Microfluidic affinity selection of active SARS-CoV-2 virus particles

We report a microfluidic assay to select active severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral particles (VPs), which were defined as intact particles with an accessible angiotensin-converting enzyme 2 receptor binding domain (RBD) on the spike (S) protein, from clinical samples. Affinity selection of SARS-CoV-2 particles was carried out using injection molded microfluidic chips, which allow for high-scale production to accommodate large-scale screening. The microfluidic contained a surface-bound aptamer directed against the virus's S protein RBD to affinity select SARS-CoV-2 VPs. Following selection (~94% recovery), the VPs were released from the chip's surface using a blue light light-emitting diode (89% efficiency). Selected SARS-CoV-2 VP enumeration was carried out using reverse transcription quantitative polymerase chain reaction. The VP selection assay successfully identified healthy donors (clinical specificity = 100%) and 19 of 20 patients with coronavirus disease 2019 (COVID-19) (95% sensitivity). In 15 patients with COVID-19, the presence of active SARS-CoV-2 VPs was found. The chip can be reprogrammed for any VP or exosomes by simply changing the affinity agent.

Liquidscan mediated HER2 amplification detection in patient samples study

e13016

Background: Overexpression of HER2 serves as an oncogenic driver in breast cancer which can result in tumor progression and distant metastases. Amplification or overexpression of HER2 occurs in approximately 15–30% of breast cancers and serves as a therapeutic, prognostic and predictive biomarker. There have been tremendous advances in HER2+ breast cancer management and there is an need to identify patients with HER2+ early breast cancer who may benefit from de-escalation or escalation of treatment. In addition, selection of HER2 therapies beyond the 2nd line setting for HER2+ metastatic breast cancer is currently unclear. Therefore, rapid monitoring tests for treatment response are needed. Liquid biopsy may provide a cost effective, sensitive, and non-invasive approach to monitor response. Methods: Whole blood (8ml) from 20 consenting patients with confirmed stage 3 or 4 metastatic breast cancer with clinical Her2 status identified by solid tissue biopsy (10 HER2+ and 10 HER2-) were collected. Circulating tumor cells were isolated on the LiquidScan system, were probed by HER2 FISH, analyzed using automated and visual microscopy. Results: Protocols were optimized to obtain morphology and cellularity of the tumor cells allowing conclusive HER2 identification for all samples. All samples from patients identified as Her2+ by standard invasive solid tumor biopsies could be identified (100% concordance), whereas for one sample that was reported as HER2-, cells were identified with the liquid biopsy having HER2+ FISH morphology. Further molecular analysis on this patient is under way. Conclusions: We were able to demonstrate that non-invasive liquid biopsy with the LiquidScan identifies HER2 status. The method has high concordance with conventional solid biopsy approach and may be a promising for patient monitoring. We will expand to larger sample sets to explore the full capacity of liquid biopsy to monitor and diagnose HER2 related diseases.

Identification of fetal aneuploidy with dual-probe fluorescence in situ hybridization analysis in circulating trophoblasts after enrichment using a high-sensitivity microfluidic platform

OBJECTIVE

To evaluate a microfluidics-based positive selection technology for isolating circulating trophoblasts (CTs) from peripheral blood of women whose pregnancies are affected by aneuploidy and to evaluate fetal karyotype using fluorescence in situ hybridization (FISH).

METHOD

Ten 18-ml samples of peripheral blood were collected consecutively from pregnant women whose fetus was affected by aneuploidy. A preservation buffer was added, and the specimens were shipped overnight to the testing laboratory at ambient temperature. The specimen was infused into the fully automated microfluidics-based LiquidScan^® instrument without pre-processing. This instrument contains microfluidic chips, which are coated with antibodies (anti-huEpCAM and a proprietary antibody mixture) specific to CT surface epitopes. FISH analysis was performed on the enriched cells.

RESULTS

Fetal aneuploidy evaluated included trisomy 21 (n = 3), trisomy 18 (n = 1), trisomy 13 (n = 1), monosomy X (n = 3), and triploidy (n = 1). CTs for analysis by FISH were identified in all samples. The average number of mononucleate cells per 1 ml of whole blood was 2.11 (range 0.38-4.63) overall and was 2.67 (range 1.13-4.63) using the proprietary combination of antibodies. FISH results were concordant with the aneuploidy based on other testing in all cases. Multinucleate cells were searched for and identified in the last seven samples (average number: 0.84/1 ml).

CONCLUSIONS

Our study demonstrates that the LiquidScan^® , a high-sensitivity microfluidic platform, can enrich circulating trophoblasts (mononucleate and multinucleate). FISH can then be used to detect fetal aneuploidy.

The key components of a successful model of midwifery-led continuity of carer, without continuity at birth: findings from a qualitative implementation evaluation

BACKGROUND

Recent UK maternity policy changes recommend that a named midwife supports women throughout their pregnancy, birth and postnatal care. Whilst many studies report high levels of satisfaction amongst women receiving, and midwives providing, this level of continuity of carer, there are concerns some midwives may experience burnout and stress. In this study, we present a qualitative evaluation of the implementation of a midwife-led continuity of carer model that excluded continuity of carer at the birth.

METHODS

Underpinned by the Conceptual Model for Implementation Fidelity, our evaluation explored the implementation, fidelity, reach and satisfaction of the continuity of carer model. Semi-structured interviews were undertaken with midwives (n = 7) and women (n = 15) from continuity of carer team. To enable comparisons between care approaches, midwives (n = 7) and women (n = 10) from standard approach teams were also interviewed. Interviews were recorded, transcribed and analysed using thematic analysis.

