Approach to the Hypoglycemic Patient

Hypoglycemia is commonly encountered in the emergency department. Patients can present with a myriad of symptoms and its presentation can mimic other more serious diagnoses. Despite the relative ease of its management, clinicians often miss the diagnosis or mismanage it even when discovered. Glucose is an important energy source for the brain and failing to recognize hypoglycemia or mismanaging it can lead to permanent neurologic disability or death. Although it is important to replenish glucose in a rapid fashion, it is equally important to discover and manage the underlying etiology to prevent further episodes of hypoglycemia.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Diagnosis and Management of Adrenal Insufficiency and Adrenal Crisis in the Emergency Department

BACKGROUND

Adrenal insufficiency can result in significant patient morbidity and mortality, but due to the range of symptoms and variable clinical course and etiologies, it can be a challenging condition to diagnose and manage.

OBJECTIVE

This narrative review will discuss the evaluation of an adult patient at risk for a new diagnosis of adrenal insufficiency and the management of a patient with known or suspected adrenal insufficiency.

DISCUSSION

A new presentation of adrenal insufficiency can range from nonspecific, minor symptoms including fatigue, to a life-threatening adrenal crisis with hemodynamic instability. Due to the variety of signs and symptoms, the diagnosis is often missed. Those with known adrenal insufficiency are at risk for adrenal crisis, which may occur due to a variety of triggers. Initial evaluation includes assessment for the underlying etiology or concomitant condition, laboratory analysis, and imaging, when clinically indicated. Although not necessary for evaluation in the emergency department setting, the diagnosis is confirmed by specific testing such as the cosyntropin stimulation test. The mainstay of treatment in adrenal crisis is hydrocortisone, intravenous fluid, glucose repletion, and treatment of the underlying acute trigger.

CONCLUSIONS

Emergency clinicians must be prepared to recognize, evaluate, and manage those with known or suspected adrenal insufficiency or adrenal crisis.

Does the Concept of the "Flipped Classroom" Extend to the Emergency Medicine Clinical Clerkship?

Introduction

Linking educational objectives and clinical learning during clerkships can be difficult. Clinical shifts during emergency medicine (EM) clerkships provide a wide variety of experiences, some of which may not be relevant to recommended educational objectives. Students can be directed to standardize their clinical experiences, and this improves performance on examinations. We hypothesized that applying a “flipped classroom” model to the clinical clerkship would improve performance on multiple-choice testing when compared to standard learning.

Methods

Students at two institutions were randomized to complete two of four selected EM clerkship topics in a “flipped fashion,” and two others in a standard fashion. For flipped topics, students were directed to complete chief complaint-based asynchronous modules prior to a shift, during which they were directed to focus on the chief complaint. For the other two topics, modules were to be performed at the students’ discretion, and shifts would not have a theme. At the end of the four-week clerkship, a 40-question multiple-choice examination was administered with 10 questions per topic. We compared performance on flipped topics with those performed in standard fashion. Students were surveyed on perceived effectiveness, ability to follow the protocol, and willingness of preceptors to allow a chief-complaint focus.

Results

Sixty-nine students participated; examination scores for 56 were available for analysis. For the primary outcome, no difference was seen between the flipped method and standard (p=0.494.) A mixed model approach showed no effect of flipped status, protocol adherence, or site of rotation on the primary outcome of exam scores. Students rated the concept of the flipped clerkship highly (3.48/5). Almost one third (31.1%) of students stated that they were unable to adhere to the protocol.

Conclusion

Preparation for a clinical shift with pre-assigned, web-based learning modules followed by an attempt at chief-complaint-focused learning during a shift did not result in improvements in performance on a multiple-choice assessment of knowledge; however, one third of participants did not adhere strictly to the protocol. Future investigations should ensure performance of pre-assigned learning as well as clinical experiences, and consider alternate measures of knowledge.

