Disparities in multimorbidity and comorbidities in rheumatoid arthritis by sex acrossthe lifespan

OBJECTIVES

Multimorbidity is burdensome for people with rheumatoid arthritis (RA). We investigated differences in multimorbidity and comorbidities by sex and age in the RA population.

METHODS

This cross-sectional analysis used national administrative claims (OptumLabs® Data Warehouse) from people with RA and non-RA comparators (matched on age, sex, race, census region, index year, and length of baseline insurance coverage) from 2010-2019. RA was determined using a validated algorithm. Multimorbidity was defined as ≥ 2 (MM2+) or ≥ 5 (MM5+) comorbidities from a validated set of 44 chronic conditions. We used logistic regression to assess associations between characteristics and multimorbidity.

RESULTS

The sample included 154,391 RA patients and 154,391 non-RA comparators. For people aged 18-50 years, RA women (vs RA men) had 7.5 and 4.4 (vs 3.2 and 0.9 in non-RA women vs non-RA men) percentage point increases for MM2+ and MM5+, respectively. For people aged 51+ years, RA women (vs RA men) had 2.1 and 2.5 (vs 1.2 and 0.3 in non-RA women vs non-RA men) percentage point increases for MM2+ and MM5+, respectively. Interactions revealed that differences in multimorbidity between women and men were exacerbated by RA (vs non-RA) (p < 0.05), with more pronounced effects in people aged 18-50. Men had more cardiovascular-related conditions, whereas RA women had more psychological, neurological, and general musculoskeletal conditions. Other comorbidities varied by sex and age.

CONCLUSION

Multimorbidity disproportionately impacts women with RA. Research, clinical, and policy agendas for rheumatic diseases should acknowledge and support the variation in care needs by sex and gender across the lifespan.

National trends in emergency conditions through the Omicron COVID-19 wave in commercial and Medicare Advantage enrollees

Objective

To evaluate trends in emergency care sensitive conditions (ECSCs) from pre-COVID (March 2018-February 2020) through Omicron (December 2021-February 2022).

Methods

This cross-sectional analysis evaluated trends in ECSCs using claims (OptumLabs Data Warehouse) from commercial and Medicare Advantage enrollees. Emergency department (ED) visits for ECSCs (acute appendicitis, aortic aneurysm/dissection, cardiac arrest/severe arrhythmia, cerebral infarction, myocardial infarction, pulmonary embolism, opioid overdose, pre-eclampsia) were reported per 100,000 person months from March 2018 to February 2022 by pandemic wave. We calculated the percent change for each pandemic wave compared to the pre-pandemic period.

Results

There were 10,268,554 ED visits (March 2018-February 2022). The greatest increases in ECSCs were seen for pulmonary embolism, cardiac arrest/severe arrhythmia, myocardial infarction, and pre-eclampsia. For commercial enrollees, pulmonary embolism visit rates increased 22.7% (95% confidence interval [CI], 18.6%-26.9%) during Waves 2-3, 37.2% (95% CI, 29.1%-45.8%] during Delta, and 27.9% (95% CI, 20.3%-36.1%) during Omicron, relative to pre-pandemic rates. Cardiac arrest/severe arrhythmia visit rates increased 4.0% (95% CI, 0.2%-8.0%) during Waves 2-3; myocardial infarction rates increased 4.9% (95% CI, 2.1%-7.8%) during Waves 2-3. Similar patterns were seen in Medicare Advantage enrollees. Pre-eclampsia visit rates among reproductive-age female enrollees increased 31.1% (95% CI, 20.9%-42.2%), 23.7% (95% CI, 7.5%,-42.3%), and 34.7% (95% CI, 16.8%-55.2%) during Waves 2-3, Delta, and Omicron, respectively. ED visits for other ECSCs declined or exhibited smaller increases.

Conclusions

ED visit rates for acute cardiovascular conditions, pulmonary embolism and pre-eclampsia increased despite declines or stable rates for all-cause ED visits and ED visits for other conditions. Given the changing landscape of ECSCs, studies should identify drivers for these changes and interventions to mitigate them.

Racial Differences in Multimorbidity and Comorbidities in Rheumatoid Arthritis

OBJECTIVE

To identify differences in multimorbidity and individual comorbidities among individuals with rheumatoid arthritis (RA), separated by race and ethnicity.

METHODS

This case-control study within OptumLabs Data Warehouse from 2010 to 2019 matched RA cases (defined by 2 codes plus prescription of an RA drug) to non-RA controls 1:1 on age, sex, race and ethnicity, region, index date of RA, and insurance coverage duration. We defined multimorbidity as the presence of ≥2 or ≥5 validated comorbidities. Logistic regression models calculated adjusted odds of multimorbidity with 95% confidence intervals (95% CIs) within each race and ethnicity.

RESULTS

We identified 154,391 RA cases and 154,391 controls (mean age 59.6, 76% female). Black enrollees had the most multimorbidity ≥2/≥5 (73.1%, 34.3%); Asian enrollees had the least (52.4%, 17.3%). Adjusted odds of multimorbidity ≥2 and ≥5 in RA cases versus controls was 2.19 (95% CI 2.16-2.23) and 2.06 (95% CI 2.02-2.09), respectively. This increase was similar across race and ethnicity. However, we observed elevated occurrence of certain comorbidities by race and ethnicity versus controls (P < 0.001), including renal disease in White enrollees (4.7% versus 3.2%) and valvular heart disease in Black and White enrollees (3.2% and 2.8% versus 2.6% and 2.2%).

CONCLUSION

Multimorbidity is a problem for all RA patients. Targeted identification of certain comorbidities by race and ethnicity may be a helpful approach to mitigate multimorbidity.

Trends and Disparities in Access to Buprenorphine Treatment Following an Opioid-Related Emergency Department Visit Among an Insured Cohort, 2014-2020

This cross-sectional study examines trends in access to buprenorphine treatment following an opioid-related emergency department (ED) visit among adults with commercial or Medicare Advantage health insurance between 2014 and 2020.

Pancreatic cancer risk to siblings of probands in bilineal cancer settings

PURPOSE

Pancreatic cancer (PC) risk is increased in families, but PC risk and risk perception have been understudied when both parents have cancer.

