Assessing the diagnostic yield of achalasia using provocative testing in high-resolution esophageal manometry: Serial diagnostic study

BACKGROUND

Chicago Classification v4.0 recommends that if achalasia is demonstrated with single water swallows (SWS); provocative testing is not required. We determine whether provocative testing in patients with suspected achalasia can change manometric findings and reproduce symptoms.

METHODS

Between 2016 and 2022, 127 consecutive manometry studies of patients with achalasia were retrospectively analyzed. All patients underwent SWS, a solid meal (SM) and/or a rapid drink challenge (RDC). Demographic data, fluoroscopy, gastroscopy, and pre-and post-treatment Eckardt scores were collated.

KEY RESULTS

Of 127 achalasia patients (50.6 ± 16.6 years and 54.6% male), all completed a SM and 116 (91.3%) completed RDC; overall 83 were naïve (65.4%) to previous therapy. 15.4% patients with normal integrated relaxation pressure (IRP) on SWS demonstrated obstruction with RDC. SM gave a different achalasia phenotype in 44.9% of patients (p ⟨ 0.001). Twelve patients with normal IRP during SWS had persistent/recurrent obstruction during provocative testing; 83.3% had previous achalasia therapy. None of 13 patients with Type III (TIII) achalasia with SWS exhibited a change in manometric findings with provocative testing. Impedance bolus heights were lower in patients with TIII achalasia and those with normal IRP with SWS. During the SM, symptoms were reproduced in 56.7% of patients. Forty-six of 103 patients (44.7%) underwent therapy based upon the final achalasia subtype which was defined by the provocative test result of the high-resolution manometry (HRM) study. All treatments were effective, regardless of the achalasia subtype.

CONCLUSIONS AND INFERENCES

Manometric findings remain unchanged when TIII achalasia is diagnosed with SWS. In patients with normal IRP, Type I, or Type II achalasia during SWS, provocative testing can alter achalasia phenotype or uncover achalasia where diagnosis is unclear. Further, it can reproduce symptoms. Such findings can personalize and guide effective therapeutic decisions.

1291 DO PATIENTS UNDERSTAND THEIR RESPECT FORMS? A QI PROJECT REVIEWING PHRASES USED AND WHETHER THEY ARE MEANINGFUL TO PATIENTS

Background

Hospital based Quality Improvement Project focusing on adapting language used on Recommended Summary Plan for Emergency Treatment and Care (ReSPECT) forms to improve patient understanding.

Introduction

ReSPECT forms have been used to document patient wishes and appropriate escalation of treatment in our hospital since 2019. There continues to be a lack of understanding of phrases used amongst both patients and healthcare professionals; the hospital receives regular complaints. This project explored patients’ perceptions of language used and their thoughts on the ReSPECT discussion, to better guide discussions and documentation.

Methods

A questionnaire collecting qualitative and quantitative data was performed with 24 patients aged between 59-95 years old with ReSPECT forms on a medical ward (Geriatrics/ Endocrine).

Results

The phrases ‘DNACPR’ and ‘Not for ITU’ were understood by 5/24 patients (21%), ‘Ward based ceiling of care’ was understood by only 1/24 (4%) and ‘prioritising comfort care’ understood by 8/24 patients (34%). Only 6/24 (25%) of patients said they were a ‘little upset’ by their admission conversation about ReSPECT and no patients surveyed were ‘very upset’.

Conclusions

This first QI cycle found that overall, most patients did not understand the language commonly used on ReSPECT forms, particularly ‘ward-based ceiling of care’. The majority were not upset by the ReSPECT conversation, so a fear of upsetting the patient should not be a barrier to having a clear discussion. The next step in our QI work will be to explore phrases that are better understood by patients and then feedback findings so that we can develop a digital ReSPECT form with drop down options for phrases better understood by patients to describe ceilings of care.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

527 The Challenge to Improve Patient Education for Newly Inserted Urinary Catheters on Discharge from the Emergency Department

Aim

To improve education in patients with new urinary catheters on discharge from the Emergency Department (ED), decreasing the incidence and healthcare burden of subsequent catheter-associated complications.

Method

Qualitative study design was employed to survey all Healthcare Professionals (HCPs) working in the ED and establish the quality and means of information currently provided. A novel trust-endorsed proforma with information leaflet was created with urology team input and uploaded to the ED website. Staff were updated via email, WhatsApp and verbally and re-surveyed after 6 months. Survey responses were evaluated with descriptive statistical analysis.

