A67 RISK FACTORS ASSOCIATED WITH CRITICAL CARE AFTER INPATIENT GASTROINTESTINAL ENDOSCOPY: A 5-YEAR TERTIARY HOSPITAL STUDY

Background

A subset of hospitalized patients will require critical care after their gastrointestinal endoscopy (GIE) and predicting which patients are at high risk of requiring critical care remains an important challenge.

Purpose

To identify protective and aggravating clinical risk factors associated with critical care involvement within 7 days of inpatient GIE in adults and to develop a tool that could assist in risk-stratifying patients at high risk of requiring critical care post-endoscopy.

Method

This was a single-centre retrospective case-control study of adult patients who underwent inpatient GIE while admitted to ward-level care at Toronto General Hospital from years 2015 to 2019. Cases were defined by inpatients who required critical care response team and/or critical care admission within 7 days of GIE, compared to control patients who did not require critical care throughout admission. Chart review and linked secondary sources were used with defined inclusion and exclusion criteria. Both univariate and multivariate analyses were performed comparing patient baseline, clinical history (including cardiovascular, respiratory, other co-morbidities) and endoscopy characteristics.

Result(s)

We identified a total of 275 patients with 302 endoscopies as cases and 2069 patient controls who satisfied inclusion criteria. Critical care involvement was most commonly due to cardiovascular-related complications (n=175, 58%) followed by respiratory complications (n=117, 39%). Amongst cases, death occurred in 9 (3%), 25 (9%) and 67 (22%) within 72 hours, 7 days and 30 days respectively post endoscopy. The strongest associations with critical care involvement within 7 days after GIE included a history of discharge from critical care (OR 2.29 CI 1.70-3.04) and/or recent mechanical ventilatory support (OR 2.27 CI 1.30-3.91) in the 30 days prior to endoscopy, having several co-morbidities involving major organ systems (elevated troponin OR 3.20 CI 2.26-4.52, cirrhosis OR 2.5 CI 1.80-3.46, renal dysfunction 2.09 CI 1.57-2.78) and patients admitted under surgical (OR 3.82 CI 2.54-5.71) or transplant services (OR 4.63 CI 2.94-7.26). The majority of adverse events among cases were not found to be complications directly related to GIE (64% unlikely, 20% possible, 9% probable, 7% definite). Patients with a history of pulmonary hypertension (OR 5.68 CI 0.53-60.70) and ASA score III/IV (OR 3.28 CI 1.01-10.73) had the highest odds of probable or definite endoscopy-related adverse events.

Conclusion(s)

This study is the largest to date to examine risk factors associated with critical care requirements post GIE in the tertiary care inpatient setting. The risk factors we have identified can be used to create a tool to determine which inpatients may benefit from anesthesia consultation and support during their endoscopic procedure.

Please acknowledge all funding agencies by checking the applicable boxes below

None

Disclosure of Interest

None Declared

Autophagic adaptation is associated with exercise-induced fibre-type shifting in skeletal muscle

AIM

Acute exercise is known to activate autophagy in skeletal muscle. However, little is known about how basal autophagy in skeletal muscle adapts to chronic exercise. In the current study we aim to, firstly, examine whether long-term habitual exercise alters the basal autophagic signalling in plantaris muscle and, secondly, examine the association between autophagy and fibre-type shifting.

METHODS

Adult female Sprague-Dawley rats aged 2 months were randomly assigned to control and exercise groups. Animals in exercise group were kept in cages equipped with free access running wheels to perform habitual exercise for 5 months. Animals in the control group were caged in the absence of running wheels. Animals were sacrificed after the 5-month experimental period. Plantaris muscle tissues were harvested for analysis.

RESULTS

We showed that long-term habitual exercise enhanced basal autophagy, but without altering expressions of autophagy proteins in plantaris muscle. Interestingly, sirtuin protein, a possible regulator of autophagy, was upregulated in plantaris muscle. Furthermore, we suspected that different types of muscle fibre adapted to chronic exercise in different ways. Long-term habitual exercise resulted in fibre-type shifting from type IIX to IIA in both gastrocnemius muscle and plantaris muscle. Intriguingly, our analysis demonstrated that LC3-II protein abundance is positively correlated with the proportion of type IIA fibre whereas it was negatively correlated with the proportion of type IIX fibre in plantaris muscle. PGC-1α protein abundance was positively associated with the proportion of type IIA fibre and LC3-II in plantaris muscle.

