A comparative analysis of chronic inducible urticaria in 423 patients: Clinical and laboratory features and comorbid conditions

BACKGROUND

Chronic inducible urticaria (CIndU) is a subtype of chronic urticaria (CU) which require specific physical or non-physical triggers to occur. They may be isolated or may coexist with chronic spontaneous urticaria (CSU). Despite their frequent appearance in dermatology clinics, there is scarce information on the distinguishing features among the most common subtypes of CIndU as well as isolated CIndU versus CSU plus CIndU.

OBJECTIVES

To compare clinical and laboratory characteristics, and comorbid conditions among the most common CIndU types and isolated CIndU versus CSU plus CIndU.

METHODS

We retrospectively analysed CIndU patients and compared patients' demographic, clinical and laboratory characteristics across isolated CIndU, CSU plus CIndU, symptomatic dermographism (SD), cold urticaria (ColdU) and cholinergic urticaria (ChoU).

RESULTS

A total of 423 patients (~70% isolated CIndU, ~30% CSU plus CIndU, ~5% mixed CIndU subtypes) were included in the study. The most frequent CIndU subtypes were SD (68.6%; 290/423), ColdU (11.4%; 48/423) and ChoU (10.9%; 46/423). Isolated CIndU patients were younger than CSU plus CIndU (33.74 ± 12.72 vs. 37.06 ± 11.84, p = 0.010). Angioedema, emergency referrals, need for systemic steroids, comorbid systemic disorders were more frequent and baseline urticaria control test scores were lower in CSU plus CIndU patients (vs. CIndU, p < 0.001, p = 0.008, p < 0.001, p = 0.031, p = 0.036, respectively). Among CIndU subtypes, ChoU patients were younger (24.9 ± 12.2 vs. 34.47 ± 12.12 vs. 31.38 ± 14.95; p < 0.001) and had male predominance (p < 0.001) while SD patients had no angioedema (p < 0.001) and had higher frequency of increased total IgE levels (p = 0.006).

CONCLUSIONS

Isolated CIndU and CSU plus CIndU seems to be different endotypes of CU where CSU plus CIndU presents a more severe and refractory course. There are distinctive features of each CIndU subtype. These suggest involvement of different pathomechanistic pathways in these subtypes that need to be clarified in future studies.

Acculturation and Dental Care-Related Anxiety: An Exploratory Assessment from the Hispanic Community Health Study / Study of Latinos

This study aimed to determine the associations between acculturation, dental anxiety, and dental utilization among Hispanics/Latinos living in the US. A proxy measure of dental anxiety was available for 7539 adults who had not visited a dentist within the last year. All completed the Short Acculturation Scale for Hispanics (SASH). Bivariate logistic regression and adjusted multivariable logistic regression analysis were conducted. Approximately 22% of the sample was dentally anxious. Dental anxiety was significantly associated with SASH language scale score (OR 1.09, 95%CI 1.02, 1.18, p = 0.04), years in US (OR 1.53, 95%CI 1.23, 1.91, p < 0.0001), and preferred Spanish language (OR 1.30, 95%CI 1.05, 1.63, p = 0.0192); lower acculturation corresponded to higher dental anxiety. Adjusting for sex, age, education, income, insurance, and oral health status, level of acculturation was associated with dental anxiety (AOR 0.87, 95%CI 0.75, 0.91, p = 0.009), but neither were associated with utilization. Acculturation may be an important predictor of dental anxiety for Hispanics/Latinos living in the US.