Results

The majority of HCPs in the department reported nearly always/often providing information verbally to patients, with similar findings on re-surveying. The most commonly discussed topic with patients remained: “Common complications and where to seek advice”. HCPs reported never/rarely offering written information (75%, 74% before and after respectively) and nearly all HCPs surveyed did not know where to find patient information resources (81%, 79% respectively).

Conclusions

Written information provision remained poor despite creation of a proforma with information leaflet. A high departmental turnover of HCPs, alongside varying seasonal Covid burden may have reduced the efficacy of interventions. The findings may also be as a result of HCPs still not knowing where to locate such resources.

‘Nudge theory’ through placing leaflets next to catheter supplies, combined with improved education of new staff rotating through the department at individual inductions and the introduction of checklists are changes that have been since actioned and due to be re-surveyed in February 2022.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Oral health-related self-efficacy and fatalism in a regional South Australian Aboriginal population

OBJECTIVES

To assess the psychometric properties, including face, content, criterion and known-groups validity and reliability, of scales to measure oral health-related self-efficacy and fatalism in a regional Aboriginal adult population in Australia.

METHODS

Four hundred Aboriginal adults (aged 18-82 years, 67% female) completed a self-report questionnaire including items pertaining to oral health-related self-efficacy and fatalism. Structural validity was determined in exploratory factor analysis (EFA) with principal components analysis for each scale. Criterion validity was assessed between the instruments and theoretically related variables. Known-groups validity was investigated by comparing the scores in different population groups according to age, sex, education and employment. Reliability of the scales was assessed through internal consistency.

RESULTS

The EFA confirmed a single factor structure for self-efficacy and fatalism scales, with Cronbach's alphas of 0.93 and 0.89 respectively. The two scales were not correlated. Oral health-related self-efficacy was associated with toothbrush ownership and brushing the previous day supporting criterion validity. Oral health-related fatalism was associated with previous extractions and perceived need for extractions also supporting criterion validity. Both measures were associated with social impact of oral health as measured by the OHIP-14, supporting their criterion validity. Mixed findings were observed in terms of known-groups validity.

CONCLUSIONS

There was initial evidence that measures of oral health-related self-efficacy and fatalism displayed adequate psychometric properties in this Aboriginal community. These constructs could have implications for approaches for improving oral health among Aboriginal people.

Proteus mirabilis - a rare cause of non-HACEK Gram-negative infective endocarditis

Infective endocarditis caused by Proteus mirabilis is strikingly rare. Here, we describe the case of an 86-year old man with five recurrent septic episodes over a period of three months associated with Proteus mirabilis bacteraemia secondary to underlying Proteus endocarditis. The final diagnosis was made based on clinical findings, blood culture results and transoesophageal echocardiogram. The patient was treated medically with 6 weeks of ceftriaxone and long-term oral ciprofloxacin. On completion of intravenous therapy the patient remained well. We performed a literature review and found this to be only the fourth confirmed case of Proteus mirabilis endocarditis successfully treated with antibiotic therapy alone. This case highlights an important but rare cause of endocarditis, reinforcing the need to consider this diagnosis in recurrent Gram-negative bacteraemia even if by an atypical organism.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Monoamines differentially modulate neuropeptide release from distinct sites within a single neuron pair

Monoamines and neuropeptides often modulate the same behavior, but monoaminergic-peptidergic crosstalk remains poorly understood. In Caenorhabditis elegans, the adrenergic-like ligands, tyramine (TA) and octopamine (OA) require distinct subsets of neuropeptides in the two ASI sensory neurons to inhibit nociception. TA selectively increases the release of ASI neuropeptides encoded by nlp-14 or nlp-18 from either synaptic/perisynaptic regions of ASI axons or the ASI soma, respectively, and OA selectively increases the release of ASI neuropeptides encoded by nlp-9 asymmetrically, from only the synaptic/perisynaptic region of the right ASI axon. The predicted amino acid preprosequences of genes encoding either TA- or OA-dependent neuropeptides differed markedly. However, these distinct preprosequences were not sufficient to confer monoamine-specificity and additional N-terminal peptide-encoding sequence was required. Collectively, our results demonstrate that TA and OA specifically and differentially modulate the release of distinct subsets of neuropeptides from different subcellular sites within the ASIs, highlighting the complexity of monoaminergic/peptidergic modulation, even in animals with a relatively simple nervous system.

