expression levels were obtained.

RESULTS

All five mucin genes were expressed in the CIC samples. MUC1 and MUC4 were present at the highest level and MUC2 was at the lowest. There were no gender differences. Significant positive correlations existed between MUC2 and MUC4 and between MUC2 and MUC7 levels.

CONCLUSIONS

Normal levels and ranges of mRNAs for MUC1, MUC2, MUC4, MUC5AC and MUC7 conjunctival mucin genes have been established for the first time. These data may serve as the normal threshold values for future comparisons in different experimental and pathological conditions involving the ocular surface.

[Clinical risk factors for postoperative proliferative vitreoretinopathy (PVR). A prospective study]

PURPOSE

To identify clinical risk factors for development of postoperative PVR, to determine the incidence of this complication and its time of onset by a prospective multicentric study.

METHODS

A multicentric and prospective study of 223 patients with rhegmatogenous retinal detachment (RD) was conducted. Logistic regression analysis was used to identify risk factors for PVR among 83 variables related to preoperative, intraoperative and postoperative characteristics.

RESULTS

22 out of 223 RD developed PVR (incidence 9.9%, confidence interval 95%: 5.9-13.9). After logistic regression analysis, four variables showed an odds ratio higher than 1.0 (RD affecting 4 quadrants, cryopexy, aphakia/pseudophakia and those RD in which an encircling band was implanted). None of these factors showed a <<p>> value lower than 0.05. Most of postoperative PVR (77.2%) appeared in the first month after surgery.

CONCLUSIONS

This study establishes the incidence of PVR, and its time of onset, but it was not effective to identify clinical risk factors with a high level of confidence.

Consumer satisfaction with telehealth advice-nursing

An increase in interest in the establishment of telephone advice services has resulted in the proliferation of call centers. Despite their wide usage, research for the most part has not addressed the quality of care in relation to consumer satisfaction. This paper examines consumer outcomes of satisfaction, and follow-up with recommendations, within a framework of the nursing process and its associated components of assessment (including problem identification), care planning, intervention, and evaluation. The data for the study were obtained from seven after-hours call centers operating under the auspices of health maintenance organizations, preferred provider organizations, and private insurance companies. A sample of 157 non-redundant telephone calls from adults with medical-surgical problems were audiotaped with providers' and callers' consent. Sociodemographic information of the advice nurses, and chief complaints of the callers were obtained. The quality of nursing of the audiotaped calls was rated through an implicit review method by registered nurse raters using an advice nurse structured implicit review (AN-SIR) form developed for the study. Follow-up information was obtained through telephone calls to ascertain the consumers' perceptions of satisfaction, helpfulness, and follow-through with recommendations. Results indicated that consumers calling with a variety of general complaints contacted 32 nurses in advice nurse call centers. The quality of nursing process was found to be the best in the area of intervention. Evaluation was also well above the midpoint on a transformed scale of zero to 100. Assessment, although slightly above midpoint, was the lowest of the three components of the nursing process examined. Consumer satisfaction was high with 95.4 percent of the consumers rating the calls as completely or at least somewhat satisfied, and 93.2 percent, stating the advice was very or somewhat helpful. Exploratory regression analysis showed that the component of intervention was significantly related to consumer satisfaction. The present study pioneers the way to rate the quality of the advice nurses' interactions with consumers, and lays the groundwork for further investigations of health care provider behavior and consumer outcomes. Further studies are recommended to investigate predictors of consumer satisfaction, and cost-benefit in terms of consumer expenditures of time, funds, and energy.

Experimental Model of Corneal Haze in Chickens

PURPOSE

To develop an experimental animal model of corneal haze following photorefractive keratectomy (PRK).

METHODS

Fifteen Iber Braun hens underwent unilateral PRK for -9.00 D of myopia. The animals were sacrificed at 1, 3, and 6 months postoperatively, and light microscopy was performed.

RESULTS

Slit-lamp microscopy showed haze in the PRK-treated eyes. Histopathologic study disclosed epithelial hyperplasia, basement membrane abnormalities, and extensive anterior stromal disorganization.

CONCLUSIONS

An easy and inexpensive model of haze after PRK was developed in an animal with Bowman's layer. This new model could be useful to understand the pathophysiology and pharmacologic modulation of corneal haze.

[In vitro toxicity of non-preserved artificial-tear formulations]

PURPOSE

To analyse the putative toxic effect of three commercially available non-preserved artificial tear formulations on in vitro human conjunctival cells.