METHODS

An unbiased method defining cancer triads (proband with PC and both parents with cancer) in a prospective registry estimated risk of PC to probands' siblings in triad group 1 (no parent with PC), group 2 (1 parent with PC), and group 3 (both parents with PC). We estimated standardized incidence ratios (SIRs) using a Surveillance, Epidemiology, and End Results (SEER) reference. We also estimated the risk when triad probands carried germline pathogenic/likely pathogenic variants in any of the 6 PC-associated genes (ATM, BRCA1, BRCA2, CDKN2A, MLH1, and TP53). PC risk perception/concern was surveyed in siblings and controls.

RESULTS

Risk of PC was higher (SIR = 3.5; 95% CI = 2.2-5.2) in 933 at-risk siblings from 297 triads. Risk increased by triad group: 2.8 (95% CI = 1.5-4.5); 4.5 (95% CI = 1.6-9.7); and 21.2 (95% CI = 4.3-62.0). SIR in variant-negative triads was 3.0 (95% CI = 1.6-5.0), whereas SIR in variant-positive triads was 10.0 (95% CI = 3.2-23.4). Siblings' perceived risk/concern of developing PC increased by triad group.

CONCLUSION

Sibling risks were 2.8- to 21.2-fold higher than that of the general population. Positive variant status increased the risk in triads. Increasing number of PC cases in a triad was associated with increased concern and perceived PC risk.

Survey of Information Exchange and Advanced Use of Other Health Information Technology in Primary Care Settings: Capabilities In and Outside of the Safety Net

BACKGROUND

Advanced use of health information technology (IT) functionalities can support more comprehensive, coordinated, and patient-centered primary care services. Safety net practices may benefit disproportionately from these investments, but it is unclear whether IT use in these settings has kept pace and what organizational factors are associated with varying use of these features.

OBJECTIVE

The aim was to estimate advanced use of health IT use in safety net versus nonsafety net primary care practices. We explore domains of patient engagement, population health management (decision support and registries), and electronic information exchange. We examine organizational characteristics that may differentially predict advanced use of IT across these settings, with a focus on health system ownership and/or membership in an independent practice network as key factors that may indicate available incentives and resources to support these efforts.

RESEARCH DESIGN

We conduct cross-sectional analysis of a national survey of physician practices (n=1776). We use logistic regression to predict advanced IT use in each of our domains based on safety net status and other organizational characteristics. We then use interaction models to assess whether ownership or network membership moderate the relationship between safety net status and advanced use of health IT.

RESULTS

Health IT use was common across primary care practices, but advanced use of health IT functionalities ranged only from 30% to 50% use. Safety net settings have kept pace with adoption of features for patient engagement and population management, yet lag in information exchange capabilities compared with nonsafety net practices (odds ratio=0.52 for federally qualified health centers, P<0.001; odds ratio=0.66 for other safety net, P=0.03). However, when safety net practices are members of a health system or practice network, health IT capabilities are comparable to nonsafety net sites.

CONCLUSIONS

All outpatient settings would benefit from improved electronic health record usability and implementation support that facilitates advanced use of health IT. Safety net practices, particularly those without other sources of centralized support, need targeted resources to maintain equitable access to information exchange capabilities.

Volumetric Microsampling of Capillary Blood Spot vs Whole Blood Sampling for Therapeutic Drug Monitoring of Tacrolimus and Cyclosporin A: Accuracy and Patient Satisfaction

BACKGROUND

Immunosuppressant therapeutic drug monitoring (TDM) usually requires outpatient travel to hospitals or phlebotomy sites for venous blood collection; however Mitra® Microsampling Device (MSD) sampling could allow self-collection and shipping of samples to a laboratory for analysis. This study examined the feasibility of using volumetric microsampling by MSD for TDM of tacrolimus (TaC) and cyclosporin A (CsA) in transplant patients, along with their feedback on the process.

METHODS

MSD was used to collect TaC and CsA from venous (VB) or capillary (CB) blood. The MSDs were rehydrated, extracted, and analyzed using on-line solid phase extraction coupled to tandem mass spectrometry (SPE-MS/MS). We report an abbreviated method validation of the MSD including: accuracy, precision, linearity, carry-over, and stability using residual venous whole blood (VB) samples. Subsequent clinical validation compared serially collected MSD + CB against VB (200 µL) from transplant patients.

RESULTS

Accuracy comparing VB vs. MSD+VB showed high clinical concordance (TaC = 89% and CsA = 98%). Inter- and intra-precision was ≤11.5 %CV for TaC and CsA. Samples were stable for up to 7 days at room temperature with an average difference of <10%. Clinical validation with MSD+CB correlated well with VB for CsA (slope = 0.95, r2 = 0.88, n = 47) and TaC (slope = 0.98, r2 = 0.82, n = 49). CB vs. VB gave concordance of 94% for CsA and 79% for TaC. A satisfaction survey showed 82% of patients preferred having the capillary collection option.

CONCLUSION

Transplant patients favored having the ability to collect capillary samples at home for TaC/CsA monitoring. Our results demonstrate good concordance between MSD+CB and VB for TaC and CsA TDM, but additional studies are warranted.

Accuracy of Smoking Status Reporting: Proxy Information in a Rapidly Fatal Cancer Setting

Objective

To assess whether patients and relatives can serve as reliable proxy reporters of other family members’ cigarette-smoking history.

Patients and Methods

Two samples (325 patients, 707 relatives) were identified from the Mayo Clinic Biospecimen Resource for Pancreas Research, enrolled from November, 6, 2000, to March 15, 2018. Smoking-history data, including categorical (ever/never) and quantitative (packs per day and years smoked) smoking measures, were obtained from self-completed questionnaires by patients and relatives. Relative reports were compared with patient reports on self; patient reports were compared with relative reports on self.

Results

Overall, spouses and first-degree relatives (FDRs) were accurate (94.5%) when reporting patient ever smoking; spouse reports were 98.6% sensitive and 97.7% accurate. Accuracy of patient reports was 97.8% for spouse smoking and 85.5% for FDR smoking; accuracy varied by relationship of FDR. When not concordant, patients generally over-reported daily packs smoked by relatives and under-reported years smoked. Within a 25% agreement range, spouse reports about patients’ daily packs smoked was 46.7%, and years smoked was 69.6%, whereas FDRs were 50% and 64.6%, respectively. When not concordant, relatives generally over-reported daily packs smoked by patients, but no consistent pattern was observed of over- or under-reporting years smoked by patients.

