334 FASTTRAX - A FRACTURE RESPONSE SERVICE FOR NURSING HOME RESIDENTS

Background

Nursing Home Residents (NHR) are the frailest group of older people and require a gerontologically attuned approach to care. The new FastTrax fracture response service has been developed as a result of a Quality Improvement (QI) project to evaluate the need for this service. The data leading to the development of this pathway is presented here. FastTraX ensures NHR receive optimal orthopaedic and gerontological care without necessity for emergency department (ED) presentation.

Methods

A retrospective, medical chart review was completed on all NHRs who presented over12-months to a level-4 hospital ED following a fall/injury. Included patients were nursing home residents with suspected fracture discussed with the on-call orthopaedic service. Patients who required more complex imaging other than plain film or with known/suspected head trauma were excluded. Data collected included demographics, clinical and imaging details, and care outcomes.

Results

In 2021, there were sixty-nine (mean age 80.3, 82.6% female) NHR presentations to the ED with fracture/ injury where orthopaedic opinion was sought following x-ray. Just-under half, 49.2 % (34/69) of patients were admitted, all of whom had confirmed fractures. However, 32.3% (11/34) of admitted NHRs were conservatively treated with an average length-of-stay of 3.6 days before discharge to NH. 6/34 (17.6%) of admitted NHRs died, and 5 of those deaths occurred post-operatively. Of the 50.7% (35/69) discharged directly back to NH from ED, 45.7% (16/35) of those had no fracture, whereas 54.2% (19/35) were discharged for conservative management. Therefore, potentially only 29/69 (33%) ED presentations required definitive orthopaedic/gerontological intervention necessitating admission and two-thirds are potentially avoidable.

Conclusion

The new FastTraX fracture response service is an Advanced-Nurse Practitioner (rANP) co-ordinated integrated service combining use of on-site mobile radiological diagnostics in the NH, a fast-track ambulatory orthopaedic-consult clinic, and specialist gerontological care delivered in timely response to support NH staff in avoiding ED transfer where appropriate.

16 SARS-COV-2 INFECTION AND VACCINATION PATTERNS DETERMINE LONG-TERM ANTIBODY RESPONSES IN NURSING HOME RESIDENTS: DATA FROM NH-COVAIR

Background

Older Nursing Home Residents (NHRs) are at greatest risk of morbidity and mortality from SARS-CoV-2, particularly in the context of both waning vaccine efficacy and the emergence of Variants-of-Concern (VOCs). However, the determinants of long-term vaccine-induced protective antibody responses are yet to be determined in this group.

Methods

NH-COVAIR recruited older NHRs for comprehensive clinical and frailty (NH-FRAIL) assessment. Blood samples were obtained pre-vaccination, at 6-weeks and 6-months following primary vaccination and 6-months following booster vaccination. Antibody titres were measured using both an electrochemiluminescence assay and a custom bead-based array (Luminex™) to measure antibody titre and avidity for Wuhan strain/major VOC antigens. Stepwise adjusted linear regression (log-transformed) assessed longitudinal determinants of vaccine-induced antibody responses.

Results

Of 86 participants (81.1 ± 10.8 years; 65% female), just under half (45.4%) had evidence of previous SARS-CoV-2 infection. All NHRs mounted a significant antibody-response to vaccination at 5 weeks followed by a significant decrease in antibody titre by 6 months. Previous SARS-CoV-2 infection was the strongest predictor of antibody waning at all timepoints (β: 3.59; 2.89, 4.28; P < 0.001 for 6-months). Independent of infection history, both age (β: –0.05; –0.08, –0.02; p<0.001) and frailty (β: –0.22; –0.33, –0.11; p<0.001) were associated with faster antibody waning at 6-months. Cross-reactivity and avidity were significantly lower for Beta (B.1.351) and Gamma (P.1) VOC strains (all p<0.001). Additionally, there was faster antibody waning and significantly reduced antibody avidity to Beta and Gamma VOCs in SARS-CoV-2 naïve NHRs.