MATERIAL AND METHOD

A conjunctival human epithelial cell line was exposed to Cellufresh, Oculotect and Acuolens formulations during 1, 3 and 24 hours. Cytotoxicity was measured by calculating the percentage of cell viability examination and scanning electron microscopy (SEM). Controls underwent exposure to supplement free DMEM-F12 (negative control) and exposure to 0.005% benzalkonium chloride solution (positive control).

RESULTS

Cell viability after 1 or 3 hours incubation with Cellufresh and Oculotect was similar to that obtained for negative controls. With Acuolens incubation however, cell viability showed significant reduction after 3 and 24 hours compared to control. SEM showed that Cellufresh and Oculotect exposed cells presented similar behavior to control cells. All three cell lines presented evidence of cellular surface alteration after incubation for 1 or 3 hours compared to controls, Acuolens showing the highest rate of alterations in exposed cells and an additional increment in cell loss was observed.

CONCLUSION

In the present study, non preserved artificial tears formulations showed a different degree in their in vitro toxicity, Acuolens being more toxic than Cellufresh or Oculotect.

Volvulus of the stomach in childhood: the spectrum of the disease

INTRODUCTION

During a 5-year time frame, five cases of symptomatic gastric volvulus were diagnosed and treated in our department. Four presented with the acute form of gastric volvulus and underwent emergency surgery. The fifth suffered the chronic variant of the syndrome and was benefited by nonoperative management. The cases serve to remind emergency physicians of the spectrum of gastric volvulus. The report supplements the sparse clinical description in the emergency literature.

RESULTS

In the operated patients, there were no postoperative complications. The outcome, to the time of publication, has been good in every instance. The history, etiology, presentation, and treatment of the disease are discussed in detail.

CONCLUSIONS

Not infrequently, gastric volvulus in children fails to exhibit the full gamut of signs and symptoms such as abdominal distension, vomiting, pain, and retching. For this, as well as for other stated reasons, symptomatic gastric volvulus in infancy and childhood may not be as rare as is commonly assumed.

A pilot study of a long acting somatostatin analogue for the treatment of refractory rheumatoid arthritis

OBJECTIVE

To evaluate the efficacy and safety of a long acting somatostatin analogue in a subset of patients with refractory rheumatoid arthritis (RA).

METHODS

Ten patients with active, refractory RA, who had failed to respond to at least four disease modifying antirheumatic drugs (DMARDs), were treated with monthly intramuscular injections of 20 mg of a long acting preparation of octreotide (Sandostatin-LAR) for three months. They were evaluated every two weeks in an open label pilot study. The primary measure of clinical response was the American College of Rheumatology criteria for a 20% improvement in measures of disease activity (ACR 20).

RESULTS

Eight patients completed the 14 week trial, while two patients received only one or two doses of the somatostatin analogue, but were eligible for evaluation. On an intention to treat basis 6/10 patients responded: four patients met the ACR 20 criteria at weeks 6-10, while two patients continued to improve with time, and met the ACR 50 and 70 criteria respectively, at week 14. On evaluation of the 10 patients as a group, a significant improvement (p<0.05) was noted in the mean visual analogue scales of pain, doctor's and patient's global assessment of disease activity, and in the mean number of swollen joints. Adverse effects were minor: transient bloating and loose stools, an urticarial rash (n=1), and a transient increase of liver enzymes (n=1).

CONCLUSION

Treatment with a long acting somatostatin analogue led to significant clinical improvement in a subset of patients with active, refractory RA. The treatment was relatively safe and well tolerated. Further large, placebo controlled studies are required to evaluate this drug as a potential DMARD for patients with RA.

[Acute colonic pseudo-obstruction]

Colonic Pseudo-obstruction is a poorly understood syndrome. It was first described by Ogilvie in 1948 and is characterized by signs of large bowel obstruction with a non-mechanical etiology. The suggested cause of this pathophysiology is an imbalance in the autonomic nerve supply to the colon. The syndrome affects mainly old, bedridden patients, usually hospitalised for non-colonic causes. The actual incidence of this syndrome is unknown, mainly due to the fact that spontaneous recovery may occur. When massive abdominal distention is apparent, diagnosis and treatment are usually problematic and other causes of obstruction must be ruled out. It is usually managed by water soluble contrast administered orally or rectally, or by colonic decompression. In extreme cases surgical treatment is required with significant morbidity and mortality. Pharmacologic management with parasympathomimetic drugs has been suggested recently. We describe the successful treatment of a patient with neostigmine and review the current literature.