RESULTS

For continuity of carer team midwives, manageable caseloads, extended appointment times, increased team stability, and flexible working patterns facilitated both care provided and midwives' job satisfaction. Both continuity of carer and standard approach midwives reported challenges in providing postnatal continuity given the unpredictable timing of labour and birth. Time constraints, inadequate staffing and lack of administrative support were reported as additional barriers to implementing continuity of carer within standard approach teams. Women reported continuity was integral to building trust with midwives, encouraged them to disclose mental health issues and increased their confidence in making birth choices.

CONCLUSIONS

Our evaluation highlighted the successful implementation of a continuity of carer model for ante and postnatal care. Despite exclusion of the birth element in the model, both women and midwives expressed high levels of satisfaction in comparison to women and midwives within the standard approach. Implementation successes were largely due to structural and resource factors, particularly the combination of additional time and smaller caseloads of women. However, these resources are not widely available within the resources of maternity unit budgets. Future research should further explore whether a continuity of carer model focusing on antenatal and postnatal care delivery is a feasible and sustainable model of care for all women.

Characteristics of Vibrio vulnificus isolates from clinical and environmental sources

Researchers have developed multiple methods to characterize clinical and environmental strains of Vibrio vulnificus. The aim of our study was to use four assays to detect virulence factors in strains from infected patients and those from surface waters/sediments/oysters of South Carolina and the Gulf of Mexico. Vibrio vulnificus strains from clinical (n = 81) and environmental (n = 171) sources were tested using three real-time PCR methods designed to detect polymorphisms in the 16S rRNA, vcg and pilF genes and a phenotypic method, the ability to ferment D-mannitol. Although none of the tests correctly categorized all isolates, the differentiation between clinical and environmental isolates was similar for the pilF, vcgC/E and 16S rRNA assays, with sensitivities of 74.1-79.2% and specificities of 77.4-82.7%. The pilF and vcgC/E assays are comparable in efficacy to the widely used 16S rRNA method, while the D-mannitol fermentation test is less discriminatory (sensitivity = 77.8%, specificity = 61.4%). Overall percent agreement for the D-mannitol fermentation method was also lower (66.7%) than overall percent agreement for the 3 molecular assays (78.0%-80.2%). This study demonstrated, using a large, diverse group of Vibrio vulnificus isolates, that three assays could be used to distinguish most clinical vs environmental isolates; however, additional assays are needed to increase accuracy.

Use of progression criteria to support monitoring and commissioning decision making of public health services: lessons from Better Start Bradford

BACKGROUND

Commissioning and monitoring of community-based interventions is a challenge due to the complex nature of the environment and the lack of any explicit cut-offs to guide decision making. At what point, for example, is participant enrolment to interventions, course completion or satisfaction deemed to be acceptable or sufficient for continued funding? We aimed to identify and quantify key progression criteria for fourteen early years interventions by (1) agreeing the top three criteria for monitoring of successful implementation and progress; and (2) agreeing boundaries to categorise interventions as 'meeting anticipated target' (green); 'falling short of targets' (amber) and 'targets not being met' (red).

METHODS

We ran three workshops in partnership with the UK's Big Lottery Fund commissioned programme 'Better Start Bradford' (implementing more than 20 interventions to improve the health, wellbeing and development of children aged 0-3) to support decision making by agreeing progression criteria for the interventions being delivered. Workshops included 72 participants, representing a range of professional groups including intervention delivery teams, commissioners, intervention-monitoring teams, academics and community representatives. After discussion and activities, final decisions were submitted using electronic voting devices. All participants were invited to reconsider their responses via a post-workshop questionnaire.

RESULTS

Three key progression criteria were assigned to each of the 14 interventions. Overall, criteria that participants most commonly voted for were recruitment, implementation and reach, but these differed according to each intervention. Cut-off values used to indicate when an intervention moved to 'red' varied by criteria; the lowest being for recruitment, where participants agreed that meeting less than 65% of the targeted recruitment would be deemed as 'red' (falling short of target).

CONCLUSIONS

Our methodology for monitoring the progression of interventions has resulted in a clear pathway which will support commissioners and intervention teams in local decision making within the Better Start Bradford programme and beyond. This work can support others wishing to implement a formal system for monitoring the progression of public health interventions.

Temporal and Environmental Factors Driving Vibrio Vulnificus and V. Parahaemolyticus Populations and Their Associations With Harmful Algal Blooms in South Carolina Detention Ponds and Receiving Tidal Creeks

Incidences of harmful algal blooms (HABs) and Vibrio infections have increased over recent decades. Numerous studies have tried to identify environmental factors driving HABs and pathogenic Vibrio populations separately. Few have considered the two simultaneously, though emerging evidence suggests that algal blooms enhance Vibrio growth and survival. This study examined various physical, nutrient, and temporal factors associated with incidences of HABs, V. vulnificus, and V. parahaemolyticus in South Carolina coastal stormwater detention ponds, managed systems where HABs often proliferate, and their receiving tidal creek waters. Five blooms occurred during the study (2008-2009): two during relatively warmer months (an August 2008 cyanobacteria bloom and a November 2008 dinoflagellate bloom) followed by increases in both Vibrio species and V. parahaemolyticus, respectively, and three during cooler months (December 2008 through February 2009) caused by dinoflagellates and euglenophytes that were not associated with marked changes in Vibrio abundances. Vibrio concentrations were positively and significantly associated with temperature and dissolved organic matter, dinoflagellate blooms, negatively and significantly associated with suspended solids, but not significantly correlated with chlorophyll or nitrogen. While more research involving longer time series is needed to increase robustness, findings herein suggest that certain HAB species may augment Vibrio occurrences during warmer months.

