Incorporating Cardiovascular Risk Assessment into Adolescent Reproductive Health and Primary Care Visits

STUDY OBJECTIVE

This study aimed to evaluate the usability and feasibility of incorporating a cardiovascular risk assessment tool into adolescent reproductive health and primary care visits.

METHODS

We recruited 60 young women ages 13-21 years to complete the HerHeart web-tool in two adolescent clinics in Atlanta, GA. Participants rated the tool's usability via the Website Analysis and Measurement Inventory (WAMMI, range 0-95) and their perceived 10-year and lifetime risk of cardiovascular disease (CVD) on a visual analog scale (range 0-10). Participants' perceived risk, blood pressure, and body mass index were measured at baseline and three months after enrollment. Healthcare providers (HCP, n=5) completed the WAMMI to determine the usability and feasibility of incorporating the HerHeart tool into clinical practice.

RESULTS

Adolescent participants and HCPs rated the tool's usability highly on the WAMMI with a median of 79 (IQR 65, 84) and 76 (IQR 71, 84). At the baseline visit, participants' median perceived 10-year risk of a heart attack was 1 (IQR 0, 3), and perceived lifetime risk was 2 (IQR 0, 4). Immediately after engaging with the tool, participants' median perceived 10-year risk was 2 (IQR 1, 4.3), and perceived lifetime risk was 3 (IQR 1.8, 6). Thirty-one participants chose to set a behavior change goal, and 12 participants returned for follow-up. Clinical metrics were similar at the baseline and follow-up visits.

CONCLUSION

HerHeart is acceptable to young women and demonstrates potential for changing risk perception and improving health habits to reduce risk of CVD. Future research should focus on improving retention in studies to promote cardiovascular health within reproductive health clinics.

Feasibility of recruiting adolescents into a prospective cohort study of the effects of social isolation during COVID-19

BACKGROUND

Social connection and loneliness in adolescence are increasingly understood as critical influences on adult mental and physical health. The unique impact of the social isolation imposed by the COVID-19 lockdown on emerging adults is therefore expected to be especially profound. We sought to investigate the feasibility of using ecological momentary assessment (EMA) and wearable accelerometers to characterize the effects of social isolation and/or loneliness experienced by adolescents during the COVID-19 pandemic.

METHODS

We recruited 19 participants aged 13-18 from an Adolescent Medicine practice in Atlanta, GA. Participants completed surveys at baseline and throughout a 2-week study period using EMA regarding their degree of social isolation, loneliness, family functioning, school climate, social media use, and COVID-19 experiences surrounding their physical, mental, and social domains. Six participants agreed to wear an activity tracker and heart rate measurement device for 14 days to monitor their emotional state and physical health. Participant feedback was collected via open-ended exit interviews. Feasibility of recruitment/retention, adherence, and outcome measures were investigated. Implementation was also assessed by evaluating the barriers and facilitators to study delivery. Associations between the social isolation and loneliness variables and all other variables were performed with univariate linear regression analysis with significance set at p < 0.05. The progression criteria were a recruitment rate of > 30% and a retention rate of > 80%.

RESULTS

Progression criteria were met for recruitment (76%) of participants, but not retention (38%). Adherence to EMA survey completion was highly variable with only 54% completing ≥ 1 survey a day, and accelerometry use was not feasible. Social isolation was significantly correlated with lower school climate, higher COVID-19 experiences, higher depression scores, and lower sleep quality. Loneliness also showed a significant correlation with all these factors except COVID-19 experiences.

CONCLUSIONS

EMA and wearable accelerometer use was not feasible in this longitudinal study of adolescents during the COVID-19 pandemic. Future research should further investigate barriers to conducting long-term research with adolescents and the potential effects of the pandemic on subject recruitment and retention.