Pair correlation functions and the wavevector-dependent surface tension in a simple density functional treatment of the liquid-vapour interface

We study the density-density correlation function G(r, r') in the interfacial region of a fluid (or Ising-like magnet) with short-ranged interactions using square gradient density functional theory. Adopting a simple double parabola approximation for the bulk free-energy density, we first show that the parallel Fourier transform G(z, z'; q) and local structure factor S(z; q) separate into bulk and excess contributions. We attempt to account for both contributions by deriving an interfacial Hamiltonian, characterised by a wavevector dependent surface tension σ(q), and then reconstructing density correlations from correlations in the interface position. We show that the standard crossing criterion identification of the interface, as a surface of fixed density (or magnetization), does not explain the separation of G(z, z'; q) and the form of the excess contribution. We propose an alternative definition of the interface position based on the properties of correlations between points that 'float' with the surface and show that this describes the full q and z dependence of the excess contributions to both G and S. However, neither the 'crossing-criterion' nor the new 'floating interface' definition of σ(q) are quantities directly measurable from the total structure factor S(tot)(q) which contains additional q dependence arising from the non-local relation between fluctuations in the interfacial position and local density. Since it is the total structure factor that is measured experimentally or in simulations, our results have repercussions for earlier attempts to extract and interpret σ(q).

Diet physical form, fatty acid chain length, and emulsification alter fat utilization and growth of newly weaned pigs

An experiment was conducted to examine the interplay of diet physical form (liquid vs. dry), fatty acid chain length [medium- (MCT) vs. long-chain triglyceride (LCT)], and emulsification as determinants of fat utilization and growth of newly weaned pigs. Ninety-six pigs were weaned at 20.0 ± 0.3 d of age (6.80 ± 0.04 kg) and fed ad libitum 1 of 8 diets for 14 d according to a 2(3) factorial arrangement of treatments with 6 pens per diet and 2 pigs per pen. The MCT contained primarily C8:0 and C10:0 fatty acids, whereas the LCT mainly contained C16:0, C18:0, C18:1, and C18:2. Diet physical form greatly impacted piglet growth (P < 0.001), with liquid-fed pigs (486 g/d) growing faster than dry-fed pigs (332 g/d) by 46%. Pigs fed LCT grew 22% faster (P = 0.01) than MCT-fed pigs; however, effects of emulsifier were not detected (P > 0.1). Furthermore, feed intake and G:F were 15% and 29% greater for liquid-fed pigs, and intake also was 21% greater for pigs fed LCT (P = 0.01). Diet physical form had no effect on apparent ileal fatty acid digestibility, but as expected, digestibility was greater (P < 0.001) for the MCT than the LCT diet (98.5% vs. 93.4%). Emulsification improved digestibility of most fatty acids in pigs fed LCT but not MCT (interaction, P < 0.01). Both jejunal and ileal villi height increased from 7 to 14 d postweaning (P < 0.01). Liquid-fed pigs had greater jejunal crypt depth (P < 0.05) compared with pigs fed the dry diet; however, ileal morphology was not affected by diet physical form, fat chain length, or emulsification. Plasma ketone body concentrations were 6-fold greater in pigs fed MCT than LCT, and the difference was greater in pigs fed dry diets (interaction, P = 0.01). The bile salt concentration in jejunal digesta was 2.2-fold greater in pigs fed LCT than in pigs fed MCT (P < 0.001). Collectively, we conclude that feeding liquid diets containing emulsified LCT can improve fat utilization and markedly accentuate feed intake, growth, and G:F of weanling pigs.

Nodal metastasis in endometrial cancer

PURPOSE

Besides hysterectomy and bilateral salpingo-oophorectomy, the goal of surgery in early endometrial cancer is to identify extrauterine disease. The purpose of this study was to evaluate disease characteristics and survival of patients found to have nodal metastasis at staging for endometrial cancer.

METHODS

All patients presenting to our practice from January 1993 to July 2009 with a new diagnosis of early endometrial cancer underwent pelvic and paraaortic lymph node sampling at the time of surgery as permitted by the body mass index. Patient and disease characteristics of patients with nodal metastasis were abstracted by retrospective chart review. Factors contributing to disease-free and overall corrected survival were evaluated.