Conclusions

Patients and relatives can be reliable proxies for smoking history (ever/never) in their family members, especially spouses. An accurate reporting of smoking status will help physicians to better gauge performance status and family smoking exposures to inform disease management.

The use of the Rx spin label in orientation measurement on proteins, by EPR

The bipedal spin label Rx is more restricted in its conformation and dynamics than its monopodal counterpart R1. To systematically investigate the utility of the Rx label, we have attempted to comprehensively survey the attachment of Rx to protein secondary structures. We have examined the formation, structure and dynamics of the spin label in relation to the underlying protein in order to determine feasibility and optimum conditions for distance and orientation measurement by pulsed EPR. The labeled proteins have been studied using molecular dynamics, CW EPR, pulsed EPR distance measurement at X-band and orientation measurement at W-band. The utility of different modes and positions of attachment have been compared and contrasted.

Code status discussions in psychiatric and medical inpatients

BACKGROUND

The Patient Self-Determination Act along with regulatory standards and institutional standards of care highlight the need for collaboration between care providers and patients with respect to goals of care and, in emergency situations, code status and measures to be taken in keeping with patients' wishes. Addressing code status may be lacking in patients who require psychiatric hospitalization due to the nature of psychiatric illness, relative medical stability, and a general expectation of survival. We sought to compare code status documentation and discussion between psychiatric and medical inpatients, as this knowledge will help shape future interventions for process improvement.

METHOD

We conducted a retrospective chart review of hospitalized patients in psychiatric and medical units during a 12-month period in 2008. For those with multiple admissions, we reviewed only the index (or first) hospitalization. Data collected included demographic information, clinical information regarding cancer as a primary diagnosis or a diagnosis that met National Hospice and Palliative Care Organization (NHPCO) guidelines, code status order and discussion documentation, the presence of an advance directive, length of stay, and 1-year mortality. Data were summarized using mean values, percentages, and frequencies. The 2 groups (psychiatric and medical groups) were compared.

RESULTS

The charts of 276 psychiatric patients and 317 general medical patients were reviewed. More psychiatric patients had dementia (P < .001). Medical inpatients had a higher rate of code status order documented on admission (96% vs 65%, P < .001) and "full-code, discussed" order (67% vs 33%, P < .001). Psychiatric inpatients had more "do not resuscitate/do not intubate" orders (20% vs 13%, P = .037), more frequent changes in code status order (18% vs 7%, P < .001), and a higher percentage of advance directives (46% vs 25%, P < .001).

CONCLUSIONS

A code status discussion with hospitalized patients needs to occur at admission regardless of reason for admission. Strategies are needed to improve this process for psychiatric inpatients.

Meiosis in sesquidiploid hybrids of Lycopersicon esculentum and Solanum lycopersicoides

We have synthesized diploid hybrids between Lycopersicon esculentum and Solanum lycopersicoides and have converted them to allotetraploids. Two sesquidiploids, having two complements of the former parent and one of the latter, have been obtained by backcrossing the former parent with the alloploid. In meiosis of the sesquidiploid the L. esculentum chromosomes exhibit strong preferential pairing, consistently forming 12 bivalents, whereas the S. lycopersicoides chromosomes remain unpaired. This chromosomal comportment conforms with expectations based on meiosis of the 2x and 4x hybrids. Condensation of the S. lycopersicoides univalents is retarded in early diakinesis but their development appears normal at later stages. Presumably as a consequence of the orderly behavior of the L. esculentum bivalents and consequent contribution to each gamete, fertility of the sesquidiploids is higher than in L. esculentum autotriploids. The normally strict self-incompatibility is somewhat relaxed in the sesquidiploids. Extra S. lycopersicoides chromosomes can be transmitted from the sesquidiploid as pistillate parent, and the aneuploid progeny are viable. Establishment of alien addition races and their utilization to transmit desired genes from S. lycopersicoides to L. esculentum are anticipated.

Investigating public health impacts of deer in a protected drinking water supply watershed

The World Health Organisation's (WHO) Water Safety Plans highlight the need for preventative risk management when managing water contamination risks. As part of this approach, a management framework incorporating multiple barriers is necessary and there is a need to validate those barriers through scientific evidence. This paper reports on a study undertaken to validate the effectiveness, in terms of pathogen numbers, of having protected watersheds. The study aimed to determine if the deer population in a protected watershed carried Cryptosporidium and whether or not it was human infectious. Deer faecal samples were collected from the protected watersheds over a 12 month period and analysed using a new method, developed as part of this project, for genotyping Cryptosporidium. Early results showed the presence of Cryptosporidium, but following a refinement in the method no human infectious Cryptosporidium was detected. The results give some confidence that having protected watersheds is an effective barrier against pathogen contamination. They do not, however, imply that continued monitoring and management of the deer should cease. To maintain compliance with the Water Safety Plans, continual validation of barrier effectiveness is required.

Assessing the health implications of turbidity and suspended particles in protected catchments

The supply of unfiltered disinfected drinking water from Melbourne's fully protected catchments means that the water-quality managers must ensure that the source water poses no public health risk. High turbidity is currently used as a surrogate of pathogens, and harvesting of water is based on its measurement. The work presented here summarises suspended particle and associated pathogen, microbial indicator and faecal biomarker concentrations collected to (a) quantify turbidity in an Australian water supply system and (b) assess the possibility of increasing water harvesting from selected tributaries. Pathogens and microbial indicators were present in low numbers in these source waters; increased turbidity during storm events was not associated with an increase in pathogen concentration. The results confirmed that protected catchments, along with good management, were effective barriers to pathogen contamination. Aesthetic issues still need to be addressed, but no measurable increase in microbiological risk was associated with storm-generated particles.

Effect of knowledge of chronologic age on the variability of pediatric bone age determined using the Greulich and Pyle standards

OBJECTIVE

The purpose of this study was to investigate the impact of knowing chronologic age on the variability of pediatric bone age determination using the method of Greulich and Pyle.

