Myocarditis in Minnehaha County, South Dakota, 1880-1939

From 1920 to 1940 in Minnehaha County there was an apparent striking increase in the incidence of fatal myocarditis and chronic myocarditis. Based on an analysis of the interment records of the Mt. Pleasant Cemetery, word frequency studies in two prominent American medical journals and a general review of related medical publications, we explore this increase. We conclude that there was no actual increase in the frequency of inflammatory disorders of the myocardium in Minnehaha County during this period. Rather, it appears that the use of the diagnostic terms was a matter of choice among local physicians that was not supported by contemporaneous clinical and pathophysiologic publications in available journals.

Fatal Accidental Drowning in Minnehaha County, South Dakota, 1880-1939

Drowning is currently the second leading cause of injury-related death for children 1-4 years of age in the United States and is the leading cause of death worldwide for boys ages 5-14 years. The World Health Organization (WHO) classifies it as a public health threat and advocates for reducing drowning deaths by understanding geographical, cultural, and societal risk factors. To these three we added a fourth: historical studies. To that end, we analyzed accidental causes of death between January 1, 1880, and December 31, 1939, in Minnehaha County, South Dakota, based on interment records from the Mt. Pleasant Cemetery. From these six decades (1880-1939) of data, we classified 217 cases as accidental deaths. Drowning was the leading cause of accidental mortality, accounting for 50 accidental deaths (23%). Drowning deaths were analyzed by the decedents' age and date of death. We discuss specific historical drowning risk factors and hypothesize how they may have affected drowning deaths from 1880-1939 in Minnehaha County.

Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

440 Training in Microbiological Sampling for Toe Amputations in Diabetic Foot Disease: A Survey of UK Vascular Trainees

Aim

To determine usual practice and extent of training received by United Kingdom (UK) vascular surgery trainees in microbiological sampling for toe amputations in diabetic patients.

Method

A prospective online survey was distributed via social media networks and trainee organisations. All vascular surgery trainees in the UK were invited to participate. A total of 29 responses were included in the analysis.

Results

86% of respondents have been trained in toe amputations during registrar training. 66% have not been taught which samples to send for microbiological analysis. 10% receive regular training reviews in toe amputations. There is significant variability in the types of samples sent by trainees for microbiological analysis and the majority of trainees did not know how their samples are processed in the laboratory.

Conclusions

Toe amputations appear to be a neglected aspect of training for UK vascular surgery registrars. Lack of consistency in microbiological sampling techniques may prevent optimum antimicrobial stewardship and therefore increase the risk of further complications including major amputation. Inclusion of diabetic foot sepsis as a critical condition in the new vascular surgery curriculum may help to address this issue. A national consensus needs to be reached on how microbiological samples should be taken and processed in order for trainees to be taught in a consistent manner.

Examining Trajectories of Change for Prosperous Forest Landscapes in Cambodia

Tropical forest landscapes are undergoing rapid transition. Rural development aspirations are rising, and land use change is contributing to deforestation, degradation, and biodiversity loss, which threaten the future of tropical forests. Conservation initiatives must deal with complex social, political, and ecological decisions involving trade-offs between the extent of protected areas and quality of conservation. In Cambodia, smallholders and industrial economic land concessions drive deforestation and forest degradation. Rural economic benefits have not kept pace with development aspirations and smallholders are gradually expanding agriculture into protected forests. We examine the drivers and effects of rural forest landscape transitions in Cambodia to identify trade-offs between conservation and development. Using historical trends analysis and information gathered through key informant interviews, we describe how local communities perceive social and ecological changes, and examine the implications of local development aspirations for conservation. We explore three scenarios for the future of conservation in Cambodia, each with different conservation and community development outcomes. We contend that conservation efforts should focus on strengthening governance to meet social and environmental requirements for sustainable forest landscapes. We suggest potential entry points for governance improvements, including working with local decision-makers and fostering collaboration between stakeholders. There is a need for realistic priority setting in contested tropical forest landscapes. Prosperous rural economies are a necessary but not sufficient condition for conservation.