Pars planitis: epidemiology, treatment, and association with multiple sclerosis

During retrospective and prospective studies, we attempted to determine the clinical characteristics, treatment, and visual outcome of patients with pars planitis and to evaluate the association between pars planitis and multiple sclerosis (MS). The retrospective study included 44 patients with pars planitis, who had been examined between October 1986 and January 1999. We analyzed age, sex, visual acuity (VA), median follow-up time, and medical and surgical treatments. The prospective study, which included 21 consecutive patients with pars planitis, was performed to determine the presence of MS. In the retrospective study, the mean patient age was 22.4 years (SD +/- 11.5) and the median follow-up was 34.9 months (SD +/- 27.2). Complications included macular edema (47.7%), vitreous opacities (38.6%), papillitis (38.6%), vasculitis (36.4%), and cataract (20.5%). Forty patients (90.9%) had a final bilateral VA better than 20/40. In the prospective study, magnetic resonance imaging (MRI) was performed. Demyelinating lesions were found in 10 (47.6%) of the 21 patients and relapsing-remitting clinically definite MS was diagnosed in seven (33.3%). With the exception of age, no significantly statistical differences were observed when the visual prognosis and the clinical and epidemiologic characteristics were compared between the two groups of patients with and without associated MS; a diagnosis of MS was more frequently made in patients over 25 years of age. With appropriate treatment, patients with pars planitis have a good visual prognosis. Because the presence of demyelinating lesions seems to be high among patients with pars planitis, MRI should be considered, especially in patients over 25 years of age.

Bupivacaine wound instillation via an electronic patient-controlled analgesia device and a double-catheter system does not decrease postoperative pain or opioid requirements after major abdominal surgery

To assess the analgesic efficacy of patient-controlled bupivacaine wound instillation, 50 patients undergoing major intraabdominal surgery were enrolled into this prospective, placebo-controlled, double-blinded study. In all cases, a standard general anesthetic was administered. On completion of surgery, two multihole 20-gauge epidural catheters were tunneled through the proximal and distal apices of the surgical wound and placed above the fascia such that the tips were at the margin of the first and second thirds of the surgical wound, respectively. Postoperatively, a patient-controlled analgesia (PCA) device was connected to the instillation system. Either bupivacaine 0.25% (Bupivacaine Group) or an equal volume of sterile water (Control Group) was administered. The PCA device was programmed to deliver 9.0 mL with a 60-min lockout interval and no basal infusion. During the first six postoperative hours, a coinvestigator administered "rescue" morphine (2 mg IV). Thereafter, meperidine 1 mg/kg IM was administered on patient request for additional analgesia. Instillation attempts and actual number of injections were similar between the groups. The mean number of pump infusions and the mean "rescue" opioid requirements during the 24-h study period were similar between the groups. The total "rescue" morphine administered during the first six postoperative hours was 16 +/- 17 mg vs 18 +/- 14 mg for the Bupivacaine and Control Groups, respectively. The total meperidine administered during this period was 1.6 +/- 1.4 mg/kg and 2 +/- 1.2 mg/kg for the Bupivacaine and Control Groups, respectively. Preoperatively, hourly for the first six postoperative hours, and on removal of the instillation catheter, patient-generated visual analog scales for pain were similar at rest, on coughing, and after leg raise. In conclusion, bupivacaine wound instillation via an electronic PCA device and a double-catheter system does not decrease postoperative opioid requirements after surgery performed through a midline incision.

IMPLICATIONS

After major abdominal surgery performed through a 20-cm incision, repeated 0.25% bupivacaine wound instillation via an electronic patient-controlled analgesia device and a double-catheter system does not decrease postoperative pain or opioid requirements.

Experimental acute necrotising pancreatitis: evaluation and characterisation of a model of intraparenchymal injection of sodium taurocholate in rats

OBJECTIVES

To evaluate a simple model that produces progressive dose dependent pancreatitis, by intraparenchymal injection of sodium taurocholate.

DESIGN

Open laboratory study.

SETTING

Teaching hospital, Israel.

MATERIALS

Forty eight Wistar rats.

INTERVENTIONS

Sodium taurocholate was injected, 0.3 ml/100 g body weight, in concentrations of 5% and 10% into the pancreatic parenchyma of 32 Wistar rats, resulting in two distinct groups of severity. In 16 sham controls, saline was injected into the pancreas in similar fashion. Blood samples were withdrawn before, and 6, 24, 48, and 72 hours after induction of pancreatitis.