RESULTS

Forty-three patients with an early endometrial cancer were found to have pelvic and/or paraaortic nodal metastasis. Thirty-three percent of patients with nodal metastasis had papillary serous or clear cell cancers. Such tumors were often superficially invasive, yet were more likely to demonstrate lymphovascular space involvement as compared to endometrioid cancers. Furthermore, in a global model of disease-free and overall corrected survival, only tumor histology (endometrioid vs non-endometrioid) was a significant prognostic factor. Excluding clear cell and papillary serous tumors, only tumor grade was a significant prognostic factor in disease-free survival and overall corrected survival in patients with endometrioid adenocarcinomas and nodal involvement. Following adjuvant treatment after surgery, the recurrences were nearly evenly divided between pelvic, paraaortic nodal and distant sites. Only four of 33 (12%) patients treated with adjuvant pelvic radiation experienced a failure in the irradiated field. Furthermore, none of the patients experiencing a paraaortic nodal recurrence received adjuvant radiation to this site.

CONCLUSIONS

The data suggest a benefit to the use of adjuvant radiation for local control of disease. Furthermore, the use of paclitaxel and carboplatinum chemotherapy also appears a promising adjunct in patients with endometrioid histologies and nodal spread. Papillary serous and clear cell cancers contributed disproportionately to the incidence of nodal metastasis and an adverse prognosis following further adjuvant therapy of patients with nodal disease. Despite taxol/carboplatinum chemotherapy, over half of the patients with non-endometrioid cancers recurred, as opposed to one of 19 endometrioid cancers so treated. The ideal form of adjuvant treatment for such patients remains problematic.

Randomized clinical trial of folate supplementation in patients with peripheral arterial disease

BACKGROUND

The aim was to determine whether folate supplementation improved arterial function in patients with peripheral arterial disease (PAD).

METHODS

Individuals with PAD were randomly assigned to receive 400 microg folic acid (45 patients) or 5-methyltetrahydrofolate (5-MTHF) (48) daily, or placebo (40) for 16 weeks. Primary endpoints were changes in plasma total homocysteine (tHcy), ankle : brachial pressure index (ABPI) and pulse wave velocity (PWV). Secondary outcomes were changes in plasma inflammatory markers.

RESULTS

Plasma tHcy was significantly reduced in folic acid and 5-MTHF groups compared with controls: median difference: - 2.12 (95 per cent confidence interval - 3.70 to - 0.75) micromol/l (P = 0.002) and - 2.07 (-3.48 to - 0.54) micromol/l (P = 0.007) respectively. ABPI improved significantly: median difference 0.07 (0.04 to 0.11) (P < 0.001) and 0.05 (0.01 to 0.10) (P = 0.009) respectively. Brachial-knee PWV (bk-PWV) decreased significantly in individuals receiving 5-MTHF and tended to be reduced in those taking folic acid compared with controls: median difference: - 1.10 (-2.20 to - 0.20) m/s (P = 0.011) and - 0.90 (-2.10 to 0.00) m/s (P = 0.051) respectively. Plasma levels of inflammatory markers were not affected.

CONCLUSION

Folate administration reduced plasma homocysteine, and slightly improved ABPI and bk-PWV.

Colorectal cancer risk prediction tool for men and women without known susceptibility