Conclusion

Older NHRs are capable of mounting protective antibody responses to SARS-CoV-2 vaccination. Responses were more durable, with a greater cross-reactivity to and avidity for VOCs in those with previous SARS-CoV-2 infection. Increasing age and greater frailty in NHRs was associated with faster antibody waning. Our findings support ongoing serological surveillance and use of additional vaccine doses in older NHRs, particularly in those without previous SARS-CoV-2 exposure.

130 CHARACTERISTICS AND OUTCOMES OF OLDER NURSING HOME RESIDENTS ATTENDING AN EMERGENCY DEPARTMENT

Background

Older nursing home (NH) residents are among the most vulnerable members of society, often with multiple comorbidities and complex care needs. The Emergency Department (ED) is a common point of access to the acute hospital for NH residents. This study aims to review characteristics and outcomes of older NH residents presenting to ED over one year.

Methods

A prospective cohort study was carried out. NH residents aged 50 years and older attending ED of a university teaching hospital over one year (01/10/2019-30/09/2020) were included. Data on demographics, comorbidities, functional status, frailty and details of ED attendance were collected.

Results

There were a total of 515 ED attendances by 341 NH residents over one year. Mean age was 76.3 years (50-103 years; SD ± 10.9). 50.9% (n=262) were female. Mean Charlson Comorbidity Index (CCI) was 5 (0-12; SD ± 2.1). 46.6% (n=240) had a dementia diagnosis. A mean of 12.6 medications (0-31; SD ± 5.3) were prescribed in the NH. Mean Clinical Frailty Score (CFS) was 6.5 (3-9; SD ± 0.9). Mean Barthel Index (BI) was 8.9 (0-20; SD ± 6.0). 38.3% (n=197) of presentations occurred “in-hours”. Mean Manchester Triage Score (MTS) was 2.54 (1-5; SD ± 0.7) with 92.0% (n=474) scoring 1-3. Delirium was documented in 31.8% (n=164). Mean ED Length of Stay (LOS) was 13.7hours (0-80hours; SD ± 11.0). 14.6% (n=75) were discharged without follow-up. 61.2% (n=315) were admitted to hospital. Mean hospital (LOS) was 9.7days (0-191 days) and 8.7% (n=47) of those admitted died in hospital. 12 months after ED presentation, 40.4% (n=138) of the cohort had died.

Conclusion

NH residents are a frail group, with high levels of multimorbidity, polypharmacy and significant care needs. This complexity is reflected in the numbers requiring urgent review on attendance, rates of delirium, ED LOS and hospital admission rates. Dedicated NH liaison teams may enhance care and improve outcomes for this cohort.

356 OLDER PERSONS LIVING ALONE IN INTEGRATED CARE: DEPRESSION, LOW EDUCATION AND FUEL POVERTY

Background

An important consequence of population ageing has been the increasing number of older adults who live alone. According to TILDA data, older adults with the lowest levels of education tend to experience most social isolation and there is a strong association between living alone and loneliness. We sought to compare the cohort of patients open to the Integrated Care for Older Persons (ICPOP) team in a University Teaching Hospital serving a community area of approx. 300,000 population, to this national dataset.

Methods

A convenience sample of 174 patients who underwent comprehensive geriatric assessment via domiciliary visit between July 2021-May 2022 by was analysed. Data was anonymised and analysis was performed using SPSS v.27.

Results

The average age was 81.5 (±8.1) with 63% women in the sample. Eighty-five older adults i.e. 49% of the sample either lived alone or spent more than 21 hours alone per 24-hour period. Compared to those who live with someone, those who lived alone had higher rates of likely depression as determined by Geriatric Depression Score (6.6 vs 4.8 p=0.007). They were also likely to have less educational attainment, as determined by years spent in full time education (11.81 vs 10.42 42 p= 0.0016) and those living alone had overall less central heating in their homes than those not living alone (64/85 vs 81/89 p=0.0109). There were no significant differences in the rates of polypharmacy, falls, dementia and home ownership between groups. There were higher levels of frailty in the group living with someone than those living alone as determined by Clinical Frailty Scale (6.14 vs 5.23 p&lt;0.001).

Conclusion

A high proportion of patients seen by our ICPOP team live alone and have complex care needs that require an innovative, multidisciplinary approach. Financial vulnerability in this group is likely to compound isolation and loneliness.