MATERIALS AND METHODS

Radiographs of the left hand of 107 patients were interpreted by four radiologists on two separate occasions, once with and once without knowledge of the patient's chronologic age at time of interpretation. Twenty-five radiographs were randomly selected and reevaluated twice by each radiologist. Interobserver and intraobserver variability were calculated and compared for the two conditions. The distribution of studies with normal and abnormal findings was then compared across knowledge conditions for all observers and by individual observer, using two standard deviations above and below chronologic age as the range of "normal".

RESULTS

When the chronologic age was known, the interobserver reliability coefficient for knowledge of chronologic age was 0.954 and when not known, 0.952. The intraobserver reliability coefficients when chronologic age was known ranged from 0.944 to 0.967, and when not known from 0.938 to 0.980. Observers interpreted 58% (248/428) of the radiographs as having normal findings when chronologic age was known and 48% (205/428) when chronologic age was not known.

CONCLUSION

Knowing chronologic age before assessing bone age radiographs does not affect the reproducibility of assessment. However, observers are more likely to interpret the radiograph as showing normal findings when chronologic age is known than if the interpretation is performed with the observer unaware of chronologic age.

Residual oil fly ash amplifies allergic cytokines, airway responsiveness, and inflammation in mice

Particulate matter (PM) air pollution may increase symptom severity in allergic asthmatics. To examine possible interaction, or greater than additive responses, between PM effects and allergic responses, an ovalbumin-sensitized and challenged (OVA) mouse model of allergic airways disease was utilized. After challenge, mice were intratracheally instilled with saline vehicle or 3 mg/kg (approximately 60 microg) residual oil fly ash (ROFA), a transition metal-rich emission source PM sample. Physiological and inflammatory responses were examined 1, 3, 8, and 15 d later. In response to intravenously administered methacholine, ROFA increased total respiratory system resistance and decreased compliance 1 d after exposure, whereas effects of OVA lasted at least 15 d after exposure. Significant interactions between OVA and ROFA were mainly observed 8 d after challenge and exposure, especially with respect to compliance. A strong interaction (p < 0.01) between OVA and ROFA exposure resulted in 8-fold (1 d) and 3-fold (3 d) increases in bronchoalveolar lavage (BAL) fluid eosinophil numbers. A similarly strong interaction (8-fold) was observed in BAL fluid interleukin-4 (IL-4) 1 d after challenge and exposure. Significant though less strong interactions were also found with respect to IL-4 and IL-5 by 3 d postchallenge/exposure. This study shows that allergen challenge and exposure to emission source particulate matter containing relatively high levels of transitions metals can interact to increase Th2 cytokine production, eosinophil recruitment, and airway hyperresponsiveness in previously sensitized mice.

Imaging features of avulsion injuries

Avulsion injuries are common among participants in organized sports, especially among adolescent participants. Imaging features of both acute and chronic avulsion injuries of the pelvis, knee, ankle and foot, shoulder, and elbow were evaluated to help distinguish these injuries from more serious disease processes such as neoplasm and infection. At radiography, acute injuries (ie, those resulting from extreme, unbalanced, often eccentric muscular contractions) may be associated with avulsed bone fragments, whereas subacute injuries have an aggressive appearance that may include areas of mixed lysis and sclerosis. Chronic injuries (ie, those resulting from repetitive microtrauma or overuse) or old inactive injuries may be associated with a protuberant mass of bone and may bear a striking resemblance to a neoplastic or infectious process. Although not usually required, computed tomography is helpful in the diagnosis if radiographic findings are equivocal or if the injury is not in the acute phase. MR imaging is best suited for the evaluation of injuries to muscles, tendons, and ligaments. Recognition of characteristic imaging features and familiarity with musculotendinous anatomy will aid in accurate diagnosis of avulsion injuries.

A prospective randomized trial of prevention measures in patients at high risk for contrast nephropathy: results of the P.R.I.N.C.E. Study. Prevention of Radiocontrast Induced Nephropathy Clinical Evaluation

OBJECTIVES

This study was done to test the hypothesis that a forced diuresis with maintenance of intravascular volume after contrast exposure would reduce the rate of contrast-induced renal injury.

BACKGROUND

We have previously shown a graded relationship with the degree of postprocedure renal failure and the probability of in-hospital death in patients undergoing percutaneous coronary intervention. Earlier studies of singular prevention strategies (atrial natriuretic factor, loop diuretics, dopamine, mannitol) have shown no clear benefit across a spectrum of patients at risk.

METHODS

A prospective, randomized, controlled, single-blind trial was conducted where 98 participants were randomized to forced diuresis with intravenous crystalloid, furosemide, mannitol (if pulmonary capillary wedge pressure <20 mm Hg), and low-dose dopamine (n = 43) versus intravenous crystalloid and matching placebos (n = 55).

RESULTS

The groups were similar with respect to baseline serum creatinine (2.44+/-0.80 and 2.55+/-0.91 mg/dl), age, weight, diabetic status, left ventricular function, degree of prehydration, contrast volume and ionicity, and extent of peripheral vascular disease. The forced diuresis resulted in higher urine flow rate (163.26+/-54.47 vs. 122.57+/-54.27 ml/h) over the 24 h after contrast exposure (p = 0.001). Two participants in the experimental arm versus five in the control arm required dialysis, with all seven cases having measured flow rates <145 ml/h in the 24 h after the procedure. The mean individual change in serum creatinine at 48 h, the primary end point, was 0.48+/-0.86 versus 0.51+/-0.87, in the experimental and control arms, respectively, p = 0.87. There were no differences in the rates of renal failure across six definitions of renal failure by intent-to-treat analysis. However, in all participants combined, the rise in serum creatinine was related to the degree of induced diuresis after controlling for baseline renal function, r = -0.36, p = 0.005. The rates of renal failure in those with urine flow rates greater than 150 ml/h in the postprocedure period were significantly lower, 8/37 (21.6%) versus 28/61 (45.9%), p = 0.03.

CONCLUSIONS

Forced diuresis with intravenous crystalloid, furosemide, and mannitol if hemodynamics permit, beginning at the start of angiography provides a modest benefit against contrast-induced nephropathy provided a high urine flow rate can be achieved.