CONCLUSION

These results suggest that basal autophagy is enhanced in plantaris muscle after long-term habitual exercise and associated with fibre-type shifting.

Comparative genomics of methicillin-resistant Staphylococcus aureus ST239: distinct geographical variants in Beijing and Hong Kong

BACKGROUND

The ST239 lineage is a globally disseminated, multiply drug-resistant hospital-associated methicillin-resistant Staphylococcus aureus (HA-MRSA). We performed whole-genome sequencing of representative HA-MRSA isolates of the ST239 lineage from bacteremic patients in hospitals in Hong Kong (HK) and Beijing (BJ) and compared them with three published complete genomes of ST239, namely T0131, TW20 and JKD6008. Orthologous gene group (OGG) analyses of the Hong Kong and Beijing cluster strains were also undertaken.

RESULTS

Homology analysis, based on highest-percentage nucleotide identity, indicated that HK isolates were closely related to TW20, whereas BJ isolates were more closely related to T0131 from Tianjin. Phylogenetic analysis, incorporating a total of 30 isolates from different continents, revealed that strains from HK clustered with TW20 into the 'Asian clade', whereas BJ isolates and T0131 clustered closely with strains of the 'Turkish clade' from Eastern Europe. HK isolates contained the typical φSPβ-like prophage with the SasX gene similar to TW20. In contrast, BJ isolates contained a unique 15 kb PT1028-like prophage but lacked φSPβ-like and φSA1 prophages. Besides distinct mobile genetic elements (MGE) in the two clusters, OGG analyses and whole-genome alignment of these clusters highlighted differences in genes located in the core genome, including the identification of single nucleotide deletions in several genes, resulting in frameshift mutations and the subsequent predicted truncation of encoded proteins involved in metabolism and antimicrobial resistance.

CONCLUSIONS

Comparative genomics, based on de novo assembly and deep sequencing of HK and BJ strains, revealed different origins of the ST239 lineage in northern and southern China and identified differences between the two clades at single nucleotide polymorphism (SNP), core gene and MGE levels. The results suggest that ST239 strains isolated in Hong Kong since the 1990s belong to the Asian clade, present mainly in southern Asia, whereas those that emerged in northern China were of a distinct origin, reflecting the complexity of dissemination and the dynamic evolution of this ST239 lineage.

Combined treatment with a dipeptidyl peptidase-IV inhibitor (sitagliptin) and an angiotensin II type 1 receptor blocker (losartan) promotes islet regeneration via enhanced differentiation of pancreatic progenitor cells

AIM

The existence of pancreatic progenitor cells (PPCs) with differentiation capacity in the adult pancreas has rendered that promotion of islet regeneration is feasible. The dipeptidyl peptidase-IV inhibitor sitagliptin and the angiotensin II type 1 receptor (AT(1) receptor) blocker losartan have a common target action in the pancreata. Thus, we evaluated the synergistic/additive effects of these two drugs on the differentiation of islet progenitors.

METHODS

The acute and chronic effects of sitagliptin and losartan, individually or in combination, on islet regeneration in vivo were investigated by using a streptozotocin-induced type 1 diabetes mouse model. Their effects were also examined on an in vitro PPCs model derived from human foetal pancreas.

RESULTS

A chronic combination treatment enhanced glucose tolerance in diabetic mice associated with an increased ratio of β cells to islet; an acute combination treatment resulted in a marked increase in the production of neurogenin 3 (NGN3(+)) cells in proximity to CK7(+) ductal cell and an increased presence of insulin(+) /CK7(+) cells. The in vitro study revealed that a combination treatment significantly enhanced mRNA expression of NGN3, NKX6.1 and PDX-1 during PPCs differentiation into human islet-like cell clusters (ICCs). Despite no apparent changes in insulin release, the combined treatment resulted in increasing production of peroxisome proliferator-activated receptor γ (PPARγ) during PPC differentiation.