Promoting Participation in Pulmonary Rehabilitation after Hospitalization for Chronic Obstructive Pulmonary Disease, Strategies of Top-performing Systems: A Qualitative Study

Rationale: Pulmonary rehabilitation (PR) after hospitalization for chronic obstructive pulmonary disease (COPD) is recommended by guidelines; however, few patients participate, and rates vary between hospitals. Objectives: To identify contextual factors and strategies that may promote participation in PR after hospitalization for COPD. Methods: Using a positive-deviance approach, we calculated hospital-specific rates of PR after hospitalization for COPD among a cohort of Medicare beneficiaries. At a purposive sample of high-performing and innovative hospitals in the United States, we conducted in-depth interviews with key stakeholders. We defined high-performing hospitals as having a PR rate above the 95th percentile, at least 6.58%. To learn from hospitals that demonstrated a commitment to improving rates of PR, regardless of PR rates after discharge, we identified innovative hospitals on the basis of a review of American Thoracic Society conference research presentations from prior years. Interviews were audio-recorded and transcribed verbatim. Using a directed content analysis approach, transcripts were coded iteratively to identify themes. Results: Interviews were conducted with 38 stakeholders at nine hospitals (seven high-performers and two innovators). Hospitals were diverse regarding size, teaching status, PR program characteristics, and geographic location. Participants included PR medical directors, PR managers, respiratory therapists, inpatient and outpatient providers, and others. We found that high-performing hospitals were broadly focused on improving care for patients with COPD, and several had recently implemented new initiatives to reduce rehospitalizations after admission for COPD in response to the Centers for Medicare and Medicaid Services/Medicare's Hospital Readmission Reduction Program. Innovative and high-performing hospitals had systems in place to identify patients with COPD that enabled them to provide patient education and targeted discharge planning. Strategies took several forms, including the use of a COPD navigator or educator. In addition, we found that high-performing hospitals reported effective interprofessional and patient communication, had clinical champions or external change agents, and received support from hospital leadership. Specific strategies to promote PR included education of referring providers, education of patients to increase awareness of PR and its benefits, and direct assistance in overcoming barriers. Conclusions: Our findings suggest that successful efforts to increase participation in PR may be most effective when part of a larger strategy to improve outcomes for patients with COPD. Further research is necessary to test the generalizability of our findings.

Abstract P136: Young Women Accept a Developmentally Appropriate Cardiovascular Risk Assessment Tool That Changes Their Perceived Risk of Heart Disease

Introduction: Cardiovascular disease (CVD) remains the leading cause of death for women in the US, yet many young women are unaware of their lifetime risk of CVD. We employed user-centered design principles to adapt a validated CVD risk prediction tool for young women.

Hypothesis: We hypothesized that young women would rate the tool (HerHeart) as user-friendly, be likely to recommend it to their friends, experience a change in their perceived risk of CVD, and report intent to change their health habits after engaging with it.

Methods: We recruited 13 young women ages 13-21 from two clinical practices in Atlanta, GA to engage with the HerHeart CVD risk prediction tool. Participants rated the tool’s usability via the Website Analysis and Measurement Inventory (WAMMI), which is scored from 0 to 100. Participants rated their perceived 10-year and lifetime risk of CVD on a visual analog scale from 0 (Never going to happen) to 10 (Definitely will happen) before and after completing the tool. Participants reported their likelihood of recommending the tool to their friends and changing their health habits from 0 (Not likely at all) to 10 (Extremely likely).

Results: Participants rated the tool’s usability highly on the WAMMI (M = 78.62 +/- 9.70). Participants’ perceived 10-year risk of a heart attack increased from a mean of 0.85 +/- 0.99 to 1.83 +/- 1.90, and perceived lifetime risk increased from a mean of 2.38 +/- 2.72 to 2.75 +/- 2.63, on the 10-point scale after engaging with the tool. Participants were more than likely to recommend HerHeart to their friends (M = 8.00 +/- 2.22) and to report intent to change their health habits (M = 8.82 +/- 1.47) after completing the tool. Participant data captured in the HerHeart tool are shown in the Table.

Conclusions: The HerHeart tool is acceptable to young women and demonstrates potential for changing their risk perception and improving their health habits to reduce their risk of CVD. Recruitment is ongoing and will include input from clinicians on the feasibility of incorporating the tool in clinical practice.