231 NURSING HOME RESIDENTS PRESENTING TO THE EMERGENCY DEPARTMENT WITH FALLS

Background

Nursing Home Residents (NHR) are the most-frail group of older persons, with many comorbidities that increase their risk of falling. Falls are a frequent reason for ED attendance by NHR’s as it is for all older persons, but little is reported on their characteristics and outcomes specifically.

Methods

A prospective cohort study of all NH presentations with falls to the ED of a university teaching hospital over a one-year period. Detailed operational and clinical phenotype characteristics, and outcomes were recorded in all instances.

Results

There were 519 ED presentations by 344 NHR over one year. Almost half of all presentations (48.2%, 250/519), were as result of a fall, by 172 residents. The majority were female (137/250, 55%), with an average age of 77.8 years (±10.8). Many, 84.3% (145/172), had a prior fall in the past six-months. Almost half had a diagnosis of dementia (124/250, 49.6%). A third mobilised with a Zimmer-frame (83/250), and 10.8% (27/250) wheelchair. 33.2% (83/250) had visual impairment. The mean Barthel Index was 9.55 (±5.12) indicating high-dependency. NHRs fallers frequently attended ED outside routine working hours, with 36.8% (92/250) and 27.6% (69/250) presenting after 5pm (Monday to Friday), or at the weekend respectively. 54.8% of patients were admitted (137/250), and only 25.6% of patients had review by a GP prior to ED-referral (64/250). The average Length Of Stay (aLOS) for admitted NHR fallers was 10.4 (±9.1) days. Injurious falls were noted in only 10.4% (26/250) presentations. aLOS for those admitted with documented injuries (14/26, 54%) was 5.0 days (±7.0, n=14).

Conclusion

NH residents have complex clinical needs and falls is a frequent reason for attending ED. Better access to “out of hours” clinical support within the NH, and better integrated falls prevention programmes/ care pathways between NHs and primary/secondary services are necessary to enhance care and optimise falls prevention.

953 PREVIOUS SARS-COV2 INFECTION, AGE AND FRAILTY PREDICT 6-MONTH BNT162B2 VACCINE-INDUCED ANTIBODY TITRE IN NURSING HOME RESIDENTS

Introduction

Older nursing home residents are the population at greatest risk of morbidity and mortality from SARS-CoV-2 infection. No studies have examined the determinants of long-term antibody responses post-vaccination in this group.

Method

Longitudinal cohort study in residents of 5 nursing homes assessed prior to vaccination and at both 5-weeks and 6-months post SARS-CoV2 vaccine (BNT162b2). Comprehensive clinical assessment was performed, including assessment for comorbidity, frailty (NH-FRAIL) and SARS-CoV-2 infection history. Serum Nucleocapsid and Anti-Spike Receptor Binding Domain (RBD) antibodies were analysed at all timepoints and an in vitro Angiotensin Converting Enzyme (ACE2) Receptor-Spike RBD neutralisation assay used to assess serum neutralisation capacity.

Results

Of 86 participants (81.1 ± 10.8 years; 65% female), just-under half (45.4%; 39/86) had evidence of previous SARS-CoV-2 infection. All participants demonstrated a significant antibody response to vaccination at 5-weeks and a significant decline in this response by 6-months. SARS-CoV-2 infection history was the strongest predictor of antibody titre (log-transformed) at both 5-weeks (β: 3.00; 95% CI [Confidence Interval]: 2.32, 3.70; p &lt; 0.001) and 6-months (β: 3.59; 95% CI: 2.89, 4.28; p &lt; 0.001). Independent of SARS-CoV-2 infection history, both age in years (β: -0.05; 95% CI: −0.08, −0.02; p &lt; 0.001) and frailty (β: -0.22; 95% CI: −0.33, −0.11; p &lt; 0.001) were associated with a lower antibody titre at 6-months. Antibody titres at both 5-weeks and 6-months significantly correlated with in vitro neutralisation capacity.