A cluster randomised controlled trial and economic evaluation of a structured training programme for caregivers of inpatients after stroke: the TRACS trial

BACKGROUND

The majority of stroke patients are discharged home dependent on informal caregivers, usually family members, to provide assistance with activities of daily living (ADL), including bathing, dressing and toileting. Many caregivers feel unprepared for this role and this may have a detrimental effect on both the patient and caregiver.

OBJECTIVE

To evaluate whether or not a structured, competency-based training programme for caregivers [the London Stroke Carer Training Course (LSCTC)] improved physical and psychological outcomes for patients and their caregivers after disabling stroke, and to determine if such a training programme is cost-effective.

DESIGN

A pragmatic, multicentre, cluster randomised controlled trial.

SETTING

Stratified randomisation of 36 stroke rehabilitation units (SRUs) to the intervention or control group by geographical region and quality of care.

PARTICIPANTS

A total of 930 stroke patient and caregiver dyads were recruited. Patients were eligible if they had a confirmed diagnosis of stroke, were medically stable, were likely to return home with residual disability at the time of discharge and had a caregiver available, willing and able to provide support after discharge. The caregiver was defined as the main person--other than health, social or voluntary care provider--helping with ADL and/or advocating on behalf of the patient.

INTERVENTION

The intervention (the LSCTC) comprised a number of caregiver training sessions and competency assessment delivered by SRU staff while the patient was in the SRU and one recommended follow-up session after discharge. The control group continued to provide usual care according to national guidelines. Recruitment was completed by independent researchers and participants were unaware of the SRUs' allocation.

MAIN OUTCOME MEASURES

The primary outcomes were self-reported extended ADL for the patient and caregiver burden measured at 6 months after recruitment. Secondary outcomes included quality of life, mood and cost-effectiveness, with final follow-up at 12 months.

RESULTS

No differences in primary outcomes were found between the groups at 6 months. Adjusted mean differences were -0.2 points [95% confidence interval (CI) -3.0 to 2.5 points; p = 0.866; intracluster correlation coefficient (ICC) = 0.027] for the patient Nottingham Extended Activities of Daily Living score and 0.5 points (95% CI -1.7 to 2.7 points; p = 0.660; ICC = 0.013) for the Caregiver Burden Scale. Furthermore, no differences were detected in any of the secondary outcomes. Intervention compliance varied across the units. Half of the participating centres had a compliance rating of > 60%. Analysis showed no evidence of higher levels of patient independence or lower levels of caregiver burden in the SRUs with better levels of intervention compliance. The economic evaluation suggests that from a patient and caregiver perspective, health and social care costs, societal costs and outcomes are similar for the intervention and control groups at 6 months, 12 months and over 1 year.

CONCLUSIONS

We have conducted a robust multicentre, cluster randomised trial, demonstrating for the first time that this methodology is feasible in stroke rehabilitation research. There was no difference between the LSCTC and usual care with respect to improving stroke patients' recovery, reducing caregivers' burden, or improving other physical and psychological outcomes, nor was it cost-effective compared with usual care. Compliance with the intervention varied, but analysis indicated that a dose effect was unlikely. It is possible that the immediate post-stroke period may not be the ideal time for the delivery of structured training. The intervention approach might be more relevant if delivered after discharge by community-based teams.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49208824.

FUNDING

This project was funded by the MRC and is managed by the NIHR (project number 09/800/10) on behalf of the MRC-NIHR partnership, and will be published in full in Health Technology Assessment; Vol. 17, No. 46. See the NIHR Journals Library website for further project information.

Introducing structured caregiver training in stroke care: findings from the TRACS process evaluation study

OBJECTIVE

To evaluate the process of implementation of the modified London Stroke Carers Training Course (LSCTC) in the Training Caregivers After Stroke (TRACS) cluster randomised trial and contribute to the interpretation of the TRACS trial results. The LSCTC was a structured competency-based training programme designed to help develop the knowledge and skills (eg, patient handling or transfer skills) essential for the day-to-day management of disabled survivors of stroke. The LSCTC comprised 14 components, 6 were mandatory (and delivered to all) and 8 non-mandatory, to be delivered based on individual assessment of caregiver need.

DESIGN

Process evaluation using non-participant observation, documentary analysis and semistructured interviews.

PARTICIPANTS

Patients with stroke (n=38), caregivers (n=38), stroke unit staff (n=53).

SETTINGS

10 of the 36 stroke units participating in the TRACS trial in four English regions (Yorkshire, North West, South East and South West, Peninsula).

RESULTS

Preparatory cascade training on delivery of the LSCTC did not reach all staff and did not lead to multidisciplinary team (MDT) wide understanding of, engagement with or commitment to the LSCTC. Although senior therapists in most intervention units observed developed ownership of the LSCTC, MDT working led to separation rather than integration of delivery of LSCTC elements. Organisational features of stroke units and professionals' patient-focused practices limited the involvement of caregivers. Caregivers were often invited to observe therapy or care being provided by professionals but had few opportunities to make sense of, or to develop knowledge and stroke-specific skills provided by the LSCTC. Where provided, caregiver training came very late in the inpatient stay. Assessment and development of caregiver competence was not commonly observed.