A comparison of airborne bacterial fallout between orthopaedic and vascular surgery

INTRODUCTION The objective of the study was to compare bacterial fallout during vascular prosthesis insertion and orthopaedic major joint replacement performed in conventional and laminar flow ventilation, respectively. MATERIALS AND METHODS A prospective single-centre case control study of 21 consecutive elective vascular procedures involving prosthetic graft insertion and 24 consecutive elective orthopaedic major joint replacements were tested for degree of bacterial fallout using agar settle plates. Preparation time, waiting time and total procedure duration were collected at the time of surgery, and bacterial colony counts on the agar settle plates from airborne bacterial fallout were counted after an incubation period. RESULTS Bacterial fallout count in vascular prosthetic graft insertion was 15-fold greater than in orthopaedic prosthetic joint insertion (15, (IQR 15) vs 1, (IQR 3) respectively, P < 0.0001, Wilcoxon). Waiting time and patient transfer did not significantly increase bacterial fallout counts during the procedure (P = 0.9). CONCLUSIONS Vascular surgical theatres have significantly higher bacterial fallout compared with orthopaedic theatres. This may be partly explained by orthopaedic surgery being routinely performed in laminar flow ventilation, a practice which has not been widely adopted for vascular surgery, in which prosthetic infection may also result in significant mortality and morbidity.

Green-to-Red Photoconversion of GCaMP

Genetically encoded calcium indicators (GECIs) permit imaging intracellular calcium transients. Among GECIs, the GFP-based GCaMPs are the most widely used because of their high sensitivity and rapid response to changes in intracellular calcium concentrations. Here we report that the fluorescence of GCaMPs--including GCaMP3, GCaMP5 and GCaMP6--can be converted from green to red following exposure to blue-green light (450-500 nm). This photoconversion occurs in both insect and mammalian cells and is enhanced in a low oxygen environment. The red fluorescent GCaMPs retained calcium responsiveness, albeit with reduced sensitivity. We identified several amino acid residues in GCaMP important for photoconversion and generated a GCaMP variant with increased photoconversion efficiency in cell culture. This light-induced spectral shift allows the ready labeling of specific, targeted sets of GCaMP-expressing cells for functional imaging in the red channel. Together, these findings indicate the potential for greater utility of existing GCaMP reagents, including transgenic animals.

Oral Papillomas Associated With Felis catus Papillomavirus Type 1 in 2 Domestic Cats

Multiple small sessile raised lesions were detected on the ventral surface of the tongue in two 13-year-old domestic cats. The lesions were incidental in both cats. Lesions from both cats appeared histologically as well-demarcated foci of markedly thickened folded epithelium that formed keratin-filled shallow cuplike structures. Large keratinocytes that contained a swollen nucleus surrounded by a clear cytoplasmic halo (koilocytes) were common, suggesting a diagnosis of a papillomavirus-induced papillomas, and papillomavirus antigen was demonstrated by immunohistochemistry. The papillomas exhibited diffuse intense cytoplasmic and nuclear immunoreactivity against cyclin-dependent kinase inhibitor 2A protein (also known as p16 or INK4a protein). Felis catus papillomavirus type 1 DNA sequences were amplified from both papillomas. The papillomas resolved in 1 cat within 3 months of diagnosis, while the papillomas were still visible 4 months after diagnosis in the other cat. This is the first evidence that these papillomas are caused by F. catus papillomavirus type 1.

Development and psychometric validation of a Health Literacy in Dentistry scale (HeLD)

BACKGROUND

Oral health literacy is emerging as a new public health challenge and poor oral health literacy is increasingly seen as an important predictor of poor oral health outcomes. Within Indigenous populations, there may be benefits to research in using a culturally acceptable, internally consistent and valid instrument to assess oral health literacy. We translated a general health literacy measure, the Health Literacy Management (HeLM) scale to make a dentally relevant scale; Health Literacy in Dentistry (HeLD).

OBJECTIVE

This study describes the development and assessment of the reliability and validity of the HeLD in an Indigenous Australian population.

DESIGN AND METHODS

The 29 item HeLD scale assesses the components of oral health literacy. The reliability and validity of the seven HeLD subscales were evaluated in a convenience sample of 209 Indigenous Australians with mean age 35 years (range 17-81) and of which 139 were female.

RESULTS

The scale was supported by exploratory factor analysis and established seven distinct and internally consistent domains of oral health literacy: Communication, Access, Receptivity, Understanding, Utilisation, Support and Economic Barriers (Cronbach's alpha = 0.91). Discriminative ability was confirmed by HeLD associations with socio-demographic variables and self-reported health ratings in the expected direction. The convergent validity and predictive validity were confirmed by HeLD scores being significantly associated with toothbrush ownership, use of a toothbrush, time since last dental visit and knowledge of the effect of cordial on the teeth.

CONCLUSIONS

The HeLD appears to be an internally valid and reliable instrument and can be used for measuring oral health literacy among rural Indigenous Australian adults.