Understanding complex drivers of wildlife crime to design effective conservation interventions

In conservation understanding the drivers of behavior and developing robust interventions to promote behavioral change is challenging and requires a multifaceted approach. This is particularly true for efforts to address illegal wildlife use, where pervasive-and sometimes simplistic-narratives often obscure complex realities. We used an indirect questioning approach, the unmatched count technique, to investigate the drivers and prevalence of wildlife crime in communities surrounding 2 national parks in Uganda and combined scenario interviews and a choice experiment to predict the performance of potential interventions designed to tackle these crimes. Although poverty is often assumed to be a key driver of wildlife crime, we found that better-off households and those subject to human-wildlife conflict and those that do not receive any benefits from the parks' tourism revenue sharing were more likely to be involved in certain types of wildlife crime, especially illegal hunting. The interventions predicted to have the greatest impact on reducing local participation in wildlife crime were those that directly addressed the drivers including, mitigating damage caused by wildlife and generating financial benefits for park-adjacent households. Our triangulated approach provided insights into complex and hard-to-access behaviors and highlighted the importance of going beyond single-driver narratives.

Physicians and Reform: The State of The Art and The Challenge to Physicians

Within the context of medical reformation outlined by Hoffman in a series of three papers in South Dakota Medicine and the challenge of legislation involving the independent practice of advanced practice nurses, we undertook two surveys of physicians and patients. We wanted to better understand physicians' attitudes toward certain opportunities for reform and how they conformed to the viewpoints of our patients. We found that, at least with respect to nurse practice legislation, physicians' perceptions were at odds with their patients over questions of access and quality. Moreover, we found attitudinal differences among physicians depending upon whether they were independent or affiliated with a health care system and whether they were primary care physicians or specialists. We concluded that physicians do not yet share the common understanding necessary to advocate for a principle of medical practice encompassing the core needs of patients and the spectrum of caregivers.

Games as Tools to Address Conservation Conflicts

Conservation conflicts represent complex multilayered problems that are challenging to study. We explore the utility of theoretical, experimental, and constructivist approaches to games to help to understand and manage these challenges. We show how these approaches can help to develop theory, understand patterns in conflict, and highlight potentially effective management solutions. The choice of approach should be guided by the research question and by whether the focus is on testing hypotheses, predicting behaviour, or engaging stakeholders. Games provide an exciting opportunity to help to unravel the complexity in conflicts, while researchers need an awareness of the limitations and ethical constraints involved. Given the opportunities, this field will benefit from greater investment and development.

Santayana's Axiom: The South Dakota State Medical Association and Medical Practice Legislation in 1929 and 2017

In 1928 members of the South Dakota State Medical Association (SDSMA or the Association) held a special meeting in Huron to consider a basic science bill that conformed "…in its entirety to the conditions existing in our state." Their draft bill proposed a standardized examination for all practitioners of the healing arts. A legislative committee, with its attorney, "…was in Pierre during the early part of the 1929 legislative session to make sure the bill was properly launched and in effective channels." Shortly after its introduction, the bill was withdrawn due to opposition from one SDSMA district whose legislative representatives were among the most influential in the legislature. A similar bill promoted by the SDSMA in 1933 also failed. It would be another six years before a basic science bill was enacted by the legislature. Eighty-nine years later, a bill governing the practice of certified nurse practitioners (NP) and certified nurse midwives (NM), including a board independent of the South Dakota Board of Medical and Osteopathic Examiners, was considered (Senate Bill 61). Introduced by a senator who characterized herself as representing the "House of Nursing," the bill challenged "…the overarching role that medicine thinks and perceives that they may have regarding advanced practice nursing practice." SB 61 passed in the senate and house and was signed by the governor. For this legislation in the 1930s and in 2017, the SDSMA's interest was defining and maintaining control of medical practice under the twin rubrics of quality and patient welfare. In both circumstances, legislators and other health care professional organizations contested not only the SDSMA's motivations, but also the evidence supporting their efforts. Our research explored (1) whether the collective viewpoints and conduct of the legislature, the SDSMA, and non-physician medical professionals are comparable in the two circumstances; and (2) if the circumstances are comparable, can we derive a useful concept or theme that could help guide the SDSMA in the future?