CONCLUSIONS

These data indicate that combined sitagliptin-losartan treatment can improve islet function by promoting the differentiation of PPCs into ICCs, perhaps via a mechanism involving PPARγ production, and could thereby, contribute to islet regeneration.

Reduced sample sizes for atrophy outcomes in Alzheimer's disease trials: baseline adjustment

Cerebral atrophy rate is increasingly used as an outcome measure for Alzheimer's disease (AD) trials. We used the Alzheimer's disease Neuroimaging initiative (ADNI) dataset to assess if adjusting for baseline characteristics can reduce sample sizes. Controls (n = 199), patients with mild cognitive impairment (MCI) (n = 334) and AD (n = 144) had two MRI scans, 1-year apart; approximately 55% had baseline CSF tau, p-tau, and Abeta1-42. Whole brain (KN-BSI) and hippocampal (HMAPS-HBSI) atrophy rate, and ventricular expansion (VBSI) were calculated for each group; numbers required to power a placebo-controlled trial were estimated. Sample sizes per arm (80% power, 25% absolute rate reduction) for AD were (95% CI): brain atrophy = 81 (64,109), hippocampal atrophy = 88 (68,119), ventricular expansion = 118 (92,157); and for MCI: brain atrophy = 149 (122,188), hippocampal atrophy = 201 (160,262), ventricular expansion = 234 (191,295). To detect a 25% reduction relative to normal aging required increased sample sizes approximately 3-fold (AD), and approximately 5-fold (MCI). Disease severity and Abeta1-42 contributed significantly to atrophy rate variability. Adjusting for 11 predefined covariates reduced sample sizes by up to 30%. Treatment trials in AD should consider the effects of normal aging; adjusting for baseline characteristics can significantly reduce required sample sizes.

Memory complaints and increased rates of brain atrophy: risk factors for mild cognitive impairment and Alzheimer's disease

AIM

To determine rates of cerebral atrophy in individuals with symptoms of memory loss but no objective cognitive impairment (SNCI) and their association with future cognitive decline.

METHODS

Thirty-two SNCI subjects, 16 with mild cognitive impairment (MCI) and 27 control subjects had clinical assessment and magnetic resonance imaging at baseline and 1 year later. Rates of whole brain atrophy (WBA), hippocampal atrophy (HA) and ventricular enlargement (VE) were measured. Our outcome was clinical diagnosis at 2 years after entry into the study.

RESULTS

The MCI group had greater rates of WBA, HA and VE than both controls and SNCI subjects. As a group SNCI subjects did not have significantly greater rates of atrophy than the controls. However, SNCI subjects who progressed to MCI or dementia had increased rates of atrophy compared with those who remained stable.

DISCUSSION

Individuals with memory complaints but no objective memory deficits, who progress to MCI or dementia, have increased rates of cerebral atrophy.

Sequential non-traumatic femoral shaft fractures in a patient on long-term alendronate

Fractures associated with osteoporosis are common among elderly people and postmenopausal women. Bisphosphonate is an effective anti-resorptive drug commonly used for the prevention and treatment of osteoporosis. There are, however, concerns about potential side-effects during long-term treatment with alendronate. We report a case where an 82-year-old woman who had been taking alendronate for 10 years presented with two episodes of non-traumatic femoral shaft fracture. An iliac bone biopsy showed severely suppressed bone turnover, suggestive of adynamic bone disease. We suspect the bone turnover suppression was related to the prolonged use of alendronate.

A randomised controlled trial of the electric heating pad vs forced-air warming for preventing hypothermia during laparotomy

A randomised controlled trial was conducted to compare the efficacy of upper body forced-air warming (Bair Hugger, Augustine Medical model 500/OR, Prairie, MN) with that of an electric heating pad (Operatherm 202, KanMed, Bromma, Sweden) for maintenance of intra-operative body temperature in 60 patients undergoing laparotomy under general anaesthesia. The nasopharyngeal temperature was recorded throughout the operative period. The mean (SD) final temperatures were 36.2 (0.4) degrees C with forced-air warming and 35.5 (1.0) degrees C with electric heating pad (p < 0.01). Upper body forced-air warming is more effective than the heating pad for maintenance of body temperature during laparotomy.