Case report: paraarticular soft-tissue osteoma of the hip

A case of paraarticular soft-tissue osteoma of the hip is presented. The patient is a 30-year-old white male with a two year history of progressive left hip pain. Plain film and cross-sectional imaging in conjunction with pathologic correlation are used to make the diagnosis. The lesion lacks the typical zoning pattern of myositis ossificans, shows no direct communication with native bone, and is extraarticular in location as opposed to synovial osteochondromatosis. Soft tissue osteomas most commonly occur around the knee, the foot, and the ankle. Soft tissue osteomas are rare tumors and this case is unusual in that it occurs around the hip.

High-resolution dosimetry using radiochromic film and a document scanner

A method of reading exposed radiochromic film is described which has significant advantages over conventional densitometry. The method employs a document scanner and associated software for imaging the film. The resulting images are easily analysed using standard software to yield high-resolution dose maps. A calibration was performed which relates scanner signal to dose, allowing for the determination of dose at any point on an exposed film. Results obtained using a broad-band densitometer are compared to those where the scanner has been used. The technique was used to measure the dose distribution around a COMS-type ophthalmic applicator.

Ozone uptake in healthy adult males during quiet breathing

Experimental measurements of ozone (O3) uptake are needed for validation of dosimetry model parameters and in predictions as well as for determining factors affecting uptake and for making comparisons between subpopulations or across species. In this study, 10 healthy adult male subjects were exposed to 0.3 ppm O3 while seated and breathing naturally through the nose or mouth. Total respiratory tract O3 uptake, spontaneous breathing parameters, and respiratory gas exchange were measured for 10 min under steady-state conditions. The exposure protocol was replicated in each subject approximately 2 weeks after the first visit. On each visit, health exams were performed and spirometric lung measurements were obtained. The experimental design provided comparisons of total O3 uptake during nasal and oral breathing, differences in uptake in an individual at two time points, and an examination of between-subject variability in O3 uptake. Exposure to O3 had no effect on the breathing parameters or gas exchange. Oral and nasal breathing frequency averaged 16.2 +/- 1.1 (SE) and 16.0 +/- 1.2 breaths per minute with tidal volumes averaging 651 +/- 46 and 669 +/- 67 ml, respectively. A significant correlation (p < 0.01) was found for the minute volume during resting breathing with the percentage of uptake. The percentage of O3 uptake was consistently higher (p = 0.02) during oral breathing (76.5% +/- 3.3) than during nasal breathing (73.1% +/- 3.0) although this difference may not be biologically significant. The variability in percentage of uptake between subjects was substantial with calculated uptakes ranging from 51 to 96%, a difference of about 45%. Variability in percentage of uptake for an individual was less with the maximal difference between the first and second visits being about 20%; the average difference, however, was only about 3%. We conclude that total percentage of O3 uptake is approximately 75% in adult males during resting breathing. It is slightly greater during oral than during nasal breathing, will vary considerably among subjects, and is moderately reproducible within a subject.

Restrictive lung disease in rats exposed chronically to an urban profile of ozone

The potential for irreversible lung impairment resulting from life-long ozone (O3) exposure remains uncertain. To address this question, young adult rats (male, F-344) were exposed to a simulated urban profile of O3 for 1, 3, 13, 52, or 78 wk, after which pulmonary function tests were performed. To assess reversibility of effects, cohorts from the 13-, 52-, and 78-wk groups were evaluated, respectively, after an additional 6, 27, and 17 wk of clean air. Static and dynamic lung properties were based on measurements of lung volume apportionment, respiratory system compliance (Crs), DLCO, multibreath N2 washout, and maximum expiratory flow-volume relationships. Electrocardiography was also performed in unanesthetized, restrained rats after 52 and 78 wk, as were determinations of wet and dry lung weights, lung collagen, and associated connective tissue crosslinks. Small (< 10%) but significant reductions in TLC and RV were noted after 13, 52, and 78 wk of O3 exposure. At 13 and 52 wk, N2 washout was enhanced, though at 78 wk it was similar to control. None of these changes appeared progressive with continued O3 exposure. Post exposure to clean air did not completely reverse the reduction in TLC. Additionally, Crs, though not affected during O3 exposure, decreased during the air recovery. No O3-related changes in collagen were apparent, however. Thus, near life-long exposure of F-344 rats to a worse-case, urban profile of O3 appears to have led to a functionally restrictive, i.e. "stiffened," lung without overt fibrosis. Furthermore, certain aspects of the O3-induced effect were not fully reversible.

Cactus thorn embedded in the cartilaginous proximal tibia

Images

Septic knee from Ilizarov transfixation tibial pin

Images

Sports fractures

Fractures occur in athletes and dramatically influence performance during competitive and recreational activities. Fractures occur in athletes as the result of repetitive stress, acute sports-related trauma and trauma outside of athletics. The literature provides general guidelines for treatment as well as a variety of statistics on the epidemiology of fractures by sport and level of participation. Athletes are healthy and motivated patients, and have high expectations regarding their level of function. These qualities make them good surgical candidates. Although closed treatment methods are appropriate for most sports fractures, an aggressive approach to more complicated fractures employing current techniques may optimize their subsequent performance.