Conclusion and Implications

In older nursing home residents, SARS-CoV-2 infection history was the strongest predictor of anti-spike antibody titres at 6-months, whilst age and frailty were independently associated with lower titres at 6-months. Antibody titres significantly correlated with in vitro neutralisation capacity. Whilst older SARS-CoV-2 naïve nursing home residents may be particularly vulnerable to breakthrough SARS-CoV-2 infection, the relationship between antibody titres, SARS-CoV-2 infection and clinical outcomes remains to be fully elucidated in this cohort.

Transcriptional Signatures of Sleep Duration Discordance in Monozygotic Twins

Introduction

Habitual short sleep duration is associated with adverse metabolic, cardiovascular, and inflammatory effects. Co-twin study methodologies account for familial (eg, genetics and shared environmental) confounding, allowing assessment of subtle environmental effects, such as the effect of habitual short sleep duration on gene expression. Therefore, we investigated gene expression in monozygotic twins discordant for actigraphically phenotyped habitual sleep duration.

Methods

Eleven healthy monozygotic twin pairs (82% female; mean age 42.7 years; SD = 18.1), selected based on subjective sleep duration discordance, were objectively phenotyped for habitual sleep duration with 2 weeks of wrist actigraphy. Peripheral blood leukocyte (PBL) RNA from fasting blood samples was obtained on the final day of actigraphic measurement and hybridized to Illumina humanHT-12 microarrays. Differential gene expression was determined between paired samples and mapped to functional categories using Gene Ontology. Finally, a more comprehensive gene set enrichment analysis was performed based on the entire PBL transcriptome.

Results

The mean 24-hour sleep duration of the total sample was 439.2 minutes (SD = 46.8 minutes; range 325.4-521.6 minutes). Mean within-pair sleep duration difference per 24 hours was 64.4 minutes (SD = 21.2; range 45.9-114.6 minutes). The twin cohort displayed distinctive pathway enrichment based on sleep duration differences. Habitual short sleep was associated with up-regulation of genes involved in transcription, ribosome, translation, and oxidative phosphorylation. Unexpectedly, genes down-regulated in short sleep twins were highly enriched in immuno-inflammatory pathways such as interleukin signaling and leukocyte activation, as well as developmental programs, coagulation cascade, and cell adhesion.

Conclusions

Objectively assessed habitual sleep duration in monozygotic twin pairs appears to be associated with distinct patterns of differential gene expression and pathway enrichment. By accounting for familial confounding and measuring real life sleep duration, our study shows the transcriptomic effects of habitual short sleep on dysregulated immune response and provides a potential link between sleep deprivation and adverse metabolic, cardiovascular, and inflammatory outcomes.

A pilot randomized controlled trial comparing effectiveness of prism glasses, visual search training and standard care in hemianopia

OBJECTIVE

Pilot trial to compare prism therapy and visual search training, for homonymous hemianopia, to standard care (information only).

METHODS

Prospective, multicentre, parallel, single-blind, three-arm RCT across fifteen UK acute stroke units.

PARTICIPANTS

Stroke survivors with homonymous hemianopia.

INTERVENTIONS

Arm a (Fresnel prisms) for minimum 2 hours, 5 days per week over 6 weeks. Arm b (visual search training) for minimum 30 minutes, 5 days per week over 6 weeks. Arm c (standard care-information only).

INCLUSION CRITERIA

Adult stroke survivors (>18 years), stable hemianopia, visual acuity better than 0.5 logMAR, refractive error within ±5 dioptres, ability to read/understand English and provide consent.

OUTCOMES

Primary outcomes were change in visual field area from baseline to 26 weeks and calculation of sample size for a definitive trial. Secondary measures included Rivermead Mobility Index, Visual Function Questionnaire 25/10, Nottingham Extended Activities of Daily Living, Euro Qual, Short Form-12 questionnaires and Radner reading ability. Measures were post-randomization at baseline and 6, 12 and 26 weeks.

RANDOMIZATION

Randomization block lists stratified by site and partial/complete hemianopia.

BLINDING

Allocations disclosed to patients. Primary outcome assessor blind to treatment allocation.