AN ACTION PLAN FOR ORGANIZATIONS SERVING OLDER ADULTS AND THEIR CAREGIVERS DURING PUBLIC HEALTH EMERGENCIES

During public health emergencies, it is critical to maintain the continuity of services and resources essential to health and safety. Public health emergencies can disproportionately affect older adults and their caregivers. Organizations, including community-based, faith-based, rural, and tribal organizations, can play a vital role during a public health emergency response given their familiarity with the community’s unique needs and resources. With support from the CDC Foundation and technical assistance from the Centers for Disease Control and Prevention, NORC at the University of Chicago conducted a study to identify public health interventions to meet the needs of older adults and their caregivers during public health emergencies. Methods included an extensive search of peer-reviewed and grey literature in Spanish and English to identify interventions on six topics: deconditioning; deferral of medical care; elder abuse and neglect; management of chronic conditions; social isolation; and caregiving. NORC identified 300 public health interventions to support older adults and their caregivers during public health emergencies with a focus on underserved populations, including programs to support racial and ethnic minority populations, people with disabilities, and rural and tribal communities. NORC developed Search. Find. Help., a virtual resource library, and an Action Plan to support organizations in using these interventions. Search. Find. Help., which houses the Action Plan, has had 34,000 unique users. This session focuses on how organizations that serve older adults and caregivers can use the Action Plan’s four phases to select, adapt, implement, and evaluate public health interventions before or during a public health emergency.

Farmland Preservation and Urban Expansion: Case Study of Southern Ontario, Canada

Farmland is an essential resource for the sustainability and security of human food systems. Preserving an agricultural land base is critical, as it is significantly affected by local, national, and global urbanization. This research introduces a case of farmland preservation in southern Ontario. This area contains some of Canada's most finite and productive soils but has an agricultural system facing enormous pressure from urban expansion. This paper reviews the farmland preservation policy framework within Ontario and provides insight into the role of different levels of government in protecting this critical resource. It also provides data at a regional level that provides the basis to evaluate the success of provincial and local policies. By tracking agricultural land conversion through local Official Plan Amendments (OPAs), this study documents farmland loss across southern Ontario between 2000 and 2017. Implemented and approved by local government and designed with public input, municipal Official Plans outline and describe land-use planning policies on how municipalities should use lands to meet community needs and desires. OPAs are formal and legally binding administrative changes to a municipal Official Plan decided through an open public process, which are required to change local land-use designations that conform with the long-term vision for growth and physical development. These OPAs may include the conversion of farmlands for non-farm uses (or, in contrast, the protection of agricultural lands). Over time, they will reveal the loss of farmlands in each community for different uses (and reflect changing priorities). Using OPAs to track the conversion of prime agricultural land is an innovative and rigorous methodological contribution, given the lack of data documenting long-term changes to the availability of agricultural lands and the impacts of urbanization on farmland conversion. Measuring farmland loss with this approach can be transferred and applied to contexts where municipalities are the entities responsible for agricultural land-use planning, outside of Ontario and beyond. Data from 36 counties/regions shows that the provincial policies and local planning framework have worked in tandem to affect the agricultural land base in southern Ontario significantly. In Central Ontario, the most urbanized area of Canada, the Province's Greenbelt Plan has significantly reduced the rates of farmland loss since 2005, while the Growth Plan and other policies contributed to enhanced municipal control over agricultural land conversion. Specifically, the Inner Ring municipalities have played increasingly active roles in agricultural land protection with both planning approaches and local initiatives. Outer Ring municipalities have seen increasing urbanization pressure. Data on farmland loss for non-agricultural use showed large-scale municipal-led urban boundary expansions and small-scale individual applications on policy changes. In Western Ontario, over the past two decades, there has been no obvious upward or downward trend of farmland loss. Most of the farmland conversion cases in this region were small-scale applications to create small lots on existing agricultural land to allow non-agricultural uses such as commercial, recreational, residential, and agricultural-related facilities. Since 2000, Southeastern Ontario, which has the smallest provincial share of prime agricultural land, has experienced limited farmland loss, consisting primarily of small-scale, individual applications on land-use re-designations (partially reflecting reduced acreages of prime agricultural land). The provincial policy impact on farmland preservation is not as evident in this region. The findings and methodology of this study contribute to the groundwork on farmland availability and land-use planning policy development and research by providing a baseline enumeration of farmland availability and the effect of farmland protection policies at provincial and municipal levels within Ontario's land use planning regime.