The interaction of octopamine and neuropeptides to slow aversive responses in C. elegans mimics the modulation of chronic pain in mammals

Octopamine (OA) appears to function as the invertebrate counterpart of norepinephrine (NE) in the modulation of a number of key behaviors. In C. elegans, OA signaling is complex, mediated by at least three distinct α-adrenergic-like receptors and appears to activate more global peptidergic signaling cascades that have the potential to dramatically amplify the octopaminergic signal. These OA-dependent peptidergic signaling cascades involve an array of neuropeptides that activate receptors throughout the nervous system and have the potential to both directly and indirectly modulate locomotory decision-making. In this commentary we highlight the use of C. elegans as a model to expand our understanding of noradrenergic signaling in mammals, specifically as it relates to the role of NE in anti-nociception.

Immunomodulatory effects of vitamin D: implications for GVHD

GVHD remains a major source of morbidity and mortality after allogeneic BMT. GVHD is mediated by alloreactive T cells derived from the hematopoietic graft that target host tissues. Pre-clinical models have shown that presentation of alloantigens by host DCs results in the activation of donor-derived T cells that mediate GVHD. Strategies that interfere with the Ag-presenting capacity of DCs after allogeneic transplantation may decrease the risk of developing GVHD. Vitamin D is a hormone essential for calcium metabolism that shows immunomodulatory properties. We showed that correction of vitamin D deficiency appeared to mitigate manifestations of GVHD. In pre-clinical studies, we have shown that vitamin D inhibits DC maturation, polarizes T-cell populations toward the expression of Th2 as compared with Th1 cytokines, and blunts allogeneic T-cell proliferation in response to DC stimulation. Exposure to vitamin D resulted in increased expression of IDO, an enzyme responsible for tryptophan metabolism that is upregulated in tolerizing DCs. These data suggest that exposure to vitamin D results in immature DC populations that bias toward tolerizing rather than stimulatory T-cell populations. Vitamin D may therefore have a role in the prevention of GVHD.

The efficacy of a commercial ELISA as an alternative to virus neutralisation test for the detection of antibodies to EAV

Infection with equine arteritis virus is a notifiable disease with sporadic occurrence in the UK. As stallions may harbour the virus after infection, horses are screened for exposure by serological testing prior to breeding. The virus neutralisation test is considered the 'gold standard' serological screening test, but it is time-consuming and labour intensive; consequently there is a move towards more rapid screening methodology. In this study, a commercially available EVA antibody ELISA is assessed. The ELISA performed poorly with a specificity [corrected] of 26% and a sensitivity [corrected] of 96% in the samples analysed. It was concluded that this ELISA would be of little value for reducing sample turnaround time. The study emphasises the need for in-house validation of commercially available kits.

Reproduction and Captive Breeding as a Tool for Mammal Conservation: The Role of Modem Zoos

There is a growing awareness in the scientific research community of the role that zoological institutions can play in the conservation of threatened or endangered species. Zoos themselves have changed and become more focussed on the contributions they can make to regional conservation objectives, driven in part by the "World Zoo Conservation Strategy" published in 1993. Perth Zoo has committed itself to this strategy and established a collaborative scientific research program with Conservation and Land Management (CALM), WA, to develop captive breeding techniques for a number of Western Australian native species. To achieve this objective, the zoo has established a sub-program known as the Native Species Breeding Program. This consists of 6 specialist keepers who are charged with developing specialised skills in captive husbandry of selected species, and the implementation of research projects. All of the species under study are part of recovery plans, and many of the species are being produced for release under the objectives of those plans and as part of CALM&apos;s "Western Shield Project". Mammal species under study are the Numbat, Chuditch, Dibbler, Djoongari (Shark Bay Mouse) and the Wopilkara (Greater Stick Nest Rat). Currently, Chuditch, Numbats and Djoongari bred in captivity have been the subject of re-introduction programs. The results of these breeding programs and the subsequent releases of selected species into different habitats in Western Australia will be presented, along with a discussion of the issues which relate to the limitations of captive breeding as a conservation tool.

Growth and Sexual Dimorphism in the Dibbler, Parantechinus apicalis (Marsupialia, Dasyuridae)

Sexual dimorphism in animals has been recognised as being associated with particular breeding strategies or mating systems since Darwin&apos;s Origin of Species. Frequently, in polygamous situations, females express a variety of attributes to attract males, and males compete with each other for access to females. This produces different selective pressures in each sex, which in tum produces differing morphologies (Leigh 1995). Thus, the emphasis of morphological studies of sexual differences tends to focus on adults and not the growth patterns that generate those differences. Growth patterns in marsupials have been shown to be variable between species (Gemmell and Hendrikz 1993). Previous studies of dasyurid species in captivity concluded that the onset of dimorphism occurs prior to or during weaning (Whitford, Fanning and White 1982; Williams and Williams 1982), but wild animals are not sexually dimorphic until after weaning (Soderquist 1995). These studies have generally examined the growth rates of males and females and the timing of the onset of sexual dimorphism, but little attention has been focussed on how the differences between the sexes are generated.