Assessing and Promoting Cardiovascular Health for Adolescent Women: User-Centered Design Approach

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death among women in the United States. A considerable number of young women already have risk factors for CVD. Awareness of CVD and its risk factors is critical to preventing CVD, yet younger women are less aware of CVD prevalence, its risk factors, and preventative behaviors compared to older women.

OBJECTIVE

The purpose of this study is to assess CVD awareness among adolescent and young adult women and develop a lifestyle-based cardiovascular risk assessment tool for the promotion of CVD awareness among this population.

METHODS

This study used a 3-phase iterative design process with young women and health care practitioners from primary care and reproductive care clinics in Atlanta, Georgia. In phase 1, we administered a modified version of the American Heart Association Women's Health Survey to young women, aged 15-24 years (n=67), to assess their general CVD awareness. In phase 2, we interviewed young women, aged 13-21 years (n=10), and their health care practitioners (n=10), to solicit suggestions for adapting the Healthy Heart Score, an existing adult cardiovascular risk assessment tool, for use with this age group. We also aimed to learn more about the barriers and challenges to health behavior change within this population and the clinical practices that serve them. In phase 3, we used the findings from the first 2 phases to create a prototype of a new online cardiovascular risk assessment tool designed specifically for young women. We then used an iterative user-centered design process to collect feedback from approximately 105 young women, aged 13-21 years, as we adapted the tool.

RESULTS

Only 10.5% (7/67) of the young women surveyed correctly identified CVD as the leading cause of death among women in the United States. Few respondents reported having discussed their personal risk (4/67, 6%) or family history of CVD (8/67, 11.9%) with a health care provider. During the interviews, young women reported better CVD awareness and knowledge after completing the adult risk assessment tool and suggested making the tool more teen-friendly by incorporating relevant foods and activity options. Health care practitioners emphasized shortening the assessment for easier use within practice and discussed other barriers adolescents may face in adopting heart-healthy behaviors. The result of the iterative design process was a youth-friendly prototype of a cardiovascular risk assessment tool.

CONCLUSIONS

Adolescent and young adult women demonstrate low awareness of CVD. This study illustrates the potential value of a cardiovascular risk assessment tool adapted for use with young women and showcases the importance of user-centered design when creating digital health interventions.

134 Quantitative Assessment of Visual Function for Pituitary Macroadenomas: A Practical Scoring Algorithm

Introduction

There is a myriad of existing terms by which visual capacity is recorded. The lack of a standardised categorisation of observations commonly results in ambiguities. We report the utility of a visual function score (VFS) in patients managed by transsphenoidal surgery.

Method

A VFS (expressed as a percentage) with a maximum score of 20 was calculated for each eye using the Snellen VA (40% weighting: score 0-8) and Humphrey Allergan 30-2 automated visual field (60% weighting: score 0-12).

Results

280 patients (560 eyes) underwent transsphenoidal pituitary adenoma resections with complete pre- and post-operative visual function assessment. Mean age 56 years; 56.4% male. 26.1% were treated by endoscopic technique and 73.9% were treated by microscopic technique. Pre-operative vision was normal in 38.0% eyes. All these had full post-operative vision. In patients with pre-operative visual loss (347 eyes), the mean pre-operative VFS rose from 70.8% to 87.5% post-operatively. 43.8% eyes attained full post-operative vision, 28% improved, and 25.6% remained unchanged. 9 patients (2.6%) had worse immediate post-operative vision.

Conclusions

The VFS is a convenient single measure of visual function that may facilitate local and national audit of transsphenoidal surgery. Studies are planned to correlate this with patient reported visual quality of life measures.

Content analysis of promotional material for asthma-related products and therapies on Instagram

BACKGROUND

Increasingly, social media is a source for information about health and disease self-management. We conducted a content analysis of promotional asthma-related posts on Instagram to understand whether promoted products and services are consistent with the recommendations found in the Global Initiative for Asthma (GINA) 2019 guidelines.