RESULTS

Eighty-seven patients were recruited: 27-Fresnel prisms, 30-visual search training and 30-standard care; 69% male; mean age 69 years (SD 12). At 26 weeks, full results for 24, 24 and 22 patients, respectively, were compared to baseline. Sample size calculation for a definitive trial determined as 269 participants per arm for a 200 degree² visual field area change at 90% power. Non-significant relative change in area of visual field was 5%, 8% and 3.5%, respectively, for the three groups. Visual Function Questionnaire responses improved significantly from baseline to 26 weeks with visual search training (60 [SD 19] to 68.4 [SD 20]) compared to Fresnel prisms (68.5 [SD 16.4] to 68.2 [18.4]: 7% difference) and standard care (63.7 [SD 19.4] to 59.8 [SD 22.7]: 10% difference), P=.05. Related adverse events were common with Fresnel prisms (69.2%; typically headaches).

CONCLUSIONS

No significant change occurred for area of visual field area across arms over follow-up. Visual search training had significant improvement in vision-related quality of life. Prism therapy produced adverse events in 69%. Visual search training results warrant further investigation.

A systematic review of non-surgical treatments for lentigo maligna

Lentigo maligna (LM) is the most common melanocytic malignancy of the head and neck. If left untreated, LM can progress to lentigo maligna melanoma (LMM). Complete surgical excision is the gold standard for treatment, however, due to the location, size, and advanced age of patients, surgery is not always acceptable. As a result, there is ongoing interest in alternative, less invasive treatment modalities. The objective was to provide a structured review of key literature reporting the use of radiotherapy, imiquimod and laser therapy for the management of LM in patients where surgical resection is prohibited. An independent review was conducted following a comprehensive search of the National Library of Medicine using MEDLINE and PubMed, Embase, Scopus, ScienceDirect and Cochrane Library databases. Data were presented in tabular format, and crude data pooled to calculate mean recurrence rates for each therapy. 29 studies met the inclusion criteria: radiotherapy 10; topical imiquimod 10; laser therapies 9. Radiotherapy demostrated recurrence rates of up to 31% (mean 11.5%), with follow-up durations of 1-96 months. Topical imiquimod recurrence rates were up to 50% (mean 24.5%), with follow-up durations of 2-49 months. Laser therapy yielded recurrence rates of up to 100% (mean 34.4%), and follow-up durations of 8-78 months. in each of the treatment series the I(2) value measuring statistical heterogeneity exceeded the accepted threshold of 50% and as such a meta-analysis of included data were inappropriate. For non-surgical patients with LM, radiotherapy and topical imiquimod were efficacious treatments. Radiotherapy produced superior complete response rates and fewer recurrences than imiquimod although both are promising non-invasive modalities. There was no consistent body of evidence regarding laser therapy although response rates of up to 100% were reported in low quality studies. A prospective comparative trial is indicated and would provide accurate data on the long-term efficacy and overall utility of these treatments.

Presentation, management and outcomes in acute pituitary apoplexy: a large single-centre experience from the United Kingdom

OBJECTIVE

To study the presentation, management and outcomes and to apply retrospectively the Pituitary Apoplexy Score (PAS) (United Kingdom (UK) guidelines for management of apoplexy) to a large, single-centre series of patients with acute pituitary apoplexy.

DESIGN

Retrospective analysis of casenotes at a single neurosurgical centre in Liverpool, UK.

RESULTS

Fifty-five patients [mean age, 52·4 years; median duration of follow-up, 7 years] were identified; 45 of 55 (81%) had nonfunctioning adenomas, four acromegaly and six prolactinomas. Commonest presenting features were acute headache (87%), diplopia (47·2%) and visual field (VF) defects (36%). The most frequent ocular palsy involved the 3rd nerve (81%), followed by 6th nerve (34·6%) and multiple palsies (19%). Twenty-three patients were treated conservatively, and the rest had surgery either within 7 days of presentation or delayed elective surgery. Indications for surgery were deteriorating visual acuity and persistent field defects. Patients presenting with VF defects (n = 20) were more likely to undergo surgery (75%) than to be managed expectantly (25%). There was no difference in the rates of complete/near-complete resolution of VF deficits and cranial nerve palsies between those treated conservatively and those who underwent surgery. Endocrine outcomes were also similar. We were able to calculate the PAS for 46 patients: for the group treated with early surgery mean, PAS was 3·8 and for those managed conservatively or with delayed surgery was 1·8.