e15002

Background: Given the high incidence of colorectal cancer (CRC), and the availability of procedures that can detect disease and remove precancerous lesions, there is a need for a model that estimates the probability of developing CRC across various age intervals and risk factor profiles. Methods: The development of separate CRC absolute risk models for men and women included estimating relative risks and attributable risk parameters from population-based case-control data separately for proximal, distal, and rectal cancer and combining these estimates with baseline age-specific cancer hazard rates based on Surveillance, Epidemiology, and End Results (SEER) incidence rates and competing mortality risks. Results: For men, the model included a cancer- negative sigmoidoscopy/colonoscopy in the last 10 years, polyp history in the last 10 years, history of CRC in first-degree relatives, aspirin and nonsteroidal anti-inflammatory drug (NSAID) use, cigarette smoking, body mass index (BMI), current leisure-time vigorous activity, and vegetable consumption. For women, the model included sigmoidoscopy/colonoscopy, polyp history, history of CRC in first-degree relatives, aspirin and NSAID use, BMI, leisure-time vigorous activity, vegetable consumption, hormone-replacement therapy (HRT), and estrogen exposure on the basis of menopausal status. For men and women, relative risks differed slightly by tumor site. A validation study in independent data indicates that the models for men and women are well calibrated. Conclusions: We developed absolute risk prediction models for CRC from population-based data, and a simple questionnaire suitable for self-administration. This model is potentially useful for counseling, for designing research intervention studies, and for other applications.

No significant financial relationships to disclose.

Audio computer assisted interviewing to measure HIV risk behaviours in a clinic population

OBJECTIVES

To examine whether audio computer assisted survey interviewing (ACASI) influenced responses to sensitive HIV risk behaviour questions, relative to interviewer administration of those questions (IAQ), among patients attending a sexually transmitted infection (STI) clinic and whether the impact of interview mode on reporting of risk behaviours was homogeneous across subgroups of patients (defined by age, sex, and previous STI clinic experience).

METHODS

1350 clinic patients were assigned to complete a detailed behavioural survey on sexual risk practices, previous STIs and symptoms, condom use, and drug and alcohol use using either ACASI or IAQ.

RESULTS

Respondents assigned to ACASI were more likely to report recent risk behaviours such as sex without a condom in the past 24 hours (adjusted OR = 1.9), anal sex (adjusted OR = 2.0), and one or more new partners in the past 6 months (adjusted OR = 1.5) compared to those interviewed by IAQ. The impact of ACASI varied by sex but, contrary to expectations, not by whether the patient had previously visited an STI clinic. Mode of survey administration made little difference within this population in reports of STI knowledge, previous STIs, STI symptoms, or illicit drug use.

CONCLUSION

ACASI provides a useful tool for improving the quality of behavioural data in clinical environments.

HFE mutations in an inflammatory arthritis population

OBJECTIVES

To determine the value of screening patients with inflammatory arthritis for haemochromatosis-associated mutations in the HFE gene.

METHODS

We screened 1000 patients with inflammatory arthritis and 1000 controls for the HFE gene mutations that are associated with haemochromatosis. The arthritis patients were diagnosed between 1989 and 1995 and their blood DNA was archived as part of the Norfolk Arthritis Register project.

RESULTS

Five out of 1000 (0.005) patients in the arthritis group were homozygous for the HFE C282Y mutation. This frequency is the same as the frequency of 5/1000 (0.005) for C282Y homozygosity observed in the normal population. It is slightly above the predicted frequency of homozygosity of 0.0044 derived from the gene frequency in the normal population.

CONCLUSIONS

These data suggest that most of the C282Y homozygotes occurred in this arthritis group by chance and that their arthritis was incidental to their HFE genotype. This implies that screening for HFE mutations among patients with inflammatory arthritis would infrequently identify patients whose arthritis might benefit from additional treatment.

Increased DNA oxidative susceptibility without increased plasma LDL oxidizability in Type II diabetes: effects of alpha-tocopherol supplementation