METHODS

We collected every Instagram post incorporating a common, asthma-related hashtag between September 29, 2019 and October 5, 2019. Of these 2936 collected posts, we analyzed a random sample of 266, of which, 211 met our inclusion criteria. Using an inductive, qualitative approach, we categorized the promotional posts and compared each post's content with the recommendations contained in the 2019 GINA guidelines. Posts were categorized as "consistent with GINA" if the content was supported by the GINA guidelines. Posts that promoted content that was not recommended by or was unrelated to the guidelines were categorized as "not supported by GINA".

RESULTS

Of 211 posts, 89 (42.2%) were promotional in nature. Of these, a total of 29 (32.6%) were categorized as being consistent with GINA guidelines. The majority of posts were not supported by the guidelines. Forty-one (46.1%) posts promoted content that was not recommended by the current guidelines. Nineteen (21.3%) posts promoted content that was unrelated to the guidelines. The majority of unsupported content promoted non-pharmacological therapies (n = 39, 65%) to manage asthma, such as black seed oil, salt-room therapy, or cupping.

CONCLUSIONS

The majority of Instagram posts in our sample promoted products or services that were not supported by GINA guidelines. These findings suggest a need for providers to discuss online health information with patients and highlight an opportunity for providers and social media companies to promote evidence-based asthma treatments and self-management advice online.

Pleomorphic liposarcoma of bone: a rare primary malignant bone tumour

BACKGROUND

Liposarcoma is an extremely rare primary bone sarcoma.

CASE PRESENTATION

We report a case of primary pleomorphic liposarcoma that arose in an 18 year old male in the metaphysis of the left tibia. Plain radiographs showed a partly sclerotic lesion and MR imaging a heterogeneous tumour predominantly isointense on T1- and high-signal on T2-weighted sequences with focal areas of increased T1 signal that suppressed with fat saturation. PET/CT showed marked FDG uptake (SUV = 17.1) in the primary tumour as well as a metastasis in the right distal femur and multiple small pulmonary metastases. Histologically, the tumour was a pleomorphic liposarcoma containing large tumour cells with vacuolated cytoplasm and hyperchromatic pleomorphic nuclei as well as numerous lipoblasts and scattered brown fat-like cells. Tumour cells strongly expressed FABP4/aP2, a marker of adipocyte differentiation, and UCP1, a marker of brown fat, but not S100. The case was treated with neoadjuvant MAP chemotherapy, resulting in extensive (> 95%) necrosis in the primary tumour and almost complete resolution of the femoral and pulmonary metastases.

CONCLUSIONS

Pleomorphic liposarcoma can present as a sclerotic primary malignant bone tumour; markers of adipose differentiation are useful in histological diagnosis and neoadjuvant MAP chemotherapy results in significant tumor necrosis.

Prevalence of spinous process impingement in thoracic vertebrae on radiographs of clinically-unaffected dogs

OBJECTIVES

To assess the prevalence of impinged spinous processes in asymptomatic dogs.

METHODS

One hundred and ninety lateral thoracic radiographs of asymptomatic dogs radiographed for reasons other than spinal pain, were retrospectively reviewed by two board-certified radiologists. Images were assessed for impinged spinous processes and graded for narrowing, sclerosis or remodelling of the spinous processes.

RESULTS

The prevalence of impinged spinous processes in unaffected dogs was 33·2%. Seventy-five of 79 (95%) lesions were located between T8 and T11. Impingement of the spinous processes was more common in older dogs and larger dogs displayed more frequent and more severe impingement of the spinous processes compared with smaller breeds.

CLINICAL SIGNIFICANCE

Spinous process impingement is common in animals with no history of spinal pain, indicating that this radiographic finding should be interpreted with caution.