A Case of Silent Q Fever Endocarditis

Q fever endocarditis is a rare, culture negative endocarditis caused by Coxiella burnetii, a spore-forming gram negative coccobacillus. Presenting symptoms can be very non-specific; thus, diagnosis may be delayed. We present a case of a 65-year-old male patient with history of aortic aneurysm who complained of chronic fatigue. He was found to have aortic valve vegetation on routine echocardiography. Q fever endocarditis was diagnosed based on elevated Q fever serology; there was absence of fever. This case illustrated a rare, under-recognized and atypical manifestation of Q fever endocarditis. We would like to encourage physicians of rural states like South Dakota to remain vigilant when it comes to screening for the suspected cases of Q fever, specifically in cases of unexplained fatigue and valvulopathy.

Analysis of blood donor motivations

INTRODUCTION

Blood and blood products are essential medical treatments for all age groups. The primary source for blood products in the U.S. is volunteer donors. Thus, donor recruitment and donor retention are vital factors for a blood bank to maintain its supply. We proposed that developing a better understanding of donors' motivations to donate would improve a blood bank's ability to secure a more robust supply of blood.

METHODS

Individuals ages 18-36 were approached to participate in the study during their blood donation appointment by completing a questionnaire. SAS software was used to statistically analyze the responses. Univariate analysis was done using Fisher's exact test. A multivariate model was constructed controlling for age and marital status, including the variables that were significant in univariate analysis.

RESULTS

No individual motivating or inhibiting factor reached statistical significance. The odds ratio for subsequent donation for donors with 10-plus donations versus those with one to three donations was 4.296 (p-value 0.004). The odds ratio regarding donors' likelihood of returning to donate for those donating within three to six months versus 1-plus year was 4.806 (p-value < 0.001). No employer was found to discourage blood donations.

CONCLUSIONS

Although no individual factors were found to be statistically significant, the identification of optimal time intervals and total number of donations at which donors are more likely to return may allow for more strategic scheduling of blood drives, increasing the likelihood of a donor returning while also increasing the total number of donations for that individual.

Safety and efficacy of ocrelizumab in patients with rheumatoid arthritis and an inadequate response to at least one tumor necrosis factor inhibitor: results of a forty-eight–week randomized, double-blind, placebo-controlled, parallel-group phase III trial

OBJECTIVE

To evaluate the safety and efficacy of ocrelizumab plus methotrexate (MTX) or leflunomide (LEF) in patients with active rheumatoid arthritis (RA) and an inadequate response to tumor necrosis factor α inhibitors.

METHODS

This was a multicenter randomized, double-blind, placebo-controlled, parallel-group study that continued over 48 weeks. Patients receiving stable doses of MTX or LEF were randomized to receive 2 infusions of placebo (n = 277), ocrelizumab 200 mg (n = 278), or ocrelizumab 500 mg (n = 285) on days 1 and 15 as well as at weeks 24 and 26. Coprimary end points were the proportion of patients with response according to the American College of Rheumatology 20% improvement criteria (ACR20) at weeks 24 and 48. Secondary end points included the change from baseline in the modified Sharp/van der Heijde score (SHS) and the ACR50/70 responses.

RESULTS

ACR20 responses were 22.0% in the placebo group, 42.2% in the ocrelizumab 200 mg group, and 47.9% in the ocrelizumab 500 mg group at 24 weeks and 19.5%, 48.7%, and 50.7%, respectively, at 48 weeks (P < 0.0001 versus placebo for each comparison at each time point). At 48 weeks, patients receiving both doses of ocrelizumab showed significantly improved ACR50 and ACR70 responses of ~3-fold versus placebo. Only those in the ocrelizumab 500 mg group showed statistically significant (P = 0.0017) inhibition of joint damage progression (mean change in the SHS) relative to placebo (61% inhibition) at 48 weeks. Overall adverse events and infections during the 48 weeks of study were comparable in all treatment groups. Serious infections were observed more frequently in patients taking ocrelizumab (5.1% and 4.3%) than in those taking placebo (2.5%).