Needs of Chinese families of critically ill patients

Critical illness and subsequent hospitalization are stressful for patients and their family members. The purpose of this descriptive study was to identify the family members' perceptions of their immediate needs within 48 to 96 hours following admission of a relative to a critical care unit in Hong Kong and to compare their perceptions with the critical care nurses' perceptions of the family needs. A convenience sample of 37 Chinese family members and 45 registered nurses completed a self-report Chinese version of the Critical Care Family Need Inventory. The 10 most important and 10 least important family needs were identified by family members and by nurses and the results were compared. Conclusions were drawn about the implications for nurses in planning and implementing quality family-centered care for critically ill patients.

Differences in diagnostic approach between family physicians and other specialists in patients with unintentional body weight loss

BACKGROUND

Unintentional weight loss is a diagnostic dilemma with diverse diagnostic possibilities for physicians.

OBJECTIVES

Our study focused on the evaluation of differences in diagnostic approach between family physicians and physicians in other specialties.

METHODS

Outpatients who visited National Taiwan University Hospital from January 1996 to December 1996 with unintentional weight loss of 5% or more within 6 months were recruited by a computer search. All data were obtained from a structured medical record audit.

RESULTS

There was no significant difference in the utilization of common diagnostic laboratory tests between the two groups. However, other specialists ordered more carcinoembryonic antigen tests (P < 0.01) and hepatitis B antigen tests (P < 0.05), but fewer upper gastrointestinal tract barium studies (P < 0.05) than family physicians. For patients without a definite final diagnosis, the diagnostic total costs for laboratory tests and imaging studies were lower for family physicians than other specialists (P < 0.01). For patients with biomedical disorders, the diagnostic cost was not significantly different between the two groups. For patients with psychological disorders, the costs for imaging studies were lower for family physicians than for other specialists (P < 0.05) but there was no significant difference in the total costs between these two groups.

CONCLUSIONS

We conclude that the different approaches between the two groups are due to different training backgrounds and characteristics of practice. The patient-centred concepts of family physicians might be more cost-effective in dealing with undifferentiated problems.

The needs of the family of critically ill neurosurgical patients: a comparison of nurses' and family members' perceptions

In this study, researchers identified the important needs of family members of critically ill neurosurgical patients and explored the relationship between needs and unmet needs as perceived by nurses and family members. A total of 52 family members and 36 nurses in three neurosurgical special care units in Hong Kong were asked to complete the Chinese version of the 45-item Critical Care Family Needs Inventory. The rank order of most important needs reported by family members indicates that the majority of needs are related to assurance; needs for support and comfort were much less important. When rating needs, nurses underrated most of the needs considered important by family members. Needs for proximity were also underrated in importance by nurses when compared to family ratings, and needs for support were heavily overrated by nurses. The needs for proximity were least met. An inverse relationship between nurses' ratings of importance and the frequency of unmet needs was demonstrated. The most important need that was also largely unmet was having a specific person call when unable to visit. The findings of this study indicate areas of unmet need that require additional nursing interventions.

Development of a Chinese chronic illness-related stress inventory for primary care

This study evaluates the construct validity and internal consistency of a Chronic Illness-Related Stress Inventory (CRSI) for primary care Chinese patients and studies the relationship between chronic illness-related stress and sociodemographic characteristics and indices of disease severity. A total of 301 patients were interviewed using a structured questionnaire. The responses to the CRSI were divided into a frequency scale and a severity scale. Six factors including physical integrity and discomfort, psychosocial function and economic burdens, self-fulfillment and daily life, sexual function, self-esteem, and diet limitations were obtained for each CRSI scale. Except for the last factor, all other factors and the scale as a whole for both scales have a Cronbach alpha of > 0.90. The results of the convergent and discriminant validity analysis were promising. In addition, chronic illness-related stress was related to insurance status and the self-perceived severity of disease.

Mortality trends of elderly people in Taiwan from 1974 to 1994

BACKGROUND

the hypothesis that disability and death will eventually be compressed to a period late in life needs empirical confirmation.