RESULTS

Six hours after taurocholate injection, there was a sharp increase in the plasma activities of amylase, lipase, and lactate dehydrogenase (LDH). After 24 hours plasma activities of amylase and lipase decreased to near normal values while LDH remained slightly increased for 48 hours and decreased only after 72 hours. At 6 hours after the injection, interleukin-6 (IL-6) concentrations had increased slightly in the 5% group and decreased to the baseline values at 24 hours. In the 10% group, the increase in IL-6 values was significantly greater than in the 5% group (p = 0.04), and correlated well with severity of pancreatitis as defined by histology (p = 0.01) and mortality (p = 0.037). Twenty four hours after injection of taurocholate, morphological changes comprising diffuse necrosis of the pancreas, fat necrosis, and intestinal dilatation secondary to paralytic ileus were severe. Histopathological examination of the pancreas showed good correlation with the clinical findings and with mortality. No morphological changes were detected when saline was injected into the pancreas (sham control), and only mild rises of IL-6, lipase, amylase, and LDH activities were seen at 6 hours after injection. The mortality, after 10 days, was 80% in the 10% taurocholate group, 30% in the 5% taurocholate group, and 0 in the sham control group (p < 0.05).

CONCLUSION

The intraparenchymal injection of taurocholate is easy to perform and highly reproducible. The histopathological injury is dose-dependent, as is the mortality. We conclude that this model is valuable for the study of new treatments for pancreatitis.

[Laparoscopic cholecystectomy--1,000 procedures in a surgical department]

The first 1,000 laparoscopic cholecystectomies performed in our department were reviewed. There was no operative mortality; conversion to open cholecystectomy was necessary in 2%. In the last 600 cases the rate of conversion had decreased to 0.5%. There was common bile duct injury in 0.3%, with the injuries identified during primary surgery. This clinical experience is consistent with previous studies, which proved that laparoscopic cholecystectomy is safe and should replace open operation as the procedure of choice.

Octreotide treatment in patients with severe acute pancreatitis

We investigated the effect of octreotide in the treatment of severe acute pancreatitis in a case-control study. Experimental and clinical studies on the effect of octreotide in the treatment of acute pancreatitis have shown controversial results. Since January 1992, we have been conducting a prospective randomized study on the effect of octreotide in severe acute pancreatitis, in three hospitals in Israel. The entering criteria included three or more of the Ranson prognostic signs and CT findings of severe pancreatitis. Patients were randomly assigned to conservative treatment either with or without octreotide (0.1 mg subcutaneously three times a day). The end points of the study included: complication rate (ARDS, sepsis, renal failure, pseudocyst, fistula, and abscess), length of hospital stay, and mortality. From January 1992 to December 1996, 60 patients entered the study. After evaluating the files, 10 patients were excluded due to failure to meet the entering criteria, incomplete data, or incorrect diagnosis. Of the remaining 50 patients, 25 were assigned to octreotide (treatment group) and 25 to conservative treatment only (control group). The two groups matched with regard to age, sex, etiology, and severity of the disease. The complication rate was lower in the treatment group with regard to sepsis (24% vs 76%, P = 0.0002) and ARDS (28% vs 56%, P = 0.04). The hospital stay was shorter in the treatment group (20.6 vs 33.1 days, P = 0.04). Two patients died in the treatment group and eight in the control group (P < 0.019). These results suggest that octreotide may have a beneficial effect in the treatment of severe acute pancreatitis.

Effects of unilateral deprivation in postnatal development of the olfactory bulb in an altricial rodent, the gerbil (Meriones unguiculatus)

To establish if olfactory bulb sensitivity to functional deprivation is related to the degree of development at birth, we studied the effects of surgical closure of one naris in the gerbil olfactory bulb development. The naris closure was performed at three different ages: at birth, P7 and P14 and maintained for 30 or 60 days. In coronal sections we measured total bulbar surface area and surface area of the different bulbar layers establishing an estimate multiple regression model for the percentage of surface area decrease in the deprived bulb related to non deprived one. The internal and external plexiform layers are the most sensitive layers to deprivation and age and duration of deprivation were factors in their mathematical models. The glomerular layer showed a surface reduction of about 25% without dependence either on age or duration. The deprived glomerular layer showed a much lower tyrosine hydroxylase-immunoreactivity and immunoreactive cell density than those in the non deprived one. However, differences in calbindin-immunoreactive and NADPH-diaphorase positive cell density between deprived and non deprived glomerular layer were not significant. Our results indicate that olfactory bulb sensitivity to functional deprivation is not related to the degree of precocity and changes in age and duration of deprivation cause different effects on the olfactory bulb layers.

Treatment of acute colonic pseudo-obstruction with neostigmine

BACKGROUND

Colonic pseudo-obstruction is a poorly understood syndrome, described by Ogilvie, and characterized by signs of large-bowel obstruction, without a mechanical cause. An imbalance in the autonomic nerve supply to the colon has been suggested as the pathophysiology. Recently, promising results with pharmacologic manipulation with neostigmine have been described.