Survivors of childhood leukaemia treated with haematopoietic stem cell transplantation and total body irradiation should undergo screening for diabetes by oral glucose tolerance tests

AIMS

Childhood cancer survivors treated with haematopoietic stem cell transplantation (HSCT) and total body irradiation are at an increased risk of developing diabetes early in life due to insulin resistance and β-cell dysfunction, but the optimal screening method is unknown. The National Institute for Health and Care Excellence guidelines for community diabetes screening recommend using fasting glucose ≥ 7 mmol/l and/or HbA1c ≥ 48 mmol/mol (6.5%) for diagnosis and, fasting glucose 5.5-6.9 mmol/l or HbA1c 42-47 mmol/mol (6-6.5%) to indicate high risk. This study aimed to evaluate the sensitivities of fasting glucose and HbA1c in the diagnosis of diabetes and impaired glucose tolerance in childhood HSCT survivors.

METHOD

The patients were 35 (male = 19) HSCT survivors from a single UK centre under follow-up from 2006 to 2013. Patients had a median age (range) of 19.2 (13.1-26.2) years and had been treated for acute lymphoblastic (n = 31) or myeloid (n = 4) leukaemia when aged 7.8 (2.4-16.7) years. The outcome measures were oral glucose tolerance test (OGTT), fasting glucose and HbA1c .

RESULTS

OGTT identified 6 patients with diabetes (120-min glucose ≥ 11.1 mmol/l), 12 with impaired glucose tolerance (120-min glucose 7.8-11.0 mmol/l) and 2 with impaired fasting glucose (≥ 7 mmol/l). Fasting glucose ≥ 7 mmol/l or HbA1c ≥ 48 mmol/mol identified two of the six patients with diabetes diagnosed on OGTT. Fasting glucose ≥ 5.5 mmol/l and HbA1c ≥ 42 mmol/mol identified three and two patients, respectively, with diabetes. Only 1 of 12 patients with impaired glucose tolerance had a fasting glucose ≥ 5.5 mmol/l and none had HbA1c ≥ 42 mmol/mol (≥ 6%).

CONCLUSIONS

The fasting glucose and HbA1c cut-offs used in UK population screening only identified one-third of HSCT survivors with diabetes and do not identify those at risk. Diabetes screening in HSCT survivors requires standard OGTTs.

A case-control study of risk factors for death from 2009 pandemic influenza A(H1N1): is American Indian racial status an independent risk factor?

Historically, American Indian/Alaska Native (AI/AN) populations have suffered excess morbidity and mortality from influenza. We investigated the risk factors for death from 2009 pandemic influenza A(H1N1) in persons residing in five states with substantial AI/AN populations. We conducted a case-control investigation using pandemic influenza fatalities from 2009 in Alaska, Arizona, New Mexico, Oklahoma and Wyoming. Controls were outpatients with influenza. We reviewed medical records and interviewed case proxies and controls. We used multiple imputation to predict missing data and multivariable conditional logistic regression to determine risk factors. We included 145 fatal cases and 236 controls; 22% of cases were AI/AN. Risk factors (P 45 years vs. <18 years], pre-existing medical conditions (mOR 7·1), smoking (mOR 3·0), delayed receipt of antivirals (mOR 6·5), and barriers to healthcare access (mOR 5·3). AI/AN race was not significantly associated with death. The increased influenza mortality in AI/AN individuals was due to factors other than racial status. Prevention of influenza deaths should focus on modifiable factors (smoking, early antiviral use, access to care) and identifying high-risk persons for immunization and prompt medical attention.

Salivary gland myoepithelial carcinoma

Salivary gland myoepithelial carcinoma (MC) or malignant myoepithelioma is a rare entity. MC usually presents as a slow-growing painless mass arising in the parotid gland, but may involve other salivary glands. This tumour may be particularly locally aggressive, but its clinical and biological features are not yet fully understood. MC may arise from pre-existing benign lesions, such as pleomorphic adenomas or benign myoepitheliomas, or may arise de novo. It usually affects patients over 50 years old, with no gender preference. Because it is often asymptomatic, the presentation and diagnosis can be delayed by months, even years. The current WHO classification considers MC to be an intermediate- to high-grade malignancy. Other published data suggest it is likely to be a high-grade neoplasm, consistent with its aggressive behaviour. Its epidemiology, histopathological features, immunohistochemical profile, clinical behaviour and optimal management are not well understood. Following review of the current literature we aim to address these.