OBJECTIVES

we have examined the secular trends of life expectancy and common causes of death in the aged population of Taiwan.

METHOD

we compared the life expectancy, causes of death and probability of death for people at birth, at age 65 and at age 85 for both sexes from 1974 to 1994 using data from Taiwan government statistics.

RESULTS

there has been a substantial gain in life expectancy, especially for men age 85 and over, in the past 20 years. . Mortality due to stroke, ischaemic heart disease, hypertension and chronic pulmonary disease has declined. There has been a steep increase in cancer deaths and deaths associated with diabetes mellitus. Tuberculosis and injury-related deaths have declined but pneumonia deaths have increased. For elderly people, the probability of dying from cancer and ischaemic heart disease increased with time. However, the probability of dying from stroke decreased. Although there was a decrease in probability of deaths associated with falls, there was an increase of deaths due to 'frailty' (as judged by falls, pneumonia and septicaemia).

CONCLUSIONS

cancer is a major cause of death in the elderly population of Taiwan. This rapidly expanding elderly population seemed to suffer from poorer health in the later period of their life.

Different cis-regulatory DNA elements mediate developmental stage- and tissue-specific expression of the human COL2A1 gene in transgenic mice

Expression of the type II collagen gene (human COL2A1, mouse Col2a1) heralds the differentiation of chondrocytes. It is also expressed in progenitor cells of some nonchondrogenic tissues during embryogenesis. DNA sequences in the 5' flanking region and intron 1 are known to control tissue-specific expression in vitro, but the regulation of COL2A1 expression in vivo is not clearly understood. We have tested the regulatory activity of DNA sequences from COL2A1 on the expression of a lacZ reporter gene in transgenic mice. We have found that type II collagen characteristic expression of the transgene requires the enhancer activity of a 309-bp fragment (+2, 388 to +2,696) in intron 1 in conjunction with 6.1-kb 5' sequences. Different regulatory elements were found in the 1.6-kb region (+701 to +2,387) of intron 1 which only needs 90-bp 5' sequences for tissue-specific expression in different components of the developing cartilaginous skeleton. Distinct positive and negative regulatory elements act together to control tissue-specific transgene expression in the developing midbrain neuroepithelium. Positive elements affecting expression in the midbrain were found in the region from -90 to -1,500 and from +701 to +2,387, whereas negatively acting elements were detected in the regions from -1,500 to -6,100 and +2,388 to +2,855.

Screening of depression in patients with chronic medical diseases in a primary care setting

BACKGROUND

Patients with chronic medical diseases may have depression that is not recognized by their primary care physicians.

OBJECTIVES

We aimed to examine the application of Zung's Self-Rating Depression Scale (SDS) in the screening of depression in primary care patients with chronic medical diseases in a Chinese population.

METHODS

We studied 268 patients with chronic medical diseases in the Family Medicine Outpatient Clinic using a structured questionnaire including basic demographic data, a Chinese version of the SDS and a rating for the self-perceived severity of physical condition. The severity of chronic medical diseases was assessed by the authors using the Duke University Severity of Illness Scale from a chart audit. Fifty patients were randomly selected for a diagnostic interview according to the DSM-IV criteria. The construct validity and internal consistency reliability, sensitivity and specificity of the SDS were examined.

RESULTS

The results revealed that the SDS has good construct validity and internal consistent reliability in the evaluation of depression in Chinese patients with chronic medical diseases. A cut-off point of 55 had a sensitivity of 66.7% and a specificity of 90.0%. Depressed patients reported more cognitive symptoms than depressed affect and physical symptoms. Female patients had more severe depressed affect than male patients, but males had more prominent diurnal variation of mood than females.

CONCLUSIONS

We concluded that SDS can be a good screening tool for depression in Chinese patients with chronic medical diseases. Owing to constraints in the expression of sexual desire in the Chinese, elderly subjects tended to report loss of libido in the response to the SDS.