CONCLUSIONS

Contextual factors including service improvement pressures and staff perceptions of the necessity for and work required in caregiver training impacted negatively on implementation of the caregiver training intervention. Structured caregiver training programmes such as the LSCTC are unlikely to be practical in settings with short inpatient stays. Stroke units where early supported discharge is in place potentially offer a more effective vehicle for introducing competency based caregiver training.

LINKED TRACS CLUSTER RANDOMISED CONTROLLED TRIAL NUMBER

ISRCTN49208824.

Health services use in eating disorders

BACKGROUND

This study examined healthcare services used by adults diagnosed with an eating disorder (ED) in a large health maintenance organization in the Pacific Northwest.

METHOD

Electronic medical records were used to collect information on all out-patient and in-patient visits and medication dispenses, from 2002 to 2004, for adults aged 18-55 years who received an ED diagnosis during 2003. Healthcare services received the year prior to, and following, the receipt of an ED diagnosis were examined. Cases were matched to five comparison health plan members who had a health plan visit close to the date of the matched case's ED diagnosis.

RESULTS

Incidence of EDs (0.32% of the 104,130 females, and 0.02% of the 93,628 males) was consistent with prior research employing treatment-based databases, though less than community-based samples. Most cases (50%) were first identified during a primary-care visit and psychiatric co-morbidity was high. Health services use was significantly elevated in all service sectors among those with an ED when compared with matched controls both in the year preceding and that following the receipt of the incident ED diagnosis. Contrary to expectations, healthcare utilization was found to be similarly high across the spectrum of EDs (anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified).

CONCLUSIONS

The elevation in health service use among women both before and after diagnosis suggests that EDs merit identification and treatment efforts commensurate with other mental health disorders (e.g. depression) which have similar healthcare impact.

Cell culture modeling of specialized tissue: identification of genes expressed specifically by follicle-associated epithelium of Peyer's patch by expression profiling of Caco-2/Raji co-cultures

Peyer's patch follicle-associated epithelium (FAE) regulates intestinal antigen access to the immune system in part through the action of microfold (M) cells which mediate transcytosis of antigens and microorganisms. Studies on M cells have been limited by the difficulties in isolating purified cells, so we applied TOGA mRNA expression profiling to identify genes associated with the in vitro induction of M cell-like features in Caco-2 cells and tested them against normal Peyer's patch tissue for their expression in FAE. Among the genes identified by this method, laminin beta3, a matrix metalloproteinase and a tetraspan family member, showed enriched expression in FAE of mouse Peyer's patches. Moreover, the C. perfringens enterotoxin receptor (CPE-R) appeared to be expressed more strongly by UEA-1(+) M cells relative to neighboring FAE. Expression of the tetraspan TM4SF3 gene and CPE-R was also confirmed in human Peyer's patch FAE. Our results suggest that while the Caco-2 differentiation model is associated with some functional features of M cells, the genes induced may instead reflect the acquisition of a more general FAE phenotype, sharing only select features with the M cell subset.

Sub-types of deep dyslexia: a case study of central deep dyslexia

A case study is reported of a female patient (JAH), who following a left middle cerebral artery infarct, presented with the cardinal symptoms of deep dyslexia and deep dysphasia (semantic errors when reading and repeating words aloud, respectively). Detailed assessment revealed impaired performance across modalities for many tasks, but particularly those tasks that depend on an intact store of semantic knowledge. Her acquired dyslexia is best characterised as deep dyslexia of a central sub-type.

Peptidoglycan recognition protein expression in mouse Peyer's Patch follicle associated epithelium suggests functional specialization

Mammalian Peyer's Patches possess specialized epithelium, the follicle associated epithelium (FAE), and specialized cells called M cells which mediate transcytosis of antigens to underlying lymphoid tissue. To identify FAE specific genes, we used TOGA gene expression profiling of microdissected mouse Peyer's Patch tissue. We found expression of laminin beta3 across the FAE, and scattered expression of peptidoglycan recognition protein (PGRP)-S. Using the M cell specific lectin Ulex europaeus agglutinin 1 (UEA-1), PGRP-S expression was nearly exclusively co-localized with UEA-1+ M cells. By contrast, the related gene PGRP-L was expressed among a subset of UEA-1 negative FAE cells. Expression of these proteins in transfected cells demonstrated distinct subcellular localization. PGRP-S showed a vesicular pattern and extracellular secretion, while PGRP-L showed localization to both the cytoplasm and the cell surface. The potential function of these PGRP proteins as pattern recognition receptors and their distinctive cellular distribution suggests a complex coordination among specialized cells of the FAE in triggering mucosal immunity and innate immune responses.

Travoprost compared with latanoprost and timolol in patients with open-angle glaucoma or ocular hypertension

PURPOSE

This study evaluated the safety and intraocular pressure-lowering efficacy of two concentrations of travoprost (0.0015% and 0.004%) compared with latanoprost 0.005% and timolol 0.5% in patients with open-angle glaucoma or ocular hypertension.

METHODS

Eight hundred one patients with open-angle glaucoma or ocular hypertension were randomly assigned to travoprost 0.0015%, travoprost 0.004%, latanoprost 0.005%, or timolol 0.5%. The efficacy and safety of travoprost (0.0015% and 0.004%) daily was compared with latanoprost daily and timolol twice daily for a period of 12 months.