Meeting Needs of Diverse Older Adults and Caregivers During Public Health Emergencies: What Can We Learn From COVID-19?

With support from the CDC Foundation and technical assistance from the Centers for Disease Control and Prevention, NORC at the University of Chicago conducted studies to examine the needs and concerns of older adults and unpaid caregivers during COVID-19, including their trusted sources of COVID-19 information and available public health interventions. Methods included a nationally representative survey of 1,030 adults aged 50+ years using computer-assisted telephone and web interviewing; online focus groups with older adults and caregivers in Spanish and English; a survey and interviews with stakeholder organizations; secondary analysis of U.S. caregiver surveys; analysis of public social media posts; and searches of peer-reviewed and grey literature in Spanish and English to identify interventions. Results suggest that needs and concerns differed among older adult subpopulations, including racial and ethnic minority populations, people with lower incomes, rural and tribal populations, people with limited English proficiency, and people with disabilities as well as caregivers. Older adults perceived news media, the internet, and healthcare providers as important resources for COVID-19 information, although trusted sources varied by race and ethnicity, urbanicity, and income. Findings suggested the need to increase awareness of existing public health interventions and resources to support older adults and caregivers during public health emergencies like COVID-19. Strategies for tailoring communication for diverse older adults and caregivers include partnering with national organizations, leveraging community-level infrastructure, and disseminating information through trusted sources. Studying the needs of older adults and caregivers during COVID-19 can inform future public health emergency response priorities.

SARS-CoV-2 prevalence and immunity: a hospital-based study from Malawi

Background

COVID-19 transmission and disease dynamics in sub-Saharan Africa are not well understood. Our study aims to provide insight into COVID-19 epidemiology in Malawi by estimating SARS-CoV-2 prevalence and immunity after SARS-CoV-2 infection in a hospital-based setting.

Methods

We conducted a hospital-based, convenience sampling, cross-sectional survey for SARS-CoV-2 in Lilongwe, Malawi. Participants answered a questionnaire and were tested for SARS-CoV-2 by enzyme-linked immunosorbent assay and real-time reverse-transcription polymerase chain reaction (RT-PCR). A surrogate virus neutralization test (sVNT) was performed in seropositive samples to estimate immunity. Poisson regression was used to assess SARS-CoV-2 point prevalence association with demographic and behavioral variables.

Findings

The study included 930 participants. We found a combined point prevalence of 10.1%. Separately analyzed, RT-PCR positivity was 2.0%, and seropositivity was 9.3%. Of tested seropositive samples, 90.1% were sVNT positive. We found a high rate (45.7%) of asymptomatic SARS-CoV-2 infection. SARS-CoV-2 point prevalence was significantly associated with being a healthcare worker.

Interpretation

Our study suggests that official data underestimate COVID-19 transmission. Using sVNTs to estimate immunity in Malawi is feasible and revealed considerable post-infection immunity in our cohort. Subclinical infection and transmission are probably a game-changer in surveillance, mitigation and vaccination strategies.

Interprofessional learning in ambulatory care

BACKGROUND

Interprofessional practice amongst health care professionals can facilitate effective collaboration and can improve health outcomes for patients. Interprofessional clinical placements have mainly been established within inpatient settings; however, ambulatory care settings can also provide interprofessional education. This study evaluates an interprofessional placement in ambulatory care for medical and nursing students.

METHODS

Medical and nursing students undertook a 2-week interprofessional placement in respiratory, diabetes and chronic pain clinics, as well as within the patient's home. An electronic post-placement survey including 14 fixed-response and five open-ended questions was conducted to evaluate the students' experiences.