Near-lifetime exposure of the rat to a simulated urban profile of nitrogen dioxide: pulmonary function evaluation

To investigate the potential for up to a near-lifetime exposure to high-ambient levels of nitrogen dioxide (NO2) to induce functional lung damage, groups of rats were exposed to air or a simulated urban profile of NO2 (0.5 ppm background, 1.5 ppm peak) for 1, 3, 13, 52, or 78 weeks. The dynamic, static, and diffusional characteristics of the lung were evaluated postexposure in anesthetized rats. Furthermore, for the 13-, 52-, and 78-week groups, additional animals were tested after a 6-, 26-, or 17-week period in filtered air, respectively. No significant NO2 differences between exposed and control animals were found for the nitrogen washout, compliance, lung volume, or diffusion capacity of carbon monoxide measurements. At 78 weeks, however, a reduction in delta FEF25%, an estimate of convexity in the later portion of the forced expiratory flow volume curve, was observed. Breathing patterns and mechanisms were also assessed postexposure in a parallel group of similarly exposed unanesthetized rats. These rats were examined during a filtered air, 4 and 8% carbon dioxide (CO2) challenge. In the unanesthetized rat, frequency of breathing was significantly decreased and tidal volume, expiratory resistance, and inspiratory and expiratory times tended to increase. For several of these variables, the largest response also occurred at 78 weeks and seemed to be exacerbated by CO2 challenge.(ABSTRACT TRUNCATED AT 250 WORDS)

Near-Lifetime Exposure of the Rat to a Simulated Urban Profile of Nitrogen Dioxide: Pulmonary Function Evaluation

To investigate the potential for up to a near-lifetime exposure to high-ambient levels of nitrogen dioxide (NO₂) to induce functional lung damage, groups of rats were exposed to air or a simulated urban profile of NO₂ (0.5 ppm background, 1.5 ppm peak) for 1, 3, 13, 52, or 78 weeks. The dynamic, static, and diffusional characteristics of the lung were evaluated postex-posure in anesthetized rats. Furthermore, for the 13-, 52-, and 78-week groups, additional animals were tested after a 6-, 26-, or 17-week period in filtered air, respectively. No significant NO₂ differences between exposed and control animals were found for the nitrogen washout, compliance, lung volume, or diffusion capacity of carbon monoxide measurements. At 78 weeks, however, a reduction in δFEF_25%, an estimate of convexity in the later portion of the forced expiratory flow volume curve, was observed. Breathing patterns and mechanics were also assessed postexposure in a parallel group of similarly exposed unanesthetized rats. These rats were examined during a filtered air, 4 and 8% carbon dioxide (CO₂) challenge. In the unanesthetized rat, frequency of breathing was significantly decreased and tidal volume, expiratory resistance, and inspiratory and expiratory times tended to increase. For several of these variables, the largest response also occurred at 78 weeks and seemed to be exacerbated by CO₂ challenge. For both unanesthetized and anesthetized test groups, the magnitude of the changes in pulmonary function were small and their significance was borderline, thus indicating that near-lifetime exposure to the rat of a high ambient urbanprofile of N_O2 does not lead to dysfunction suggestive of degenerative lung disease.

7p deletion syndrome: an adult with mild manifestations

Deletion of 7p results in a wide spectrum of congenital abnormalities and minor facial and hand anomalies, often including craniosynostosis. We report on the oldest recognized patient with this disorder, a 24-year-old woman with an interstitial deletion from p15.3-p21.2 or p21.3. The manifestations in this patient are milder than those of previously described patients, and include borderline mental retardation, short stature, minor facial anomalies, and several skeletal changes. The absence of craniosynostosis in this patient is noteworthy, given previous suggestions that there is a specific locus for this finding in the 7p region. Twelve cases of 7p deletion, in which the missing segment overlaps that of the current case, are reviewed. This case delineates a broader spectrum for patients with 7p deletion syndrome.

Vitamin E effects on in vitro immunoglobulin M and interleukin-1 beta production and transcription in dairy cattle

Experiments were conducted to determine the effect of dietary vitamin E on in vitro IgM and interleukin-1 production and its transcription by bovine peripheral blood mononuclear cells. Cells were isolated from Jersey cows and cultured with pokeweed mitogen, a T-cell-dependent, B-lymphocyte mitogen, to stimulate polyclonal IgM production. Addition of 55 and 110 ng/ml of alpha-tocopherol at time 0 to cell cultures containing pokeweed mitogen significantly enhanced IgM production compared with control cultures containing pokeweed mitogen alone. Cultures supplemented with 55 ng/ml of alpha-tocopherol at 0, 24, or 48 h after incubation with mitogen had enhanced IgM production compared with control cultures incubated for the same duration. However, addition of alpha-tocopherol to cultures at 72 and 96 h did not affect IgM production. Production of interleukin-1 in culture supernatants obtained 24 h after stimulation with pokeweed mitogen was similar between control cultures and cultures supplemented with alpha-tocopherol. At 48 h, secretion of interleukin-1 was maintained in the supplemented cultures but declined in control cultures. Mononuclear cells obtained from steers receiving vitamin E supplement or control steers were used to examine the effects of in vivo vitamin E status on interleukin-1 mRNA expression. Concanavalin A-stimulated cells from Jersey steers fed diets supplemented with vitamin E expressed 55% higher interleukin-1 mRNA than cells from control steers.

Pulmonary effects due to subchronic exposure to oil fog

Male and in some cases female rats were exposed to an oil fog generated by flash vaporization and subsequent condensation of light-weight lubricating oil. Exposures were for 3.5 h/d, 4d/wk for 13 wk. Males were exposed at concentrations of 1.5, 0.5, 0.2 or 0.0 mg/l (1500, 500, 200, and 0 mg/m3) and a particle size of approximately 1 micron (mass median aerodynamic diameter). A number of biologic endpoints were assessed the day after the last exposure and, in some cases, after a 4 wk recovery period. Effects of 1.5 mg/l on male and female rats were compared. Diffuse accumulation of macrophages in the alveoli was observed in all oil fog exposed groups. The degree of severity was concentration dependent. Histopathologic changes were more prominent in males than in females and represented the most notable gender-related differences. Histologic effects observed one day and 4 wk post exposure were similar. Minimal histopathologic changes and minimal increase in lavage fluid protein were the only effects observed at the 0.2 mg/l exposure level. There was a significant increase in lavage fluid protein, percent lavagable polymorphonuclear leukocytes and lung wet and dry weight following exposure to both 0.5 and 1.5 mg/l. At the highest exposure concentration effects on lung weights were still evident 4 wk post exposure. Pulmonary function endpoints including total lung capacity, vital capacity, residual volume, diffusing capacity to CO, compliance, and end expiratory volume (EEV) were unaffected by oil fog exposure with the exception of EEV in males exposed at the 1.5 mg/l level. All of the changes observed following oil fog exposure were consistent with a mild inflammatory edema.

Does sunlight cause premature aging of the crystalline lens?