RESULTS

Travoprost was equal or superior to latanoprost and superior to timolol with mean intraocular pressure over visits and time of day ranging from 17.9 to 19.1 mm Hg (travoprost 0.0015%), 17.7 to 19.1 mm Hg (travoprost 0.004%), 18.5 to 19.2 mm Hg (latanoprost), and 19.4 to 20.3 mm Hg (timolol). For all visits pooled, the mean intraocular pressure at 4 PM for travoprost was 0.7 mm Hg (0.0015%, P =.0502) and 0.8 mm Hg (0.004%, P =.0191) lower than for latanoprost. Travoprost 0.004% was more effective than latanoprost and timolol in reducing intraocular pressure in black patients by up to 2.4 mm Hg (versus latanoprost) and 4.6 mm Hg (versus timolol). Based on a criterion of 30% or greater intraocular pressure reduction from diurnal baseline or intraocular pressure 17 mm Hg or less, travoprost 0.0015% and 0.004% had an overall response to treatment of 49.3% and 54.7%, respectively, compared with 49.6% for latanoprost and 39.0% for timolol. Iris pigmentation change was observed in 10 of 201 of patients (5.0%) receiving travoprost 0.0015%, six of 196 of patients (3.1%) receiving travoprost 0.004%, 10 of 194 of patients (5.2%) receiving latanoprost, and none of the patients receiving timolol (0 of 196). The average ocular hyperemia score was less than 1 on a scale of 0 to 3, indicating that on average patients experienced between none/trace and mild for all treatment groups. There were no serious, unexpected, related adverse events reported for any therapy.

CONCLUSIONS

Travoprost (0.0015% and 0.004%), a highly selective, potent prostaglandin F (FP) receptor agonist, is equal or superior to latanoprost and superior to timolol in lowering intraocular pressure in patients with open-angle glaucoma or ocular hypertension. In addition, travoprost 0.004% is significantly better than either latanoprost or timolol in lowering intraocular pressure in black patients. Travoprost is safe and generally well tolerated in the studied patient population.

Subarachnoid-pleural fistula treated with noninvasive positive-pressure ventilation. Case report

The authors describe the case of a 24-year-old man who underwent an L-1 corpectomy for spinal decompression and stabilization following an injury that caused an L-1 burst fracture. Postoperatively, an accumulation of spinal fluid developed in the pleural space, which was refractory to 1 week of thoracostomy tube drainage and lumbar cerebrospinal fluid (CSF) diversion. The authors then initiated a regimen of positive-pressure ventilation in which a bi-level positive airway pressure (PAP) mask was used. After 5 days, the CSF collection in the pleural space resolved. Use of a bi-level PAP mask represents a safe, noninvasive method of reducing the negative intrathoracic pressure that promotes CSF leakage into the pleural cavity and may be a useful adjunct in the treatment of subarachnoid-pleural fistula.

Malignant melanoma of the foot and ankle

Malignant melanoma is a serious and devastating skin disease that podiatrists may be called upon to treat. It is pertinent that delays in diagnosis and treatment of malignant melanoma be avoided. Some of the topics discussed in this article are causes, clinical features, classification, and treatment of malignant melanoma, focusing on the foot and ankle.

Gait and postural stability in obese and nonobese prepubertal boys

OBJECTIVE

To examine differences in gait and postural stability of obese and nonobese prepubertal boys.

DESIGN

Percentage of gait cycle in double support was examined to determine significant differences. Postural stability was compared using temporal and frequency measures of the center of pressure in static stance.

SETTING

Gait was examined using videography on a 30-meter walkway. Postural stability was examined using a measurement platform.

PARTICIPANTS

Ten obese (>95th percentile in body mass index) and 10 nonobese (15th to 90th percentile in body mass index) prepubertal boys aged 8 to 10yrs.

INTERVENTION

Participants were examined at three walking cadences as determined by preferred gait cadence. Full vision, darkness, and visually confused conditions were used to accentuate static postural stability differences.

MAIN OUTCOME MEASURES

In the presence of dynamic stability differences (gait), static stability measures further investigated stability differences.

RESULTS

Obese boys spent significantly (p < .02) greater percentage of gait cycle in dual stance. Obese boys showed significantly (p < .01) greater sway areas, energy, and variability primarily in the medial/lateral direction.

CONCLUSIONS

Dual stance differences suggest diminished dynamic stability in obese boys. Greater sway areas in medial/lateral direction in obese boys and the absence of significant frequency measures suggest that the instability observed in obese boys is caused by excess weight rather than underlying postural instability.

Percutaneous retrogasserian glycerol rhizolysis for treatment of chronic intractable cluster headaches: long-term results

OBJECTIVE

To analyze the long-term effectiveness and safety of percutaneous retrogasserian glycerol rhizolysis (PRGR) in the treatment of medically refractive chronic cluster headache (CH). The current mainstay of surgical intervention for these patients is percutaneous radiofrequency retrogasserian rhizotomy (PRFR). However, when performed for V1 distribution pathology, PRFR can lead to corneal anesthesia, which places the patient at risk for future visual loss. It also increases the risk of facial dysesthesia.

METHODS

In a prospective, consecutive series, 18 patients with intractable CH were followed for a mean of 5.2 years (range, 40-78 mo) after they had undergone PRGR, performed using a standard technique. The significance of this technique as an alternative to PRFR is that it should result in a lower rate of both corneal and facial anesthesia and provide an acceptable degree of pain relief.