Implementing the Agency for Health Care Policy and Research pain management pediatric guideline in a multicultural practice setting

This article describes the implementation, monitoring, and evaluation of a clinical practice guideline for managing pediatric patient pain. The standard of care used was the Agency for Health Care Policy and Research acute pain management guideline. It was used to assess current levels of care and to make recommendations for improvements. Information was gathered from a sample of 240 pediatric patients aged 1 week to 14 years. Recommendations for improving care are given. The guideline was found to be clinically useful as a general standard of care, but more work needs to be done to individualize care for specific populations, age groups, and cultures.

The incidence of hip fractures in Maori and non-Maori in New Zealand

AIMS

To investigate the incidence of hip fractures in Maori and nonMaori in New Zealand.

METHODS

The number of femoral neck fractures in patients over 60 in New Zealand for the years 1989-91 were obtained. The population data for 1991 was obtained from the 1990 census. The number of fractures was standardised for age, and the rate of fractures per 100,000 of population calculated.

RESULTS

The age standardised rates of hip fracture per 100,000 of population 1989-91 for Maori males was 197, Maori females 516, nonMaori males 288 and nonMaori females 827. These rates were higher than the rates recorded between 1973 and 1975.

CONCLUSIONS

The age-specific hip fracture rate is rising in New Zealand. However in Maori males the rate is not rising.

Structural similarity between the p17 matrix protein of HIV-1 and interferon-gamma

The human immunodeficiency virus (HIV) matrix protein, p17, forms the outer shell of the core of the virus, lining the inner surface of the viral membrane. The protein has several key functions. It orchestrates viral assembly via targeting signals that direct the gag precursor polyprotein, p55, to the host cell membrane and it interacts with the transmembrane protein, gp41, to retain the env-encoded proteins in the virus. In addition, p17 contains a nuclear localization signal that directs the preintegration complex to the nucleus of infected cells. This permits the virus to infect productively non-dividing cells, a distinguishing feature of HIV and other lentiviruses. We have determined the solution structure of p17 by nuclear magnetic resonance (NMR) with a root-mean square deviation for the backbone of the well-defined regions of 0.9 A. It consists of four helices connected by short loops and an irregular, mixed beta-sheet which provides a positively charged surface for interaction with the inner layer of the membrane. The helical topology is unusual; the Brookhaven protein database contains only one similar structure, that of the immune modulator interferon-gamma.

Candida albicans vertebral osteomyelitis in chronic renal failure

Invasive candidal infections are encountered with increasing frequency in compromised hosts but bone infection is uncommon. A woman with systemic lupus erythematosus and end-stage renal failure managed by continuous ambulatory peritoneal dialysis developed a painful thoracic kyphosis and a lytic lesion in the vertebral bodies of T10 and T11. Blood cultures were sterile but bone biopsy material contained Candida albicans which also grew on culture. Circulating immune complexes were measured in high levels and contained candida antigens and specific anti-candida antibody as determined by isoelectric focusing, immunoblotting and immunoprinting techniques. Pain persisted after anti-fungal therapy had sterilized the lesion necessitating surgical excision of affected vertebrae, kyphosis correction and iliac crest bone grafting. The titres of circulating immune complexes and anti-candidal precipitins closely paralleled the clinical course.

The precordial ECG belt for obtaining rapid reproducible precordial leads

A new, stretchable precordial ECC belt is described. It represents an excellent method for obtaining reproducible, accurate precordial ECGs and is especially useful in women and individuals with abnormal chest configurations.

Liquid protein diets and torsade de pointes

Three women, aged 27, 33, and 35 years, experienced recurrent syncope five months after losing 36 to 41 kg using liquid protein diets. No abnormalities were noted during physical examination except in one who was hypothyroid. Serum potassium levels varied between 2.9 and 3.9 mEq/liter. The ECGs demonstrated prominent U waves, QUc prolongation, and ST and T wave abnormalities, with left axis deviation in two patients. Syncopal episodes were due to ventricular tachycardia and fibrillation, which were not responsive to conventional antiarrhythmic agents used in two patients. Patients using liquid protein diets may thus experience reversible QUc prolongation giving rise to serious arrhythmias that are probably best treated with drugs that shorten the QTc interval. Caution should be exercised in the use of liquid protein diets for weight reduction in obesity.