Premature onset of presbyopia may be an early sign of cataractous lenticular changes. For many years ultraviolet radiation (UVR) has been suspected as a major factor in the degradation of the crystalline lens. Controlled laboratory studies have demonstrated that UVR does cause opacities that closely resemble those naturally occurring in the aging process. Is it true that environmental UVR is also the prime contributor in the deleterious lenticular changes that may begin with premature presbyopia, as has been postulated? This review examines the evidence supporting this and other suggested causes of early presbyopia, including genetics, nutrition, toxins, and environmental temperature. Of all factors reported to affect the onset of presbyopia, UVR has the most scientific support, but further research is necessary to conclusively establish this link.

Evaluation of effects of ozone exposure on influenza infection in mice using several indicators of susceptibility

Mice were exposed to 1 ppm O3, 3 hr/day, for 5 consecutive days. Separate groups of mice were infected with influenza following each of the individual exposures. A twofold increase in the incidence of mortality and a 3-day decrease in mean survival time were observed in mice infected after the second exposure. There were no effects on percentage mortality or mean survival time due to exposure to 1 ppm O3 in mice infected after the first, third, fourth, or fifth exposure. When the exposure concentration was lowered to 0.5 ppm, there were no effects on mortality in mice infected after the second exposure. Five, daily, 3-hr exposures to 1 ppm O3 had no effect on virus titers in the lungs of mice infected after either the second or fifth exposure. In contrast, wet lung weights were significantly enhanced over infected air controls in mice infected after the second O3 exposure at both 1 and 0.5 ppm but not at 0.25 ppm exposure concentrations. This effect on lung wet weight was observed in mice infected with a dose of virus which produced 7-33% mortality in controls as well as in mice infected with a sublethal dose of virus. Histopathologic changes due to sublethal influenza infection, including nonsuppurative pneumonitis and necrosis, squamous metaplasia and hyperplasia of the epithelium lining the bronchi and bronchioles, were more severe in mice infected after the second of five, 1 ppm O3 exposure than in comparable air controls. Sublethal infection caused a loss of lung volume with secondary reduction in diffusing capability and homogenity of ventilation distribution. These latter two effects were also exacerbated in mice infected after the second of five, 1 ppm O3 exposures as compared to air controls. When mice were infected after the fifth, 1 ppm O3 exposure, there was no effect due to ozone on either lung wet weight or histopathology. The data indicate that O3 has little if any effect on antiviral defense mechanisms since virus titers in the lungs were not affected by O3 exposure. However, mortality and morbidity, as indicated by lung wet weights, histopathology, and pulmonary function changes, were enhanced by O3 exposure in mice infected after the second of five exposures suggesting that symptoms due to infection can be enhanced in the absence of enhanced virus replication, possibly due to synergistic effects of O3 and virus in production of lung pathology.(ABSTRACT TRUNCATED AT 400 WORDS)

Pulmonary function in juvenile and young adult rats exposed to low-level NO2 with diurnal spikes

Pulmonary function was examined for juvenile and young adult Fischer 344 rats that were continuously exposed to NO2 (0.5, 1.0, or 2.0 ppm) for up to 6 wk. The exposure included twice daily 1-h spikes equal to 3 times the baseline concentration. This spike-to-baseline ratio was chosen to simulate morning and evening urban rush-hour conditions. Juvenile rats were examined after 3 and 6 wk of NO2 exposure, whereas young adult rats were examined after 1-, 3-, and 6-wk intervals. Lung volumes, compliance, and efficiency of ventilation distribution were evaluated. Lung volumes increased in the juvenile rats after 3- and 6-wk exposures to 1.0 and 2.0 ppm NO2, but were unchanged in young adult rats. Lung compliance increased in juvenile rats exposed to 1.0 or 2.0 ppm NO2 for 3 wk. However, it was unchanged in juvenile rats exposed for 6 wk or in young adult rats exposed for 1 or 3 wk. Compliance decreased in young adult rats exposed to 2.0 ppm NO2 for 6 wk and was correlated to an overall thickening of alveolar interstitium and septal tissue. However, the observed changes in pulmonary function were marginal and reversible, since lung-function measurements were not different from controls after a 3-wk recovery period.

Properties of a plasma membrane-associated cathepsin B-like cysteine proteinase in metastatic B16 melanoma variants

Activities of a cathepsin B-like cysteine proteinase have previously been observed to correlate with the malignancy of several animal and human tumors. Plasma membrane fractions of some of these tumors have been found to be enriched in cathepsin B-like activity. We have determined the subcellular distribution of this enzyme and three additional lysosomal hydrolases (cathepsin H, beta-hexosaminidase, and beta-glucuronidase) in normal murine liver and six metastatic variants of the B16 melanoma. The tissues were fractionated initially by differential centrifugation followed by Percoll density gradient centrifugation of the light mitochondrial fraction. Two fractions were obtained: an L-2 fraction enriched in all four lysosomal hydrolases; and an L-1 fraction enriched in a marker enzyme for the plasma membrane. Cathepsin B-like and beta-hexosaminidase activities, but not the other hydrolase activities, were also found to be enriched in the L-1 fractions of the metastatic B16 tumors. We explored the nature of the association of the cathepsin B-like activity with the plasma membrane using fractions from the spontaneously metastatic B16 amelanotic melanoma. Activity could not be dissociated from the plasma membrane fraction by washing with a physiological salt solution suggesting that it was not adsorbed to this fraction nonspecifically, nor could it be displaced by mannose 6-phosphate or other sugars which compete for binding to the known lysosomal receptors. High salt concentrations, low concentrations of the mild detergent saponin, mild acidification, or phosphatidylinositol-specific phospholipase C did not elute the cathepsin B-like activity. However, activity was eluted by exposure to 3-[(3-cholamidopropyl)dimethylammonio]-1-propanesulfonate, a detergent used in the purification of integral membrane proteins. The B16 amelanotic melanoma plasma membrane-associated cathepsin B-like activity had a slightly higher pH optimum and was resistant to inactivation by neutral pH and to inhibition by three low molecular weight inhibitors of cysteine proteinases. The Ki values for inhibition by leupeptin and stefin A were 20-fold higher. The presence of a cathepsin B-like cysteine proteinase at the surface of metastatic tumor cells, particularly in a form which can retain activity at physiological pH and retain activity in the presence of extracellular proteinase inhibitors, may contribute to the focal dissolution of the extracellular matrix observed at sites of contact with invading tumor cells.