CONCLUSION

Patients in both of the ocrelizumab groups met the clinical primary efficacy end points. Inhibition of change in the SHS was statistically significant at 48 weeks for those in the ocrelizumab 500 mg group. The rate of serious infections in this trial was higher for both ocrelizumab doses as compared with placebo.

Protocols for high efficiency, stage-specific retroviral transduction of murine fetal thymocytes and thymic epithelial cells

Viral vectors have the potential to provide a fast and economic alternative to transgenic methods for manipulating gene expression in studies of immune system development and function. Although protocols exist for the infection of hematopoietic precursors and peripheral T cells in vitro, critical stages of T cell differentiation are strictly dependent upon a three-dimensional thymic architecture and their analysis poses unique technical challenges. Whole fetal thymic lobes have been used as targets for retroviral and adenoviral infection, both in situ and in vitro, but this approach does not allow for discrimination between lymphoid and stromal components. Isolated thymocytes have been infected by co-culture with viral producer cells, but under these conditions they rapidly lose their developmental potential. To overcome these problems we have combined a number of efficient techniques for retroviral production, concentration, and infection that allow us to rapidly achieve significant transduction rates of purified populations of double-negative (DN) and double-positive (DP) thymocytes, single-positive (SP) T lymphocytes, as well as fetal thymic MHC II(+) epithelial cells without the need for co-culture with viral producer cells. Reaggregate thymic organ culture (RTOC) techniques were used to assess the development and function of transduced cells in defined cellular environments. As a demonstration of the utility of these methods, CD80 (B7.1) was transduced into thymic epithelial cells and shown to allow them to mediate negative selection of DP thymocytes, and to act as antigen-presenting cells (APC) to mature T cells. The ability to genetically manipulate primary cells of a specified type and differentiation stage provides a powerful complement to RTOC techniques for the study of T cell development.

Recommended policies for uses of human tissue in research, education, and quality control. Ad Hoc Committee on Stored Tissue, College of American Pathologists

As recipients of tissue and medical specimens, pathologists and other medical specialists regard themselves as stewards of patient tissues and consider it their duty to protect the best interests of both the individual patient and the public. The stewardship of slides, blocks, and other materials includes providing, under appropriate circumstances, patient materials for research, education, and quality control. The decision to provide human tissue for such purposes should be based on the specific (ie, direct patient care) and general (ie, furthering medical knowledge) interests of the patient and of society. The same standards of responsibility should apply to all medical professionals who receive and use specimens. This document proposes specific recommendations whereby both interests can be fostered safely, ethically, and reasonably.

IFN-alpha super-induction of HLA class I expression by a variant thymoma cell line involves nuclear translocation of Rel complexes

Variant thymoma lines have been described which exhibit a substantially increased level of HLA class I induction by IFN-alpha, but not by IFN-gamma, and an unchanged response of other IFN-alpha-stimulated genes (Burrone et al., EMBO J. 1985. 4: 2855-2860). We report that their amplified response correlates with the nuclear translocation of Rel transcription factors upon prolonged treatment with IFN-alpha. The variant cells contain an IkappaBalpha subset with a significantly shortened half-life, and a constitutively active form of IkappaBalpha efficiently blocks HLA class I induction. Therefore, in addition to STAT-mediated induction, prolonged exposure to IFN-alpha can affect transcription involving Rel factors, which are implicated in the regulation of numerous immune response and viral genes.