STUDY DESIGN

A prospective study was undertaken with 11 consecutive patients with clinical and radiologic signs of colonic pseudo-obstruction, in one general hospital, over a 1-year period. Patients were treated primarily with 2.5 mg of neostigmine in 100 mL of saline for 1 hour, under cardiac monitoring. Results were assessed by the clinical and radiologic responses.

RESULTS

Rapid and effective spontaneous decompression of the colon was achieved in 8 patients after a single dose of neostigmine, within a mean of 90 minutes from the beginning of treatment. In another two patients decompression occurred only after a second dose was administered 3 hours after the first dose. In one patient, no changes were observed and colonoscopic decompression was performed. No significant bradycardia was observed in any of the patients.

CONCLUSIONS

Neostigmine is a simple, safe, and effective therapy for treatment of colonic pseudo-obstruction.

The granulometer--a pocket scale for the assessment of wound healing

In spite of the availability of high-tech devices for wound assessment, plastic surgeons recognize that the color and confluence of granulation tissue are the most important indicators of open-wound healing. We developed a simple and inexpensive pocket-size scale--the Granulometer--to facilitate a finer assessment and to standardize the documentation of wound healing. This device overcomes limitations set by conditions such as lighting or recent exposure to other wounds that could distort the examiner's perception of the wound in question. In this study we examined the inter- and intraobserver variations in judgment, and the validity of the Granulometer. Our results demonstrate that skin graft viability can be predicted accurately by this eight-grade scale. Since graft survival depends on proper wound healing, we believe that the Granulometer can also be used for fine assessment of wound treatment. The low inter- and intraobserver variations indicate that the Granulometer measurements are both reproducible and accurate.

Value of logistic discriminant analysis for interpreting initial visual field defects

PURPOSE

The authors evaluate logistic discriminant analysis as a method for interpreting visual field results in initial stages of several ophthalmic diseases.

METHODS

The authors retrospectively studied the visual field defects of 96 patients with early glaucomatous damage and prospectively studied 84 subjects with normal eyes (n = 28), cataracts (n = 27), diabetic retinopathy (n = 14), or hypertensive retinopathy (n = 15). The visual fields were examined at least twice with program G1 of Octopus 500 (Interzeag AG, Schlieren, Switzerland). Only one eye per patient was randomly selected and included in the study. The authors created a database with all visual field information provided by Octopus and applied logistic discriminant analysis (SAS Logistic Procedures, SAS Institute, Cary, NC) to obtain classification rules capable of qualifying visual field defects as glaucomatous or nonglaucomatous. The rules were tested with an independent sample.

RESULTS

There were significant differences between the groups in the distribution of visual field defects tested by program G1. Logistic discriminant analysis correctly identified the glaucomatous or nonglaucomatous origin of the defects with a sensitivity of 65% to 85% and a specificity of 60% to 92%.

CONCLUSIONS

Logistic discriminant analysis is a useful tool to aid in the interpretation of early glaucomatous and nonglaucomatous visual field defects.

Clinical practicum in the ambulatory setting

To address the growing need for a well-trained ambulatory nursing staff, administrators and educators in San Diego, California, developed an integrated education plan. This article shares their strategic plan for ensuring future nursing resources in the ambulatory setting.

Stratum corneum lipids: the effect of ageing and the seasons

Stratum corneum lipids play a predominant role in maintaining the water barrier of the skin. In order to understand the biological variation in the levels and composition of ceramides, ceramide 1 subtypes, cholesterol and fatty acids, stratum corneum lipids collected from tape strippings from three body sites (face, hand, leg) of female Caucasians of different age groups were analysed. In addition, we studied the influence of seasonal variation on the lipid composition of stratum corneum from the same body sites. The main lipid species were quantified using high-performance thin-layer chromatography and individual fatty acids using gas chromatography. Our findings demonstrated significantly decreased levels of all major lipid species, in particular ceramides, with increasing age. Similarly, the stratum corneum lipid levels of all the body sites examined were dramatically depleted in winter compared with spring and summer. The relative levels of ceramide 1 linoleate were also depleted in winter and in aged skin whereas ceramide 1 oleate levels increased. The other fatty acid levels remained fairly constant with both season and age, apart from lignoceric and heptadecanoic acid which showed a decrease in winter compared with summer. The decrease in the mass levels of intercellular lipids and the altered ratios of fatty acids esterified to ceramide 1, are likely to contribute to the increased susceptibility of aged skin to perturbation of barrier function and xerosis, particularly during the winter months.