Functional evidence of persistent airway obstruction in rats following a two-hour inhalation exposure to methyl isocyanate

Pulmonary function was assessed in male, F344 rats 1,2,4,7, and 13 weeks after a single 2-hr exposure to 0, 3, 10, or 30 ppm methyl isocyanate. No significant changes were observed in the rats exposed to 3 ppm through 13 weeks. Diffusing capacity (DLco), quasistatic lung compliance, and homogeneity of ventilation, as determined by multibreath nitrogen washout, were depressed in the rats exposed to 10 and 30 ppm by 1 week after exposure. None of the rats exposed to 30 ppm survived beyond 1 week. By 13 weeks, dramatic increases in lung volumes were observed in the rats exposed to 10 ppm, while DLco and lung compliance were only mildly affected. However, volume-specific DLco and compliance were depressed in the rats exposed to 10 ppm, suggesting that lung hyperinflation or other compensatory means of increasing lung size occurred in response to the methyl isocyanate-induced lung lesion. This group also exhibited increased expiratory times during tidal breathing and severely impaired distribution of ventilated air. Collectively, these results suggest the development and likely progression of a severe, obstructive airway lesion with associated gas trapping, and the existence of a pronounced concentration-response relationship between 3 and 10 ppm methyl isocyanate exposures.

Pulmonary effects due to short-term exposure to oil fog

Rats were exposed to an oil fog generated by flash vaporation and subsequent condensation of lightweight lubricating oil. Exposures were for 3.5 h/d, 4 d/wk, for 4 wk, at concentrations of 1.5, 0.5, or 0.0 mg/l and a particle size of approximately 1 micron. Samples of respiratory tissues were taken for histopathologic analyses, lavage fluid samples were collected, and pulmonary function measurements were made the day after the last exposure. An accumulation of macrophages within the alveolar lumen, an increase in lavage fluid protein content, and an increase in total cell content in lavage fluid due to an influx of polymorphonuclear leukocytes was noted in rats exposed at the 1.5-mg level. Also, for this exposure group there was an increase in lung wet and dry weight and an increase in end-expiratory volume, and pneumonitis was observed histopathologically in 4 of 10 male rats exposed. Pneumonitis was not observed among six female rats examined. Oil fog had no effect on total lung capacity, residual volume, vital capacity, lung compliance, or the distribution of ventilated air within the lung. Effects following exposure to 0.5 mg/l were limited to slight accumulation of macrophages in the alveolar lumen and an increase in the total cells in lavage fluid, which could not be attributed to an increase in any particular cell type.

Reduced T lymphoid colony growth in patients with progressive systemic sclerosis and rheumatoid arthritis

T cell colony growth in semisolid medium, a sensitive indicator of disease-associated lymphoycte defects, was found to be depressed in patients with PSS and RA. In both disorders, more pronounced abnormalities were observed after incubation with suboptimal concentrations of the polyclonal mitogen PHA. Depletion of monocytes by adherence to plastic surfaces of addition of the prostaglandin synthetase inhibitor indomethacin did not correct the growth abnormality observed in PSS. Reduced colony-forming activity could not be attributed to serum inhibitory factors. The cellular abnormalities detected in patients with these connective tissue diseases were less pronounced than those found in SLE patients.

Genotypic variation in carboxylation of tomatoes

The gas exchange characteristics of 24 genotypes of Lycopersicon esculentum Mill. and one of L. minutum were measured with an infrared gas analyzer and dew point hygrometer in an open system. Net carbon exchange (NCE) and transpiration rate were measured at 50, 100, 150, and 300 mu1 1(-1) CO(2), and a regression of NCE versus internal lead [CO(2)] estimates was calculated. The slope of the regression curve at the CO(2) compensation point was used as the measure of carboxylation efficiency (CE). Significant genotypic differences for CE were obtained. Differences in CE did not appear to be due to differences in diffusive resistance defined as the sum of the boundary layer resistance (r(a)) and the stomatal plus cuticular resistance (r(1)). There was no correlation (r = -0.07) between (r(a) + r(1)) and CE. Within groups with nonsignificantly different means for (r(a) + r(1)) there were genotypes with extremes for CE.The zero CO(2) intercept has been used as an indication of photorespiration. Application of this method revealed a strong inverse relationship between CE and the intercept value, indicating either that photorespiration is related directly to CE or that this method is unreliable for estimating photorespiration. The fact that the variation in CE occurs at light saturation suggests that the observed differences in CE and rates of NCE are determined either by: (a) the concentration and/or kinetic properties of the photochemical reaction centers and associated electron transfer components as they affect the supply of NADPH and ATP and consequently the levels of Calvin cycle intermediates; or (b) the concentration and/or kinetic properties of ribulose 1,5-diphosphate carboxylase.

Use of the albino guinea-pig to detect the skin-sensitizing ability of chemicals

The guinea-pig has been used for over 20 years to demonstrate skin-sensitizing ability in chemical compounds. Correlation between the results of workers in this field is difficult because of the wide range of conditions under which tests for sensitizing potential have been performed. This has made difficult any attempt to compare the relative abilities of various chemical compounds to produce skin sensitization. In a routine test for skin-sensitizing potential, solutions of suspected sensitizing substance have been applied over three days to the ears of guinea-pigs, and the flanks have been challenged one week later with a range of concentrations of suspected sensitizing substance. The erythematous reaction produced 24 hours after challenge was rated and compared with that in unsensitized controls. Various alternative methods of skin testing have been compared with this ear-flank test. The ear-flank test gives good, reproducible results with many classes of chemical compound, including types of compound not previously described as giving rise to sensitization in the guinea-pig or in man, and including some compounds which are known to have carcinogenic potential. It is also demonstrated that sensitizing potential is found more frequently among aromatic (aryl) than aliphatic (alkyl) compounds. Particularly strong sensitization reactions are produced by certain aryl halides, aryl isocyanates, aryl hydrazines, N-nitroso compounds, and aromatic nitroso-compounds. An attempt is made to relate the results of animal tests to reported cases of human skin sensitization.