Suppression of tumorigenicity in Ras-transformed fibroblasts by alpha 2(I) collagen

Transformed fibroblasts exhibit reduced adhesion to substrata, a characteristic attributable in part to reduced expression/increased degradation of extracellular matrix (EM) proteins such as type I collagen. To directly assess the role of EM proteins in cellular transformation, a vKRas-transformed mouse fibroblast cell line was transfected with an alpha 2(I) collagen expression construct. Stable transfectants displaying a partial restoration of type I collagen expression showed a flatter morphology with increased adherence to the substratum. These clones also exhibited a reduced ability to clone in soft agar, slower growth kinetics, and suppression of tumorigenicity in nude mice. Restoration of type I collagen is correlated with down-regulation of ras oncogene-responsive NVL3 VL30 gene expression. These results suggest that in addition to suppressing tumorigenicity by promoting cellular adhesion and cytoskeletal organization, EM proteins such as type I collagen may also act to subvert oncoprotein signaling pathways associated with the malignant phenotype.

Regulation of cell differentiation in C2C12 myoblasts by the Id3 helix-loop-helix protein

To investigate the biological functions of the helix-loop-helix Id3 protein, we have examined the effects of ectopic modulation of Id3 expression on in vitro induced differentiation of mouse C2C12 myoblast cells. Transient and stable C2C12 transfectants expressing either inducible or constitutive levels of exogenous Id3 were impaired in their ability to differentiate in response to removal of mitogenic serum growth factors. Stable Id3 transfectants displayed an enhanced proliferative capacity associated with a delay in exit from the cell cycle in response to differentiation induction. Antisense blockade of Id3 potentiated differentiation and exit from S phase of the cell cycle. These observations suggest that Id3 functions as a negative regulator of differentiation by integrating mitogenic growth factor signaling into the gene regulatory program maintaining cell cycle progression.

[The subjective experience in catatonia: systematic study of 24 catatonic patients]

Catatonic patients are often not able to communicate their subjective experiences behind their "fassade of immobility." Therefore was retrospectively (3 weeks later) investigated subjective experiences in 24 catatonic patients with a self-assessment-scale especially for catatonia developed by us. Our results showed that catatonic patients subjectively experience less their altered movements but rather cognitive, i.e. ambivalence, or affective, i.e. intense emotions which couldn't be controlled, alterations. According to our results we were able to distinguish an emotive (intense anxiety) from a non-emotive, i.e. cognitive (predominating ambivalence), subtype in catatonia with regard to subjective experience.

Quality assurance indicators in anatomic pathology

Quality assurance indicators in anatomic pathology focus on both technical and cognitive processes that result in a written report. The written report serves as both an intermediate outcome, which, in part, determines patient care outcomes, and a source of information for quality assurance studies. General requirements of a program include procedures that meet Joint Commission on Accreditation of Healthcare Organizations requirements for data gathering, data analysis, action, and effectiveness evaluation; documentation; and personnel standards. Specific indicators in surgical pathology and cytopathology focus on timeliness of reports, diagnostic accuracy, relevance of information in reports to the care of the patient, and proficiency testing. Cytopathology requires some unique indicators because of its dual screening and diagnostic role, including detection of false-negative results and comparison of cytotechnologist and cytopathologist diagnoses. Quality assurance indicators for the autopsy include those for the autopsy pathology as a subdiscipline of pathology as well as those that integrate autopsy information into a program of clinical quality assurance.

Localized neuroblastoma treated by surgery: a Pediatric Oncology Group Study

A prospective study was designed to evaluate the outcome of patients with localized resectable neuroblastoma without regional lymph node involvement when no therapy beyond surgical resection was administered. One hundred one patients observed for 3 to 60 months had a 2-year disease-free survival of 89% (SE = 5%). Of the nine patients experiencing relapse, only three have died. There were no apparent distinguishing characteristics of the nine failures. Due to the favorable prognosis of the subset of neuroblastoma patients, prognostic factor analysis had very limited power and lacked clinical importance. Complete gross removal of the localized tumors is adequate therapy to ensure the survival of the majority of these patients.