Age and sex differences in c-Fos expression and serum corticosterone concentration following LPS treatment

Exposure to an immune challenge during peripuberty/adolescence, but not in adulthood, can cause enduring alterations in reproductive and non-reproductive behaviors. This suggests that the peripubertal/adolescent brain might respond differently to a stressor, like an immune challenge, than the adult brain. The goal of this study was to examine whether there are age and sex differences in the acute response to an immune challenge. To examine this research question, we investigated c-Fos expression in various brain regions. Corticosterone (CORT) concentration in the serum was quantified to examine hypothalamic-pituitary-adrenal axis (HPA-axis) responsiveness. Results showed that lipopolysaccharide (LPS; a bacterial endotoxin) treatment, induced a significant increase in the number of c-Fos immunoreactive cells in adult male and female mice compared to their saline controls. However, in peripubertal/adolescent mice, LPS treatment failed to increase the number of c-Fos immunoreactive cells in both male and female mice compared to their saline controls. LPS treatment also significantly increased serum CORT concentration in all mice regardless of sex and age. However, adult female mice treated with LPS showed significantly greater serum CORT concentration compared to adult and peripubertal/adolescent males and peripubertal/adolescent females treated with LPS. These findings support our hypothesis and suggest that there are important age and sex differences in acute immune response, which may allude to mechanisms for the enduring behavioral alterations, observed previously in mice exposed to an immune challenge during puberty but not in adulthood.

Phase I study of concurrent motexafin gadolinium (MGd) with radiation therapy for children with newly diagnosed brain stem gliomas (BSG): A Children’s Oncology Group study

9014

Background: MGd, a radiosensitizer that selectively accumulates in tumors, generates reactive oxygen species intracellularly. In preclinical experiments, MGd enhances RT-induced apoptosis. Methods: A multi-institutional Phase I dose escalation and pharmacokinetic (PK) study was performed in children with newly diagnosed BSG to determine the maximum tolerated dose (MTD) and dose-limiting toxicities (DLT) of MGd administered i.v. 2 to 5 hours prior to involved field radiotherapy (RT) (1.8 Gy/day, total 54 Gy). Cohort 1 received MGd, 1.7 mg/kg/dose M-F × 3 wks and cohort 2 received the same dose M, W and F × 6 wks. The 6 subsequent cohorts of 3 to 6 pts received MGd M-F × 6 weeks at doses of 1.9, 3.4, 4.4, 5.5, 7.1 and 9.2 mg/kg/dose. Serum for PK analysis, and MRI scans (MGd is detectable by MR), were obtained for analysis of drug accumulation and responses. Results: 44 pts (42 fully evaluable for toxicity) with a median age of 6 years (range 2–20) were enrolled. At the 9.2 mg/kg/dose, 2/2 pts experienced DLT. During subsequent expansion of the 7.1 and 5.5 mg/kg/dose cohorts, DLTs, including transaminitis, hypertension and urticaria, were observed in 2/5 and 2/6 pts. At the MTD of 4.4 mg/kg/dose, 1/6 pts had reversible grade 3 serum transaminase elevations. PK analysis showed biphasic elimination with a terminal t 1/2 of 6.4 h. At the MTD, serum MGd concentrations were >250 ng/ml for 24 h. Serum clearance and steady-state volume of distribution were 0.0243 L/h/kg and 0.162 L/kg. MRI for intra-tumoral MGd distribution is ongoing. One patient had a CR and 4 had a PR. The estimated median survival is 10.3 months (95% confidence interval: 8.1 months-11.5 months). Conclusions: The recommended phase II dose of MGd for children with BSG is 4.4 mg/kg/d administered M-F × 6 weeks with involved field RT. A COG phase II trial is planned.