CONCLUSIONS

Patients without VF deficits or whose visual deficits are stable or improving can be managed expectantly without negative impact on outcomes. Clinical severity based on a PAS ≥ 4 appeared to influence management towards emergency surgical intervention.

Coarse particulate matter and airborne endotoxin within wood stove homes

Emissions from indoor biomass burning are a major public health concern in developing areas of the world. Less is known about indoor air quality, particularly airborne endotoxin, in homes burning biomass fuel in residential wood stoves in higher income countries. A filter-based sampler was used to evaluate wintertime indoor coarse particulate matter (PM₁₀₋₂.₅) and airborne endotoxin (EU/m³, EU/mg) concentrations in 50 homes using wood stoves as their primary source of heat in western Montana. We investigated number of residents, number of pets, dampness (humidity), and frequency of wood stove usage as potential predictors of indoor airborne endotoxin concentrations. Two 48-h sampling events per home revealed a mean winter PM₁₀₋₂.₅ concentration (± s.d.) of 12.9 (± 8.6) μg/m³, while PM₂.₅ concentrations averaged 32.3 (± 32.6) μg/m³. Endotoxin concentrations measured from PM₁₀₋₂.₅ filter samples were 9.2 (± 12.4) EU/m³ and 1010 (± 1524) EU/mg. PM₁₀₋₂.₅ and PM₂.₅ were significantly correlated in wood stove homes (r = 0.36, P < 0.05). The presence of pets in the homes was associated with PM₁₀₋₂.₅ but not with endotoxin concentrations. Importantly, none of the other measured home characteristics was a strong predictor of airborne endotoxin, including frequency of residential wood stove usage.

Results of a residential indoor PM2.5 sampling program before and after a woodstove changeout

During 2005-2007, a woodstove changeout program was conducted in a Rocky Mountain valley community in an effort to reduce ambient levels of PM(2.5). In addition to changes in ambient PM(2.5), an opportunity was provided to evaluate the changes in indoor air quality when old stoves were replaced with US Environmental Protection Agency (EPA)-certified woodstoves. PM(2.5) samples were measured in 16 homes prior to and following the changeout. For each sampling event, PM(2.5) mass was continuously measured throughout the 24-h sampling periods, and organic/elemental carbon (OC/EC) and associated chemical markers of woodsmoke were measured from quartz filters. Results showed that average PM(2.5) concentrations and maximum PM(2.5) concentrations were reduced by 71% and 76%, respectively (as measured by TSI DustTraks). Levoglucosan was reduced by 45% following the introduction of the new woodstove. However, the concentrations of resin acids, natural chemicals found in the bark of wood, were increased following the introduction of the new woodstove. There were no discernible trends in methoxphenol levels, likely due to the semi-volatile nature of the species that were measured. Although there is some uncertainty in this study regarding the amount of ambient PM infiltration to the indoor environment, these findings demonstrated a large impact on indoor air quality following this intervention.

PRACTICAL IMPLICATIONS

Emissions from residential woodstoves are an important air quality issue (both indoors and ambient) in many regions throughout the US and the world. More specifically, woodstoves have been identified as a major source of PM(2.5) in valley locations throughout the Northern Rocky Mountains, where biomass combustion is the predominant source of home heating. In this study, we present results that demonstrate the dramatic reduction in PM(2.5) concentrations (as measured by TSI, Inc. DustTrak PM(2.5) air samplers) inside homes following the replacement of old, polluting woodstove with new EPA-certified woodstoves.

Monocular and binocular depth discrimination thresholds

BACKGROUND

Measurement of stereoacuity at varying distances, by real or simulated depth stereoacuity tests, is helpful in the evaluation of patients with binocular imbalance or strabismus. Although the cue of binocular disparity underpins stereoacuity tests, there may be variable amounts of other binocular and monocular cues inherent in a stereoacuity test. In such circumstances, a combined monocular and binocular threshold of depth discrimination may be measured--stereoacuity conventionally referring to the situation where binocular disparity giving rise to retinal disparity is the only cue present. A child-friendly variable distance stereoacuity test (VDS) was developed, with a method for determining the binocular depth threshold from the combined monocular and binocular threshold of depth of discrimination (CT).