In vivo supplementation studies of the antioxidant alpha-tocopherol in human Type II diabetes have used surrogate, rather than direct, markers of oxidative damage/antioxidant protection and have used higher doses of alpha-tocopherol than used in coronary secondary prevention trials. We tested the hypothesis that oral alpha-tocopherol in a dosage regimen used in secondary prevention trials would reduce directly observed oxidatively induced single-strand breaks in lymphocyte DNA in Type II diabetes. We studied 40 people with Type II diabetes and 30 controls in a randomized, double-blind, placebo-controlled trial of 400 i.u. of oral alpha-tocopherol daily for 8 weeks. Lymphocyte DNA single-strand breaks and low-density lipoprotein (LDL) particle size and oxidizability were measured at baseline, after 8 weeks, and after 4 weeks washout. Polymorphisms in the gene for the antioxidant enzyme paraoxonase-1 gene (position 192) were measured. The diabetics had increased DNA oxidative susceptibility (P=0.008), without increased LDL oxidative susceptibility. There was a direct relationship between DNA oxidative susceptibility and baseline plasma alpha-tocopherol in the diabetes group alone (r=0.421, r(2)=0.177 and P=0.023), but DNA and LDL oxidative susceptibility were not influenced by alpha-tocopherol supplementation in either group in this regimen. Paraoxonase-1 gene polymorphisms did not contribute to LDL or DNA oxidative susceptibility or response to alpha-tocopherol. Increased DNA oxidative susceptibility, therefore, can occur in Type II diabetes without increased LDL oxidative susceptibility, but alpha-tocopherol supplementation in this regimen has no influence on DNA or LDL oxidative susceptibility in Type II diabetes or controls. Polymorphisms in the paraoxonase gene (position 192) are not associated with differences in oxidative susceptibility or responses to alpha-tocopherol.

Incidence of liver disease in people with HFE mutations

BACKGROUND

Most patients with haemochromatosis have mutations of the HFE gene. However, the risk to people with HFE mutations of developing disease manifestations of haemochromatosis is not known.

AIMS

To determine the risk of developing cirrhosis and liver cancer in individuals with HFE mutations in a population where few people were being treated for haemochromatosis.

METHODS

215 archive biopsy specimens of liver cancer (n=34) and cirrhosis (n=190) were retrieved from histology archives. Blood samples from 1000 individuals from the normal population were also collected. DNA was extracted from the biopsy specimens and exons 2 and 4 of the HFE gene were amplified using polymerase chain reaction. The products were analysed for the C282Y (845A) and H63D (187G) mutations.

RESULTS

Three (8.8%) patients from the liver cancer group were homozygous for the C282Y mutation. Five (2.6%) patients from the cirrhosis group were homozygous for the C282Y mutation. One case fell in both the liver cancer and cirrhosis groups. C282Y homozygosity was thus significantly more frequent in both groups than in the normal population. These 215 cases are representative of a population of about 250 000 over 20 years. During this period we estimate that about 260 births or deaths of C282Y homozygous individuals occurred within this population.

CONCLUSIONS

A diagnosis of liver cancer or cirrhosis is rare in the lifetime of individuals from this population who are homozygous for the C282Y mutation (2.5%; upper 95% confidence interval (CI) = 8%). Similarly liver disease is rare among C282Y/H63D compound heterozygotes (1%; upper 95% CI = 3.5%).

Haemochromatosis gene C282Y homozygotes in an elderly male population

We found that C282Y homozygosity was not under-represented in an elderly male population. This suggests that life-threatening, haemochromatosis-related disease may not occur in many C282Y homozygotes.

Readmissions to drug abuse treatment and HIV risk behavior

The objectives of the study were (a) to investigate the characteristics of drug abuse treatment clients who return to treatment and (b) among those with readmissions, to describe changes over time in risk behavior for human immunodeficiency virus (HIV) infection and to identify factors associated with behavior change. Data were derived from a multisite HIV surveillance program in a single community; the program used a unique identifier to link HIV test results and behavioral information from multiple contacts. During a 30-month period, 1994 clients were admitted to three satellite facilities of a single treatment agency: detoxification, long-term residential, and outpatient. Of these clients, 574 (29%) had one or more readmissions to the same or a different facility during the 24 months following the index admission. Drug injectors, those tested for HIV, and those living in the community were more likely to be readmitted to treatment. There was little overall change in HIV risk behavior between the index admission and the readmission furthest in time from the index admission. Clients whose index visit was at the residential facility were more likely to reduce their injection risk behavior than those admitted to the other facilities. Clients readmitted to either the residential or the outpatient facility were more likely to have reduced their injection risk behavior than those readmitted to detoxification. Treatment facility was not associated with sexual risk behavior change. Men were more likely than women to reduce their high-risk sexual behaviors. The results underscore the need for treatment programs to make HIV testing readily available to their clients and to make special efforts to assist female clients to reduce their HIV risk.