RESULTS

Ninety-two students undertook the interprofessional placement: 74% were medical students and 26% were nursing students. The overall response rate was 81%. Students strongly supported the model of clinical supervision with the nurse educator and teaching registrar working collaboratively to facilitate the placement. Both medical and nursing students felt that the placement facilitated the development of interprofessional principles, with 78.7% agreeing or strongly agreeing with the statement 'the clinical placement allowed me to reflect on interprofessional learning and practice'. In terms of future practice, 67% of medical students and 81% of nursing students agreed that 'this placement has altered how [they] will practice as a professional in the future'. Interprofessional practice can facilitate effective collaboration and can improve health outcomes for patients DISCUSSION: Medical and nursing students found that the ambulatory care setting facilitated a mix of learning opportunities that complemented learning from the inpatient setting, and the interactions with other health professionals provided a valuable learning experience that contributed to their understanding of interprofessional practice.

Medical Informatics and the Quality of Health: New Approaches to Support Patient Care

Objectives: The Yearbook of Medical Informatics is published annually by the International Medical Informatics Association (IMIA) and contains a selection of excellent papers on medical informatics research which have been recently published (www.yearbook.uni-hd.de). The 2003 Yearbook of Medical Informatics took as its theme the role of medical informatics for the quality of health care. In this paper, we will discuss challenges for health care, and the lessons learned from editing IMIA Yearbook 2003.

Results and Conclusions: Modern information processing methodology and information and communication technology have strongly influenced our societies and health care. As a consequence of this, medical informatics as a discipline has taken a leading role in the further development of health care. This involves developing information systems that enhance opportunities for global access to health services and medical knowledge. Informatics methodology and technology will facilitate high quality of care in aging societies, and will decrease the possibilities of health care errors. It will also enable the dissemination of the latest medical and health information on the web to consumers and health care providers alike. The selected papers of the IMIA Yearbook 2003 present clear examples and future challenges, and they highlight how various sub-disciplines of medical informatics can contribute to this.

Digital Libraries and Recent Medical Informatics Research

The Yearbook of Medical Informatics is published annually by the International Medical Informatics Association (IMIA) and contains a selection of recent excellent papers on medical informatics research (http://www.med.uni-heidelberg.de/mi/yearbook/index.htm). The special topic of the just published Yearbook 2001 is “Digital Libraries and Medicine”. Digital libraries have changed dramatically and will continue to change the way we work with medical knowledge. The selected papers present recent research and new results on digital libraries. As usual, the Yearbook 2001 also contains a variety of papers on other subjects relevant to medical informatics, such as Electronic Patient Records, Health Information Systems, Health and Clinical Management, Decision Support Systems, Education, as well as Image and Signal Processing. This paper will briefly introduce the contributions covering digital libraries and will show how medical informatics research contributes to this important topic.

Medical Imaging Informatics and Medical Informatics: Opportunities and Constraints

Objectives: The Yearbook of Medical Informatics is published annually by the International Medical Informatics Association (IMIA) and contains a selection of recent excellent papers on medical informatics research (http://www.yearbook.uni-hd.de). The 2002 Yearbook of Medical Informatics took as its theme the topic of Medical Imaging Informatics. In this paper, we will summarize the contributions of medical informatics researchers to the development of medical imaging informatics, discuss challenges and opportunities of imaging informatics, and present the lessons learned from the IMIA Yearbook 2002.

Results and Conclusions: Medical informatics researchers have contributed to the development of medical imaging methods and systems since the inception of this field approximately 40 years ago. The Yearbook presents selected papers and reviews on this important topic.

In addition, as usual, the Yearbook 2002 also contains a variety of papers and reviews on other subjects relevant to medical informatics, such as Bioinformatics, Computer-supported education, Health and clinical management, Health information systems, Knowledge processing and decision support, Patient records, and Signal processing.

Towards Clinical Bioinformatics: Advancing Genomic Medicine with Informatics Methods and Tools

Objectives: To summarize the challenges facing clinical applications in the light of growing research results in genomic medicine and bioinformatics.

Methods: Analysis of the contents of the Yearbook of Medical Informatics 2004 of the International Medical Informatics Association (IMIA).