METHODS

Subjects with normal binocular function, reduced binocular function, and apparently absent binocularity were included. To measure the threshold of depth discrimination, subjects were required by means of a hand control to align two electronically controlled spheres at viewing distances of 1, 3, and 6m. Stereoacuity was also measured using the TNO, Frisby, and Titmus stereoacuity tests. BTs were calculated according to the function BT= arctan (1/tan alphaC - 1/tan alphaM)(-1), where alphaC and alphaM are the angles subtended at the nodal points by objects situated at the monocular threshold (alphaM) and the combined monocular-binocular threshold (alphaC) of discrimination.

RESULTS

In subjects with good binocularity, BTs were similar to their combined thresholds, whereas subjects with reduced and apparently absent binocularity had binocular thresholds 4 and 10 times higher than their combined thresholds (CT). The VDS binocular thresholds showed significantly higher correlation and agreement with the TNO test and the binocular thresholds of the Frisby and Titmus tests, than the corresponding combined thresholds (p = 0.0019).

CONCLUSION

The VDS was found to be an easy to use real depth (distance) stereoacuity test. The method described for calculating the BT provides one simple nonlinear solution for determining the respective contributions of binocular and monocular (MT) depth discrimination to the combined depth threshold.

Congenital infantile fibrosarcoma: a case study

Congenital infantile fibrosarcoma (CIFS) is a rare soft-tissue malignancy most commonly involving the extremities. Metastases are rare; however, local recurrence is common. Because the tumor is so rare and clinical experience is lacking, both diagnosis and treatment are difficult. The complex planning and implementation of neonatal and oncologic care require ongoing collaboration between both nursing specialties. This case study discusses the pathophysiology, diagnosis, and management of an infant with CIFS, with emphasis on the nursing care of the patient and family.

Study of receptor-mediated neurotoxins released by HIV-1-infected mononuclear phagocytes found in human brain

Although there is growing evidence that neurotoxic molecules produced by HIV-1-infected mononuclear phagocytes damage neurons, the precise mechanisms of neuronal attack remain uncertain. One class of cytotoxin involves neuronal injury mediated via the NMDA receptor. We examined blood monocytes and brain mononuclear cells isolated at autopsy from HIV-1-infected individuals for the ability to release NMDA-like neuron-killing factors. We found that a neurotoxic amine, NTox, was produced by blood monocytes and by brain mononuclear phagocytes infected with retrovirus. In vivo injections of minute quantities of NTox produced selective damage to hippocampal pyramidal neurons. NTox can be extracted directly from brain tissues infected with HIV-1 and showed structural features similar to wasp and spider venoms. In contrast to NTox, HIV-1 infection did not increase the release of the NMDA excitotoxin quinolinic acid (QUIN) from mononuclear cells. Although we found modest elevations of QUIN in the CSF of HIV-1-infected individuals, the increases were likely attributable to entry through damaged blood-brain barrier. Taken together, our data pinpoint NTox, rather than QUIN, as a major NMDA receptor-directed toxin associated with neuro-AIDS.

Immunization outreach at Income Support Centers, New York City, 1992-1993

An increase in measles occurred in New York City (NYC) during 1989-1990, affecting primarily unvaccinated preschool-aged children. Many of these children were also enrolled in Aid to Families with Dependent Children (AFDC) programs. To determine the immunization status of children receiving AFDC, immunization records were reviewed at three NYC income support centers. Records were assessed for vaccination eligibility on the day of the visit and at various ages. Seventy-six percent of the children were found eligible for vaccination on the day of their visit. Vaccination levels at two years of age were among the lowest measured in New York. Future immunization efforts should be directed toward this population.