A differential PCR assay for the detection of c-erbB 2 amplification used in a prospective study of breast cancer

AIMS

To establish a robust differential polymerase chain reaction (PCR) assay for the detection of c-erbB 2 amplification in breast cancer that can be used in a routine pathology laboratory. Once established, the assay was used in a prospective study of breast tumours to investigate the relation between c-erbB 2 amplification and both recognised prognostic features and short term clinical outcome.

METHODS

The differential PCR was used for the co-amplification of c-erbB 2 and a reference gene from 48 tumour DNA samples and control DNA samples. The ratio of the two genes was determined by image analysis of the PCR products electrophoresed on a highly resolving agarose gel.

RESULTS

The differential PCR assay was shown to be accurate and reproducible using the conditions outlined. Twenty six per cent of the breast cancer patients were shown to have c-erbB 2 amplification in their tumour biopsies. Twenty eight per cent of the patients died of their disease or had disease recurrence during the follow up period and 73% of these patients had amplification of c-erbB 2.

CONCLUSIONS

A significant association was found between c-erbB 2 amplification and early disease recurrence. This assay could be used to provide a marker for poor prognosis in breast cancer.

A high prevalence of HLA-H 845A mutations in hemochromatosis patients and the normal population in eastern England

We have examined normal individuals and all the patients currently being treated for hemochromatosis at the Norfolk and Norwich hospital for mutations in the HLA-H gene. We found a gene frequency in 200 normal subjects for teh 845A (C282Y) allele of 0.085, corresponding to a carrier frequency of 17% which is among the highest reported anywhere in the world. The frequency for the less penetrant 187G (H63D) allele was 0.16 among 58 of the normal subjects, which corresponds to a carrier frequency of 32%. All 18 hemochromatosis patients were homozygous for the 845A allele which is not significantly different from other reports in our subset of 12 unrelated patients. These findings present a snapshot of a relatively stable population containing a predicted 3,500 individuals homozygous for the 845A allele but not diagnosed with hemochromatosis. This population will be an excellent model for studies on the penetrance of the 845A homozygous genotype and population screening.

Community-wide HIV counselling and testing in central Massachusetts: who is retested and does their behavior change?

HIV counselling and testing was provided to 4267 individuals between September 1987 and June 1992 at a multi-site program, including community clinics, drug treatment programs, and a men's prison in central Massachusetts. Half of those tested reported the risk behaviors targeted by the programs: injection drug use (38.1%) and sexual contact with a drug injector (12.6%). The objectives of this study were to examine 1) factors associated with repeat HIV testing among these initially seronegative, and 2) behavior change following counselling and testing. Initially 7.4% were HIV positive, and 12.4% of those testing negative were retested within one year. Risk behavior was the only strong independent predictor of retesting (odds ratios of 3.8 and 4.2 for men reporting sex with men and recent drug injectors, respectively). Changes in risk behaviors between the time of the initial test and the second test were assessed (n = 207). Among those who continued to inject drugs at follow-up there was a reduction in the percent visiting shooting galleries (p = 0.05); no other significant behavior changes were reported. While selection bias may be responsible in part for the minimal behavior change observed, continued monitoring of risk behavior and counselling are warranted.

Admissions of injection drug users to drug abuse treatment following HIV counseling and testing

The outcomes of counseling and testing programs related to human immunodeficiency virus (HIV) infection and risk of infection among injection drug users (IDUs) are not well known or understood. A counseling and testing outcome of potential public health importance is attaining admission to drug abuse treatment by those IDUs who are either infected or who are at high risk of becoming infected. The authors investigated factors related to admission to drug abuse treatment among 519 IDUs who received HIV counseling and testing from September 1987 through December 1990 at a men's prison and at community-based testing sites in Worcester, MA. By June 1991, 123 of the 519 IDUs (24 percent) had been admitted to treatment. Variables associated with their admission included a long history of drug injection, frequent recent drug injection, cleaning injection equipment using bleach, prior drug treatment, and a positive HIV test result. Logistic regression analyses, controlling for effects of recruitment site, year, sex, and area of residence, generally confirmed the associations. IDUs in the study population who were HIV-infected sought treatment or were admitted to treatment more frequently than those who were not infected. The results indicate that access to drug abuse treatment should be facilitated for high-risk IDUs and for those who have begun to inject drugs recently.