RESULTS

Fifteen patients (83%) obtained immediate pain relief after one or two injections; the majority of them experienced relief after the first injection. CH recurred in seven patients (39%) over the course of the study. Two of these patients received a second injection, and both met with equal success. Two other patients underwent PRFR. Excluding those who underwent PRFR, the overall daily headache frequency decreased from 3.5 +/- 0.3 attacks per day preoperatively to 0.6 +/- 0.2 attacks per day at last follow-up. The severity of these headaches, as assessed by verbal pain scales, also decreased from 10 preoperatively to 4.4 +/- 1.4 at follow-up. None of the patients, including those who required a second procedure, experienced corneal anesthesia or facial dysesthesia.

CONCLUSION

This study provides the first long-term evaluation of PRGR for the treatment of medically refractive chronic CH and lends support to both the safety and long-term efficacy of this procedure. Further investigations are needed to compare directly the relative efficacy and safety of PRGR and PRFR.

Survival and functional outcome after prolonged intensive care unit stay

OBJECTIVE

To examine the functional outcome and costs of a prolonged illness requiring a stay in the surgical intensive care unit (SICU) of 7 of more days.

SUMMARY BACKGROUND DATA

The long-term benefits and costs after a prolonged SICU stay have not been well studied.

METHODS

All patients with an SICU length of stay of 7 or more days from July 1, 1996, to June 30, 1997, were enrolled. One hundred twenty-eight patients met the entry criteria, and mortality status was known in 127. Functional outcome was determined at baseline and at 1, 3, 6, and 12 months using the Sickness Impact Profile score, which ranges from 0 to 100, with a score of 30 being severely disabled. Hospital costs for the index admission and for all readmissions to Johns Hopkins Hospital were obtained. All data are reported as median values.

RESULTS

For the index admission, age was 57 and APACHE II score was 23. The initial length of stay in the ICU was 11 days; the hospital length of stay was 31 days. The Sickness Impact Profile score was 20.2 at baseline, 42.9 at 1 month, 36.2 at 3 months, and 20.3 at 6 months, and was lower than baseline at 1 year. The actual 1-year survival rate was 45.3%. The index admission median cost was $85,806, with 65 total subsequent admissions to this facility. The cost for a single 1-year survivor was $282,618 (1996).

CONCLUSIONS

An acute surgical illness that results in a prolonged SICU stay has a substantial in-hospital death rate and is costly, but the functional outcome from both a physical and physiologic standpoint is compatible with a good quality of life.

Effects of damp and mould in the home on respiratory health: a review of the literature

This review examines whether there is a direct or indirect relation between damp or mould in the home and respiratory health. Home dampness is thought to have health consequences because it has the potential to increase the proliferation of house-dust mites and moulds, both of which are allergenic. The results from the many studies conducted to investigate whether damp and mould are associated with health outcomes are difficult to compare because the methods of measuring exposures and health outcomes have not been standardized. However, the studies that have been conducted in children are probably the most reliable because the confounding effects of active smoking or occupational exposures are absent, and because the presence of symptoms of cough and wheeze have been consistently investigated in many studies. The increased risk of children having these symptoms if the home has damp or mould is fairly small with an odds ratio that is generally in the range 1.5-3.5, these estimates being statistically significant when the sample size has been large enough. This range is consistent with the measured effects of other environmental exposures which are considered important to health, such as environmental tobacco smoke or outdoor air pollutants. The potential benefits of reducing mould in the home have not been investigated, and the few studies that have investigated health improvements as a result of increasing ventilation or reducing damp in order to reduce house-dust mite levels suggest that this intervention is expensive, requires a large commitment, and is unlikely to be successful in the long term. This implies that houses need to be specifically designed for primary prevention of respiratory problems associated with indoor allergen proliferation rather than using post hoc procedures to improve indoor climate and reduce allergen load as a secondary or tertiary preventive strategy.

Spectral characteristics of postural control in elderly individuals

OBJECTIVE

To examine the feasibility of using spectral analysis techniques to identify potential biomarkers of diminished postural control in elderly individuals.

DESIGN

Data from spectral signatures (derived from postural sway) of 21 young adults and 42 elderly individuals classified as "high" or "low" risk with regard to functional balance capacity were analyzed using Risk Category (3) x Sensory Condition (3) multivariate analyses of variance. Postural control was challenged by varying the visual conditions under which individuals stood on a measurement platform.

RESULTS

Results indicated that measures of central tendency and dispersion of the spectral frequency distribution from medial-lateral components of sway (but not antero-posterior sway) clearly differentiated between "high" and "low" risk elderly. Low risk elderly were not different from young adults. High risk elderly exhibited greater dispersion and lower mean frequency than other groups.

CONCLUSIONS

Differences in spectral characteristics of medial-lateral components of sway were more related to risk category than to age. Elderly persons with high functional balance capacity displayed characteristics similar to those of young adults. Thus, spectral frequency analysis techniques may be a clinically useful tool for identifying individuals potentially at risk of falling.

An increase in hookworm infection temporally associated with ecologic change

This report describes a significant increase in the prevalence of hookworm infection in an area of Haiti where intestinal parasites are common, but hookworm has not been common. Changing environmental conditions, specifically deforestation and subsequent silting of a local river, have caused periodic flooding with deposition of a layer of sandy loam topsoil and increased soil moisture. We speculate that these conditions, conducive to transmission of the infection, have allowed hookworm to reemerge as an important human pathogen.