Survival and mortality patterns of an acquired immunodeficiency syndrome (AIDS) cohort in New York State

The survival experience and causes of death of acquired immunodeficiency syndrome (AIDS) patients were studied using a cohort of 3,699 AIDS patients in New York State, excluding New York City, whose illness was diagnosed before January 1990 at age 13 years or older. The median length of survival for all cases was 11.5 months, and survival increased over time from 5.3 months pre-1984 to 9.3 months in 1984-1986 and to 13.2 months in 1987-1989. In a Cox proportional hazards model, risk of dying was higher for persons aged 35 years or more at diagnosis and for persons with a diagnosis other than Pneumocystis carinii pneumonia or Kaposi's sarcoma whose illness was diagnosed before 1986. In this AIDS cohort, 2,834 (77 percent) persons died before 1991; 87 percent of the death certificates listed human immunodeficiency virus (HIV)/AIDS or an AIDS indicator disease as one of the multiple causes of death. The finding that 13 percent of the death certificates did not mention AIDS/HIV suggests that use of death certificates alone to count HIV-related deaths would result in an undercount. The recent expansion of the federal AIDS case definition is expected to add HIV-infected persons who die from conditions, such as recurrent pneumonia, that were not included in the earlier definition.

Hepatitis B virus DNA in peripheral-blood mononuclear cells in chronic hepatitis B after HBsAg clearance

In this study, peripheral-blood mononuclear cells from patients with chronic hepatitis B and spontaneous or therapy-induced disappearance of HBsAg were examined for HBV DNA. Samples were evaluated by in situ hybridization and polymerase chain reaction both before and after clearance of HBsAg. By in situ hybridization, positive signals were observed in 2 of 13 samples collected after HBsAg loss, in 8 of 15 samples before HBsAg loss and in 0 of 4 control patients without serological markers of active or prior HBV infection. When polymerase chain reaction analyses were performed, HBV DNA was detected in 5 of 12 HBsAg-negative samples and 10 of 15 HBsAg-positive samples from the study group. Testing of mononuclear cells after disappearance of HBsAg revealed that two of eight patients were HBV DNA positive by in situ hybridization and by polymerase chain reaction, whereas two additional patients were positive by polymerase chain reaction alone. Mononuclear cell-associated HBV DNA was detected between 2 and 9 mo after the disappearance of circulating HBsAg by in situ hybridization and as long as 4 yr later by polymerase chain reaction. These data indicate that patients who have undergone HBsAg seroconversion may nonetheless harbor HBV DNA in their peripheral-blood mononuclear cells for prolonged periods.

Is a single tricyclic antidepressant trial an active treatment for psychotic depression?

1. A retrospective chart review of 256 consecutively admitted depressed inpatients assessed their treatment response to optimal somatic therapy. 2. There were no differences in treatment response between patients with Major Depressive Episode (MD) and Major Depression with Psychosis (MD-P). 3. In addition, twenty-six studies were reviewed to clarify the role of tricyclic antidepressants (TCA) in the treatment of MD-P. The authors conclude from this literature review that TCA's should not be considered an active treatment for MD-P patients.

Predicting poststroke family function: a continuing dilemma

To determine what effect stroke might have on family interaction, common stroke outcome variables were used to predict family function for a sample of 78 families in which one member had recent onset of stroke. Traditional stroke-outcome predictors were not useful in accounting for variance in family function. The nature of family dynamics after disability may require additional research because the relationship is complex.

Effects of actinomycin D and ultraviolet and ionizing radiation on Pichinde virus

Actinomycin D (0.05 mug/ml) suppresses the synthesis of ribosomal RNA of baby hamster kidney (BHK21) cells. The production of infectious Pichinde virus was enhanced in the presence of actinomycin D, although the production of virus particles was not substantially different from cultures inoculated in the absence of the drug. By prelabeling BHK21 cells with (3)H-uridine and then allowing the virus to replicate in the presence of actinomycin D, it was possible to show that ribosomal RNA synthesized prior to infection was incorporated into the virion. A single-hit kinetics of inactivation of Pichinde virus was observed with ultraviolet light, suggesting that the virus contains only a single copy of genome per virion. Comparison of the inactivation kinetics by gamma irradiation of Pichinde virus with Sindbis and rubella virus indicated that the radiosensitive genome of Pichinde virus was about 6 x 10(6) to 8 x 10(6) daltons. This value is greater than the 3.2 x 10(6) daltons which was estimated by biochemical analysis. One possible explanation considered is that the ribosomal RNA of host cell origin is functional and accounts for the differences in genome size estimated by the two methods.