[Table: see text]

Investigation of nasal disease in the cat--a retrospective study of 77 cases

A retrospective study was undertaken to determine the prevalence of different diseases in cats referred for investigation of chronic nasal disease, to identify historical, clinical and diagnostic features which may assist in making a diagnosis, and to provide information pertaining to outcome in these cats. Diagnoses included neoplasia (30 cases), chronic rhinitis (27), foreign body (8), nasopharyngeal stenosis (5), Actinomyces infection (2), nasal polyps (2), stenotic nares (2), and rhinitis subsequent to trauma (1). The most common neoplasia was lymphosarcoma (21 cases), with a median survival of 98 days for cats treated with multiagent chemotherapy. Cats with neoplasia were older on average than the other cats, and were more likely to be dyspnoeic and have a haemorrhagic and/or unilateral nasal discharge than cats with chronic rhinitis. Cats with neoplasia were more likely to have radiographic evidence of nasal turbinate destruction, septal changes, or severe increases in soft tissue density than cats with chronic rhinitis. It was unusual for cats with diseases other than neoplasia to be euthanased as a result of their nasal disease.

Creutzfeldt-Jakob disease in unusually young patients who consumed venison

BACKGROUND

Creutzfeldt-Jakob disease (CJD) in humans and chronic wasting disease (CWD) in deer and elk occur in the United States. Recent reports of 3 unusually young patients with CJD who regularly consumed deer or elk meat created concern about the possible zoonotic transmission of CWD.

OBJECTIVE

To examine the possible transmission of CWD to humans.

PATIENTS

Three unusually young patients (aged 28, 28, and 30 years) with CJD in the United States during 1997-2000.

METHODS

We reviewed medical records and interviewed family members and state wildlife and agriculture officials. Brain tissue samples were tested using histopathologic, immunohistochemical, immunoblot, or prion protein gene analyses.

MAIN OUTCOME MEASURES

Presence or absence of established CJD risk factors, deer and elk hunting in CWD-endemic areas, and comparison of the evidence for the 3 patients with that of a zoonotic link between new variant CJD and bovine spongiform encephalopathy.

RESULTS

None of the patients had established CJD risk factors or a history of travel to Europe. Two patients hunted game animals and 1 was a daughter of a hunter. Unlike patients with new variant CJD, the 3 patients did not have a unique neuropathologic manifestation, clinicopathologic homogeneity, uniformity in the codon 129 of the prion protein gene, or prion characteristics different from those of classic variants.

CONCLUSIONS

Although the occurrence of 3 unusually young patients with CJD who consumed venison suggested a possible relationship with CWD, our follow-up investigation found no strong evidence for a causal link. Ongoing CJD surveillance remains important for continuing to assess the risk, if any, of CWD transmission to humans.

Developing and implementing a comprehensive program for children and adolescents with eating disorders

TOPIC

Treatment of eating disorders in children and adolescents across a continuum of care.

PURPOSE

To describe the development and implementation of a comprehensive pilot program for children and adolescents with eating disorders.

SOURCES

Published literature and clinical experience.

CONCLUSIONS

The pilot program to provide comprehensive care to children and adolescents has been successful. As of November 2000, the inpatient modal eating disorder census has been 4 (highest = 10, lowest = 1). With the focus on prevention and early intervention, the multidisciplinary team continues to educate the public and providers.

Impact of troponin T determinations on hospital resource utilization and costs in the evaluation of patients with suspected myocardial ischemia

The evaluation and triage of patients with suspected myocardial ischemia in the emergency department remains challenging and costly. Previous studies of cardiac troponins have focused predominantly on patients with chest pain and have not randomized patients to different diagnostic strategies. Eight hundred fifty-six patients with suspected myocardial ischemia were prospectively randomized to receive a standard evaluation, including serial electrocardiographic and creatine phosphokinase-MB determinations (controls) or a standard evaluation with the addition of serial troponin T determinations (troponin group). The primary end points were length of stay and hospital charges. Significant reductions in length of hospital stay were seen in troponin T patients both with (3.6 vs 4.7 days; p = 0.01) and without (1.2 vs 1.6 days; p = 0.03) acute coronary syndromes compared with controls. Total hospital charges were reduced in a similar fashion in troponin patients with and without acute coronary syndromes ($15,004 vs $19,202; p = 0.01, and $4,487 vs $6,187; p = 0.17, respectively) compared with controls. Troponin patients without acute coronary syndromes had fewer hospital admissions (25% vs 31%; p = 0.04), whereas troponin patients with acute coronary syndromes had shorter telemetry and coronary care unit lengths of stay (3.5 vs 4.5 days; p = 0.03) compared with controls. Thus, utilization of troponin T in a broad spectrum of emergency department patients with suspected myocardial ischemia improves hospital resource utilization and reduces costs.