Results: The Yearbook of Medical Informatics 2004 includes 32 articles selected from 22 peer-reviewed scientific journals. A special section on clinical bio-informatics highlights recent developments in this field. Several guest editors review the promises and limitations of available methods and resources from biomedical informatics that are relevant to clinical medicine. Integrated data and knowledge resources are generally regarded to be central and key issues for clinical bioinformatics. Further review papers deal with public health implications of bioinformatics, knowledge management and trends in health care education. The Yearbook includes for the first time a section on the history of medical informatics, where the significant impact of the Reisensburg protocol 1973 on international health and medical informatics education is examined.

Conclusions: Close collaboration between bio-informatics and medical informatics researchers can contribute to new insights in genomic medicine and contribute towards the more efficient and effective use of genomic data to advance clinical care.

Challenges and Perspectives of Computerassisted Instruction in Medical Education

Objectives: In this paper we discuss solutions to the problem that medical teachers and students do not use modern computer-assisted instruction systems in medical education as much as expected by their developers.

Methods: As an example for a modern problem-based CAI system we introduce the CAMPUS shell system for case-based training in medicine.

Results: CAMPUS has received several awards and positive evaluation results. Nevertheless, the usage of such systems in courses and for self-study could be increased.

Conclusions: Curricular integration of CAI as well as further improvements on existing CAI systems to increase the usage in medical education is essential.

Time to endoscopic intervention in patients with upper gastrointestinal patients can be improved with pathway provision

Background

Patients with upper gastrointestinal malignancy often require admission to hospital with dysphagia or jaundice requiring therapeutic endoscopy. Endoscopic intervention is often effective permitting rapid discharge. An efficient service would permit rapid discharge for patients who are often at the end of life. We noted that a majority of patients in hospital under the gastroenterological oncology were admitted with symptoms requiring therapeutic endoscopy.

Methods

We conducted an audit cycle of the inpatient days before and after pathway implementation.

A wait of 1 day was set as acceptable for patients with bleeding as defined by NICE guidance and we set an arbitrary standard of 2 days for patients without bleeding but requiring therapeutic endoscopy. Between the audit cycles, a pathway was built to accommodate these patients.

Results

Inpatient waits improved from a median of 3 days to 1 day. There was no difference in outcome between those presenting with bleeding and other symptoms or any difference in patients requiring different procedures.

Conclusions

Waiting times for endoscopy can be improved with the introduction of a targeted pathway of cancer patients. Further issues including cost, quality of life and nutrition require further intervention.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3335-0) contains supplementary material, which is available to authorized users.

The relationship between d-beta-hydroxybutyrate blood concentrations and seizure control in children treated with the ketogenic diet for medically intractable epilepsy

Objective

The ketogenic diet (KD) is a proven treatment for drug‐resistant (DR) seizures in children and adolescents. However, the relationship between seizure control and the most commonly measured metabolite of the diet, the ketone body d‐beta‐hydroxybutyrate (D‐BHB), is controversial. This study was performed to clarify the relationship because specific ketone bodies may be useful as biomarkers of diet efficacy.

Methods

Families of children with DR seizures were approached for participation in this open‐label, prospective study when they were referred for the KD at two western Canadian children's hospitals. Inclusion criteria included documentation of DR seizures without exclusion based on age, sex, seizure, or syndrome type. Patients were excluded if they were referred for treatment of a metabolic disorder independent of seizures. Seizures were quantified via parental report and standardized as seizure frequency per 28 days. Epilepsy syndromes were identified on the basis of the medical record. Blood D‐BHB was determined by tandem mass spectrometry.

Results

A total of 23 patients were recruited from both sites. Data from five individuals were excluded because these seizures occurred in clusters, leaving 18 patients for the primary analysis. In the latter group, a clear positive correlation was present between measures of seizure frequency and D‐BHB concentrations. However, this failed to reach statistical significance, likely because of the relatively small numbers.

Significance

A trend clearly exists between seizure frequency and D‐BHB levels, so we should not be dissuaded by the lack of statistical significance because it possibly results from methodological techniques, especially sample size. These results call for a larger prospective study in which seizure frequency is assessed at the point of care in a standardized fashion so as to determine whether D‐BHB can be used as a reliable biomarker of KD efficacy.