Self-rated health and mortality in Chinese institutional elderly persons

The relationship between self-rated health (SRH) and subsequent mortality was examined in a cohort of 411 Chinese elderly individuals living in institutions. SRH was assessed by a global health rating, by comparing health with others of the same age, and by perception of recent physical condition. Covariates including age, sex, daily activity function, instrumental daily activity function, cognitive function, self-reported visual acuity, urinary function, number of chronic conditions, number of medications, and history of falls were controlled by the Cox proportional hazard model. Elderly people who rated their global health as "fair or poor" had increased mortality compared to those in the "good" category (RR = 6.00; 95% CI 1.39-25.1) and a borderline significant increase in mortality risk for those who rated themselves in the "average" category (RR = 4.05; 95% CI 0.93-17.70). Elderly people who compared their health with others of the same age as "worse or worst" and "similar" had an RR of 2.75; 95% CI of 0.64-11.83 and RR of 2.40; 95% CI of 0.64-8.96, respectively. Elderly people who rated their physical symptoms as "moderate or severe" and "slight" had an RR of 2.54; 95% CI 0.65-9.80 and RR of 1.05; 95% CI 0.32-3.41, respectively. Age, institutional factors, and history of multiple falls were associated with an increased risk of mortality. We concluded that only the global health rating has direct predictive power for mortality in institutionalized elderly people.

SOX9 directly regulates the type-II collagen gene

Mutations in human SOX9 are associated with campomelic dysplasia (CD), characterised by skeletal malformation and XY sex reversal. During chondrogenesis in the mouse, Sox9 is co-expressed with Col2a1, the gene encoding type-II collagen, the major cartilage matrix protein. Col2a1 is therefore a candidate regulatory target of SOX9. Regulatory sequences required for chondrocyte-specific expression of the type-II collagen gene have been localized to conserved sequences in the first intron in rats, mice and humans. We show here that SOX9 protein binds specifically to sequences in the first intron of human COL2A1. Mutation of these sequences abolishes SOX9 binding and chondrocyte-specific expression of a COL2A1-driven reporter gene (COL2A1-lacZ) in transgenic mice. Furthermore, ectopic expression of Sox9 trans-activates both a COL2A1-driven reporter gene and the endogenous Col2a1 gene in transgenic mice. These results demonstrate that COL2A1 expression is directly regulated by SOX9 protein in vivo and implicate abnormal regulation of COL2A1 during, chondrogenesis as a cause of the skeletal abnormalities associated with campomelic dysplasia.

Evaluating the CELL-DYN 3500 haematology analyser in an acute general hospital

The CELL-DYN 3500 (CD3500) (Abbott Diagnostics Division, Santa Clara, CA, USA) is a multiparameter, automated haematology analyser system capable of producing 22 haematological parameters including a screening five-part differential. The evaluation was performed in a recently expanded acute care general hospital. Studies of linearity, carryover and precision were acceptable and within manufacturer's stated limits. Correlation of CD3500 with manual differential counts were good except for the basophil count. The white cell flagging system had a sensitivity of 83.6% and specificity of 88.9% with 85.6% agreement. The platelet flagging system also had comparable sensitivity and specificity rate of 88.4% and 94.5% and agreement rate of 92.2%. The overall false positive rate and false negative rate for both the white cell and platelet flags combined were 8.6% and 10.3%. All samples provided a differential with no rejection experienced. The MAPSS technology, together with the extended lyse mode and the investigational nine-part differential provides potential for future development in WBC differential.

Human COL2A1-directed SV40 T antigen expression in transgenic and chimeric mice results in abnormal skeletal development

The ability of SV40 T antigen to cause abnormalities in cartilage development in transgenic mice and chimeras has been tested. The cis-regulatory elements of the COL2A1 gene were used to target expression of SV40 T antigen to differentiating chondrocytes in transgenic mice and chimeras derived from embryonal stem (ES) cells bearing the same transgene. The major phenotypic consequences of transgenic (pAL21) expression are malformed skeleton, disproportionate dwarfism, and perinatal/neonatal death. Expression of T antigen was tissue specific and in the main characteristic of the mouse alpha 1(II) collagen gene. Chondrocyte densities and levels of alpha 1(II) collagen mRNAs were reduced in the transgenic mice. Islands of cells which express cartilage characteristic genes such as type IIB procollagen, long form alpha 1(IX) collagen, alpha 2(XI) collagen, and aggrecan were found in the articular and growth cartilages of pAL21 chimeric fetuses and neonates. But these cells, which were expressing T antigen, were not properly organized into columns of proliferating chondrocytes. Levels of alpha 1(II) collagen mRNA were reduced in these chondrocytes. In addition, these cells did not express type X collagen, a marker for hypertrophic chondrocytes. The skeletal abnormality in pAL21 mice may therefore be due to a retardation of chondrocyte maturation or an impaired ability of chondrocytes to complete terminal differentiation and an associated paucity of some cartilage matrix components.