Analysis of ras point mutations and human papillomavirus 16 and 18 in cervical carcinomata and their metastases

Paraffin-wax-embedded samples of normal cervical tissue and of primary cervical carcinomata and nodal metastases were obtained from each of 15 patients. They were analyzed for the presence of ras point mutations and human papillomavirus (HPV) types 16 and 18 using the polymerase chain reaction (PCR) and hybridization to oligomer probes. Only 1 patient was found to have a ras mutation: a codon 13 mutation of Ki-ras which was present in only two lymph node metastases, but not in the primary tumor or in a third metastasis. These results suggest that ras point mutation is not a common factor in the development of primary or metastatic cervical cancer. HPV 16 was detected in 7 of the 15 patients and was present in both primary and metastatic tumors in 6 of these 7 cases. HPV 18 was not detected in any of the 15 patients. These results do not suggest a role for HPVs 16 and 18 in producing metastatic behavior.

Use of a portable manometer as a screening procedure in voice rehabilitation

Abnormal tone in the pharyngo-oesophageal (PO) segment may lead to failure in developing oesophageal speech. Videofluoroscopy may give a qualitative assessment of the PO segment but is expensive, time consuming and lacks quantification. A custom built PO segment manometer was therefore assessed as a means of predicting eventual oesophageal speech outcome. Two groups of patients were studied. In group 1 (18 patients) the PO segment pressures were compared to their videofluoroscopy findings. Videofluoroscopy categorized the patients into four groups. The PO pressures corresponded to this grouping, pressures above 20 mmHg being associated with voice failure. In group 2 (12 patients) the PO pressures in the early post-operative period were compared to their eventual speech outcome. In all cases the pressures predicted the eventual speech outcome. The pressure manometer is a simple, cheap and portable device which is a reliable screening test to predict the potential for oesophageal speech.

Failure modes and effects analysis in clinical engineering

Failure modes and effects analysis (FMEA) is a proactive quality assurance procedure that has been commonly used to address potential design flaws and product misuses during the design stage of a product's life. FMEA is becoming commonplace among manufacturing companies but is relatively unknown outside of manufacturing circles. One potential new application of FMEA is by medical device end-users who could address design or functional concerns specific to their situation. The continued increase in the amount and complexity of medical instrumentation necessitates an aggressive stance towards safety in each hospital, such as is recommended in this paper.

Lymphocyte phenotypes in the intestinal mucosa of sheep infected with Trichostrongylus colubriformis

Monoclonal antibodies to ovine lymphocyte surface antigens were used in an immunohistochemical study of the intestine of sheep. In the epithelium CD8+ cells predominated whereas the majority of lamina propria T lymphocytes were CD4+. Infection of sheep with the parasitic nematode Trichostrongylus colubriformis including sufficiently large numbers of parasites to induce protective immunity did not alter the number of CD4+ or CD8+ lymphocytes in the intestinal mucosa. In contrast, exposure of naive sheep to a single large infection of T. colubriformis resulted in a substantial decrease in number of CD8+ cells and moderate decreases in number of CD4+ cells in the duodenal but not the jejunal mucosa. MHC class II antigens were not detected either in or on epithelial cells of the sheep small intestine.