The problem of hospital-induced malnutrition

This paper discusses the problem of hospital-induced malnutrition. Patients particularly at risk are identified and the causes of PEM are outlined.

Glomerular expression of monocyte chemoattractant protein-1 in experimental and human glomerulonephritis

BACKGROUND

Glomerular monocytes are found in a variety of renal diseases and appear to be important in the pathogenesis of glomerular injury. The mediators responsible for recruiting monocytes to the glomerulus are not well characterized. We have recently established that cultured human mesangial cells produce the specific monocyte chemoattractant, monocyte chemoattractant protein-1 (MCP-1) in response to inflammatory cytokines commonly found in glomeruli during glomerulonephritis (GN). This suggested that MCP-1 may be involved in recruiting leukocytes to the glomerulus. To date however, there is little information regarding the expression of MCP-1 during renal disease. The present study was undertaken to investigate the in vivo expression of MCP-1 during experimental and human GN.

EXPERIMENTAL DESIGN

A rodent model of anti-glomerular basement membrane GN was used to investigate glomerular MCP-1 mRNA regulation and protein expression. The presence of MCP-1 in human renal tissue was studied by immunostaining kidney biopsy material from patients with a variety of glomerulopathies.

RESULTS

MCP-1 mRNA was transiently upregulated during the early stages of experimental GN. Message levels increased in association with the monocyte influx and correlated with expression of immunoreactive MCP-1 in the nephritic glomeruli. Glomerular MCP-1 was also found in human inflammatory glomerulopathies, but not in glomerular diseases lacking a prominent monocyte infiltrate.

CONCLUSIONS

These data support a role for MCP-1 in the pathogenesis of glomerular inflammation.

Spectral signature of forces to discriminate perturbations in standing posture

This study proposes a methodology for the collection and analysis of the spectral characteristics of human movement patterns. Specifically, the purpose of this study was to determine the reliability of the spectral signature obtained from postural forces and the usefulness of the technique in identifying perturbations in standing posture. Data collected included trials of the experimental protocol under normal standing conditions and under three experimental conditions designed to perturb stability. Results of this investigation indicated that spectral signatures created from ground forces using the methodology proposed in this study were highly reliable within individuals and across different testing sessions. These data further indicate that spectral signatures obtained from ground reaction forces during standing provide a sensitive indicator of an individual's postural stability.

The Neurobehavioural Rating Scale: replication in an acute, inpatient rehabilitation setting

The Neurobehavioural Rating Scale (NRS) was developed to allow quantification of clinical observations of the behaviour of individuals following traumatic head injury. Initial validation of this instrument reported satisfactory interobserver reliability, as well as preliminary support for its validity in differentiating both severity and chronicity of head injury. In the present study, reliability and content validity of the NRS were replicated using a population of severe head injury patients undergoing inpatient rehabilitation. Concurrent, independent assessment using the NRS was conducted weekly by two members of an inpatient, traumatic head injury team. Acceptable levels of interobserver reliability were found, despite less control over observed behaviour in the naturalistic setting used. Content validity was also supported in this replication, although recommendations for 'tightening' the NRS included better definition of the seven-point severity rating for each item, as well as potential deletion of two items that contributed little to differential variance in the total NRS score. The NRS appears to be a promising clinical and research tool for assessing the neurobehavioural sequelae of traumatic head injury. Its strengths include efficiency of administration and the flexibility to administer through brief, structured interviews or observations in a naturalistic setting. Continued research on the NRS in different settings and with different populations is required to establish its validity.

Pharmacokinetics of 14C-etretinate in healthy volunteers and two patients with biliary T-tube drainage

The pharmacokinetic profile of 14C-etretinate, a retinoid that is effective in the treatment of psoriasis, was studied in six healthy male volunteers and two biliary T-tube patients. Following a 100 mg oral dose of 14C-etretinate (20 microcurie), etretinate and its major blood metabolites (etretin, isoetretin) were measured by HPLC and total carbon-14 was measured in blood, bile, urine, and feces by liquid scintillation counting. Etretinate was extensively metabolized in healthy volunteers and in T-tube patients. During the absorption phase, 75 per cent of the total radioactivity in the blood could be accounted for as etretinate, etretin, and isoetretin whereas these compounds accounted for only approximately 12 per cent of the blood radioactivity in T-tube patients over the same time period. The blood concentrations of etretinate, etretin, and isoetretin appeared to be substantially reduced in T-tube patients compared to those in healthy volunteers. A higher proportion of the total drug was excreted in the feces and bile of the T-tube patients (84 per cent) than in the feces of healthy volunteers (62 per cent). The major factor responsible for the observed decrease in etretinate blood concentrations following biliary cannulation appears to be the reduced absorption of etretinate due to the elimination of solubilizing bile salts in the duodenum. Carbon-14 related material was detected in urine and feces for as long as 3 weeks in healthy subjects supporting the previous observation that a long terminal elimination half-life exists for etretinate, even following a single dose of the compound.

The quality of life: design and evaluation of a self-assessment instrument for use with cancer patients

An attempt was made to define the concept of 'quality of life' and outline the development of a self-assessment instrument for detecting the changes in life as a whole which result from the presence and treatment of malignant disease. A comparison was made between three different scoring systems, familiar in psychometric assessment, although less familiar in nursing. The items selected for inclusion in the measurement instrument were based on an existing symptom distress scale and on the previously identified concerns of cancer patients. The relationship between such symptoms and the activities of daily living was explored. Each item, and the instrument as a whole, appeared to be reliable and to represent a valid means of assessing the impact of the disease on patient well-being. It was simple to use and straightforward to score and appeared accurately to reflect the patients' general condition.