Multi-adjustable post-operative orthosis for congenital muscular torticollis

A multi-adjustable torticollis orthosis is described for the post-operative bracing of patients after surgical correction of congenital muscular torticollis. The orthosis can be put on in the early post-operative period and the head and neck position can be maintained in the corrected, and later over-corrected position by the built-in multi-adjustable joint-mechanism. The details of the manufacturing are described. Twenty-five patients (13 girls and 12 boys) from age 1 to 22 with congenital muscular torticollis were fitted with the orthosis post-operatively for an average duration of 10 weeks. Satisfactory compliance with the orthosis was found in 23 cases. Complications were minimal (3 cases) and were related to scalp irritation which improved after minor adjustments of the halo.

[Clinical evaluation of psychiatric disorders among first-visit patients to a primary care unit]

It is important for a primary care physician to know the most common psychiatric diagnoses, criteria for these diagnoses, and proper treatment. During a 4-month period from December 1987 to March 1988, the authors conducted this prospective study in a rural group practice center and investigated 189 first-visit patients aged from 16 to 60 years. Among them, 55 cases (29.1%) were diagnosed as having psychiatric disorders which included: psychological factors affecting physical condition, 29 cases; generalized anxiety disorder, 12 cases; adjustment disorder, 10 cases; and others, 4 cases. There were no significant differences in marital status, social class, or family structure between patients with and without psychiatric disorders. However, the patients with psychiatric disorders tended to have a longer duration of illness, to exhibit more salient features of introversion and neuroticism in their personalities, to show poorer family function and to experience more stressful life events. Although all the psychiatric patients presented somatic symptoms as their primary complaints, we also found that they reported significantly higher scores for psychiatric symptoms on a self-rating scale. This study demonstrates that in order to promote comprehensive primary health care, psychiatry and behavioral science are essential training curricula for family physicians.

Uridine and cytidine transport in Escherichia coli B and transport-deficient mutants

Three mutants of Escherichia coli B which are defective in components of the transport system for uridine and uracil were isolated and utilized to study the mechanism of uridine transport. Mutant U- was isolated from a culture resistant to 77 micronM 5-fluorouracil. Mutant U-UR-, isolated from a culture of mutant U-, is resistant to 770 micronM 5-fluorouracil and 750 micronM adenosine. Mutant NUC- is resistant to 80 micronM showdomycin and has been reported previously. The characteristics of uridine transport by E. coli B and the mutants provide data supporting the following conclusions. The transport of adenosine, deoxyadenosine, guanosine, deoxyguanosine, adenine, or guanine by mutant U- and mutant U-UR- is identical with that in the parental strain. Uridine is transported by E. coli B as intact uridine. In addition, extracellular uridine is also rapidly cleaved to uracil and the ribose moiety. The latter is transported into the cells, whereas uracil appears in the medium and is transported by a separate uracil transport system. The entry of the ribose moiety of uridine is fast relative to the uracil and uridine transport processes. The Km values and the inhibitory effects of heterologous nucleosides for the transport of uridine and the ribose moiety of uridine are similar. Studies of cytidine uptake in the parental and mutant strains provide evidence that cytidine is transported by two independent systems, one of which is the same as that involved in the transport of intact uridine. Uridine inhibits but is not transported by the other system for cytidine transport. Evidence for the above conclusions was based on comparisons of the characteristics of [2-14C]uridine, [U-14C]uridine, and [2-14C]cytidine transport using E. coli B and the three transport mutants under conditions which measure initial rates. The nature of the inhibitory effects of heterologous nucleosides on the uridine transport processes and identification of extracellular components from radioactive uridine provides supportive data for the conclusions.