Immune response of sheep to oral and subcutaneous administration of live aromatic-dependent mutant of Salmonella typhimurium (SL1479)

The major objective of the present study was to determine whether oral immunization with a live aromatic-dependent strain of Salmonella typhimurium (SL1479) was capable of stimulating an intestinal immune response in sheep similar to that induced by combined intraperitoneal injection followed by oral boosting. The results showed that repeated oral immunization was incapable of stimulating an anti-flagella antibody containing cell (ACC) response in the lamina propria of the intestine even though primary oral administration of 5 x 10(9) live SL1479 gave rise to an ACC response in intestinal lymph which was predominantly of the IgM isotype. ACC reached a peak 9-10 days after oral administration when ACC comprised 0.5-1% of total lymphocytes in lymph. An ACC response of similar isotope specificity also occurred in popliteal prefemoral lymph of unprimed sheep following regional subcutaneous injection of SL1479. Oral administration of SL1479 to orally primed sheep did not reinvoke an ACC response in lymph although IgG1-ACC were observed in medullary cords of mesenteric lymph nodes of sheep 6-8 days after the booster dose of SL1479. The results suggest that the protective immunity elicited by oral administration of SL1479 cannot be attributed to induction of a local intestinal antibody production.

The urban homeless: estimating composition and size

Although homelessness has been recognized as a serious and growing urban social problem, scientifically acceptable methods for estimating the composition and size of the homeless population have been lacking. A new research approach to estimating the size and composition of undomiciled urban populations is presented, and its utility is illustrated through a description of the literal homeless of Chicago. The homeless in the Chicago sample are unaffiliated persons living in extreme poverty, with high levels of physical and mental disability. Homelessness is interpreted as a manifestation of extreme poverty among persons without families in housing markets with declining stocks of inexpensive dwelling units suitable for single persons.

Living with the mentally ill: factors affecting household complaints

Data provided by case managers in community support programs are used to analyze the problems of families providing shelter to mentally ill relatives. Factors affecting complaints in 345 family households are contrasted with factors leading to complaints in a subsample of 622 other residential alternatives. Behavioral problems are the best predictors of complaints from all households regardless of type, but some causal factors identified are unique to family residences, notably failure to perform household chores and infrequently socializing with friends. Active and passive rule violations, encompassing both do's and don'ts, are more important than clinical history and social background in understanding complaints.

Kartagener's syndrome seen on CT

The authors present a case of Kartagener's syndrome that was seen on CT. To the authors' knowledge, this is the first reported case of such. The appearance and interesting aspects of the case will be described.

Ribavirin small-particle aerosol treatment of infections caused by influenza virus strains A/Victoria/7/83 (H1N1) and B/Texas/1/84

In a double-blind study of influenza in a population of college students in 1984, ribavirin small-particle aerosol treatment of 38 patients (18 treated, 20 control) infected with a new antigenic variant, influenza virus strain A/Victoria/7/83 (H1N1), was associated with statistically significant reductions in the height and duration of fever, systemic symptoms, and virus shedding. Patients received a total of 2.4 g of ribavirin over 42 h during 68 h of hospitalization without any side effects. In addition, in a study of patients infected with influenza virus strain B/Texas/1/84 (seven treated, eight control) treated with ribavirin aerosol showed a trend of more rapid recovery than control patients.

The effect of naloxone on schedule-induced and other drinking

A dose-response study of the effect of naloxone on schedule-induced drinking confirmed that this type of drinking is resistant to the opiate antagonist at doses which depressed drinking induced by water-deprivation, hypertonic saline and salbutamol. Naloxone also failed to reduce intake of saline solution in the presence of scheduled food presentation. The findings support the suggestion that schedule-induced drinking is regulated by a system of neural control which differs from that involved in deprivation and other forms of drinking. It would appear that opiate receptors do not play a part in the regulation of schedule-induced drinking.

Autoimmune haemolytic anaemia with anti-A autoantibody

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Lymphoma with large intracavitary metastasis to the heart. Report of a case

A case if reported of a 2 1/2-year-old boy with an extensive filtration of the retroperitoneum, mediastinum, and almost every organ of the body with a very primitive type of tumor identified as a poorly-differentiated mixed histiocyticlymphocytic lymphoma. The right atrium was completely filled with a large intracavitary metastasis which caused obstruction of the venous return to the heart with subsequent death.