The Fas-FasL death receptor and PI3K pathways independently regulate monocyte homeostasis

Peripheral blood-derived monocytes spontaneously undergo apoptosis mediated by Fas-Fas ligand (FasL) interactions. Activation of monocytes by LPS or TNF-alpha prevents spontaneous monocyte apoptosis through an unknown mechanism. Here, we demonstrate that LPS and TNF-alpha up-regulate Flip and suppress spontaneous Fas-FasL mediated monocyte apoptosis and caspase 8 and 3 activation. Flip was responsible for this protection, since inhibition of Flip by antisense oligonucleotides in the presence of LPS or TNF-alpha restored monocyte sensitivity to spontaneous apoptosis. We also investigated whether the PI3K pathway contributes to the suppression of spontaneous monocyte apoptosis mediated by LPS and TNF-alpha. Monocytes treated with a reversible PI3K inhibitor (LY294002) displayed enhanced apoptosis, while LPS and TNF-alpha partially protected against apoptosis mediated by LY294002. However, direct suppression of Fas-FasL interactions by addition of neutralizing anti-FasL antibody did not further suppress LY294002-induced apoptosis in the presence of LPS or TNF-alpha. Collectively, these data demonstrate that LPS or TNF-alpha protect monocytes from death receptor-mediated apoptosis through the up-regulation of Flip, but not apoptosis initiated by inhibition of the PI3K pathway.

Elliptic flow in Au+Au collisions at square root(S)NN = 130 GeV

Elliptic flow from nuclear collisions is a hadronic observable sensitive to the early stages of system evolution. We report first results on elliptic flow of charged particles at midrapidity in Au+Au collisions at square root(S)NN = 130 GeV using the STAR Time Projection Chamber at the Relativistic Heavy Ion Collider. The elliptic flow signal, v2, averaged over transverse momentum, reaches values of about 6% for relatively peripheral collisions and decreases for the more central collisions. This can be interpreted as the observation of a higher degree of thermalization than at lower collision energies. Pseudorapidity and transverse momentum dependence of elliptic flow are also presented.

A simple strategy for improving patient contact after ED discharge

The purpose of this study was to assess strategies to improve telephone contact with adult patients discharged from the emergency department (ED). The basic procedure was a prospective, randomized, interventional trial of a convenience sample of patients 18 years or older being discharged from the ED. Patients were excluded if they had altered mental status or were unable to communicate with the College Research Associates (RAs). RAs asked intervention subjects a set of scripted questions confirming patients' telephone numbers and times for a follow-up call. Control subjects received routine discharge instructions from the ED staff. Subjects were called back within 4 days of ED discharge. Eighty-seven control subjects and 76 intervention subjects were enrolled. There were no significant demographic differences between the 2 groups. Forty-seven (54%) control subjects were contacted versus 58 (77%) in the intervention group (P <.003; Chi-square test). A simple patient interview conducted immediately before discharge confirming the patient's telephone number and setting a time for a follow-up call significantly improved patient follow-up contact rates.

Is the intrinsic thermoelectric power of carbon nanotubes positive?

The thermoelectric power (TEP) of single-walled carbon nanotubes (SWNTs) is extremely sensitive to gas exposure history. Samples exposed to air or oxygen have an always positive TEP, suggestive of holelike carriers. However, at fixed temperature the TEP crosses zero and becomes progressively more negative as the SWNTs are stripped of oxygen. The time constant for oxygen adsorption/desorption is strongly temperature dependent and ranges from seconds to many days, leading to apparently "variable" TEP for a given sample at a given temperature. The saturated TEP can be accounted for within a model of strong oxygen doping of the semiconducting nanotubes.