Comparison of dental crown height in bite impressions

A wax bite impression can serve as a reliable identification of missing and unknown children, particularly in the absence of caries and restorations. Dental crown heights in bite impressions made from noncontoured and contoured wax wafers were compared in ten patients, ranging in age from three to eight years. The contoured wax wafer produced significantly greater crown heights in the casts which were fabricated from it. The differences were most pronounced in the anterior teeth; but generally true for all the teeth.

Babesiosis in Wisconsin. A new focus of disease transmission

A confirmed case of human babesiosis was identified in August 1983 in a 54-year-old asplenic Wisconsin resident. Babesia microti was identified as the causative agent by blood smear morphology and hamster inoculation techniques. The patient's wife had clinically confirmed Lyme disease in 1981 and had serologic evidence (immunofluorescent antibody to a B microti titer of 1:1,024) of recent Babesia infection in August 1983. Mice (Peromyscus species) trapped on the patients' property and elsewhere in their Wisconsin county of residence were infected with B microti. Lyme disease and babesiosis have the same tick vector and animal reservoir; serum samples from 116 Wisconsin and Minnesota residents with clinically confirmed Lyme disease between 1980 and 1983 were tested, and none were found to have concurrent Babesia infection. This area of Wisconsin is identified as a new focus for babesiosis transmission, but the risk of transmission seems to be low.

Liver function tests and low-dose estrogen oral contraceptives

Twenty healthy female volunteers were treated with 35 microgram ethinyl estradiol and 0.4 mg norethindrone for a two-month period of time. Liver function tests (serum SGOT, SGPT, LDH, alkaline phosphatase, total bilirubin, total protein, albumin and prothrombin times) were measured at baseline and control prior to treatment, and at one and two months of therapy. There was a 1.25% incidence of abnormalities in the 320 tests conducted during therapy. During the first month of therapy, there was a 1.9% incidence of abnormal tests. 0.625% incidence of abnormal tests was seen in the second month of treatment. A 5% incidence of abnormalities (single episodes in each parameter) was seen in SGPT, LDH, total bilirubin and prothrombin time levels during the two-month period. This was well below the 10-30% incidence of abnormalities reported with 50-100 microgram of estrogen-containing birth control pills in previous studies. There seems to be little effect on liver function tests with use of estrogen preparations containing 35 microgram ethinyl estradiol.

Efficacy of estradiol vaginal cream in postmenopausal women

In a double-blind parallel study daily intravaginal administration of conjugated estrogen cream and estradiol cream for 14 days relieved vasomotor and vaginal postmenopausal symptoms in 29 postmenopausal women. By day 14, therapy with the estradiol vaginal cream resulted in plasma estrone and estradiol levels closer to those in premenopausal women than therapy with the conjugated estrogen cream. The extent of improvement and final estradiol plasma levels in the estradiol vaginal-cream group correlated. There was no correlation with severity of symptoms or estradiol plasma level at baseline. The metabolism of the conjugated estrogen cream might account for absence of correlation between improvement and final estradiol plasma levels in the conjugated vaginal-cream group.

Dose tolerance and pharmacokinetic studies of L (+) pseudoephedrine capsules in man

Dose tolerance and pharmacokinetic studies of pseudoephedrine sustained action capsules were performed in thirty-three adult male subjects who received either 120 mg or 150 mg capsules every twelve hours for seven consecutive days in a double-blind parallel design study. Although only one subject in the 150 mg group was discontinued prematurely from this study, a large number of side effects typical of CNS stimulation were seen. A placebo effect might account for a portion of these complaints, however symptoms evaluated as being due to drug were significantly more severe and persistent in the 150 mg group. Pulse rates showed a persistent and significant increase while systolic and diastolic blood pressure fell from the baseline values in both groups. A pharmacokinetic analysis of the pseudoephedrine plasma concentration-time data provided estimates of half-life and the volume of distribution/availability ratio. The values obtained were in good agreement with values reported by others. Half-life was not influenced by urine pH probably as a result of the narrow range of urine pHs observed in the subjects. Calculations of relative bioavailability suggest that the 120 mg capsule formulation has a 30% greater bioavailability compared to the 150 mg capsule.

Digoxin bioavailability: formulations and rates of infusions

The bioavailability of digoxin (lanoxin) tablets, oral aqueous solution of digoxin, and capsules containing a solution of digoxin was compared with digoxin given intravenously over 1 and 3 hr. The mean peak serum concentration of digoxin after the 1-hr intravenous infusion was 5 ng/ml, after the 3-hr infusion, 3.5 ng/ml, and after the oral solution, 2.0 ng/ml. There was an equivalent bioavailability of the oral solution and reference tablets of digoxin. The digoxin in capsules tended to be better absorbed than the reference tablets. There was 21% more digoxin excreted over 6 days after the 3 hr iv infusion than after the 1 hr iv infusion. This indicates that the calculated bioavailability of an orally administered dose of digoxin may vary with the rapidity of injection of the intravenous standard. It is estimated that an oral tablet of digoxin of 0.5 mg has about the same bioavailability as 0.35 of digoxin given by slow intravenous infusion (or 0.4 mg if calculated against a rapid intravenous injection).