PolyICLC Exerts Pro- and Anti-HIV Effects on the DC-T Cell Milieu In Vitro and In Vivo

Myeloid dendritic cells (mDCs) contribute to both HIV pathogenesis and elicitation of antiviral immunity. Understanding how mDC responses to stimuli shape HIV infection outcomes will inform HIV prevention and treatment strategies. The long double-stranded RNA (dsRNA) viral mimic, polyinosinic polycytidylic acid (polyIC, PIC) potently stimulates DCs to focus Th1 responses, triggers direct antiviral activity in vitro, and boosts anti-HIV responses in vivo. Stabilized polyICLC (PICLC) is being developed for vaccine adjuvant applications in humans, making it critical to understand how mDC sensing of PICLC influences HIV infection. Using the monocyte-derived DC (moDC) model, we sought to describe how PICLC (vs. other dsRNAs) impacts HIV infection within DCs and DC-T cell mixtures. We extended this work to in vivo macaque rectal transmission studies by administering PICLC with or before rectal SIVmac239 (SIVwt) or SIVmac239ΔNef (SIVΔNef) challenge. Like PIC, PICLC activated DCs and T cells, increased expression of α₄β₇ and CD169, and induced type I IFN responses in vitro. The type of dsRNA and timing of dsRNA exposure differentially impacted in vitro DC-driven HIV infection. Rectal PICLC treatment similarly induced DC and T cell activation and pro- and anti-HIV factors locally and systemically. Importantly, this did not enhance SIV transmission in vivo. Instead, SIV acquisition was marginally reduced after a single high dose challenge. Interestingly, in the PICLC-treated, SIVΔNef-infected animals, SIVΔNef viremia was higher, in line with the importance of DC and T cell activation in SIVΔNef replication. In the right combination anti-HIV strategy, PICLC has the potential to limit HIV infection and boost HIV immunity.

Modeling the spread of polio in an IPV-vaccinated population: lessons learned from the 2013 silent outbreak in southern Israel

BACKGROUND

Polio eradication is an extraordinary globally coordinated health program in terms of its magnitude and reach, leading to the elimination of wild poliovirus (WPV) in most parts of the world. In 2013, a silent outbreak of WPV was detected in Israel, a country using an inactivated polio vaccine (IPV) exclusively since 2005. The outbreak was detected using environmental surveillance (ES) of sewage reservoirs. Stool surveys indicated the outbreak to be restricted mainly to children under the age of 10 in the Bedouin population of southern Israel. In order to curtail the outbreak, a nationwide vaccination campaign using oral polio vaccine (OPV) was conducted, targeting all children under 10.

METHODS

A transmission model, fitted to the results of the stool surveys, with additional conditions set by the ES measurements, was used to evaluate the prevalence of WPV in Bedouin children and the effectiveness of the vaccination campaign. Employing the parameter estimates of the model fitting, the model was used to investigate the effect of alternative timings, coverages and dosages of the OPV campaign on the outcome of the outbreak.

RESULTS

The mean estimate for the mean reproductive number was 1.77 (95 % credible interval, 1.46-2.30). With seasonal variation, the reproductive number maximum range was between zero and six. The mean estimate for the mean infectious periods was 16.8 (8.6-24.9) days. The modeling indicates the OPV campaign was effective in curtailing the outbreak. The mean estimate for the attack rate in Bedouin children under 10 at the end of 2014 was 42 % (22-65 %), whereas without the campaign the mean projected attack rate was 57 % (35-74 %). The campaign also likely shortened the duration of the outbreak by a mean estimate of 309 (2-846) days. A faster initiation of the OPV campaign could have reduced the incidence of WPV even if a lower coverage was reached, at the risk of prolonging the outbreak.

CONCLUSIONS

OPV campaigns are essential for interrupting WPV transmission, even in a developed country setting with a high coverage of IPV. In this setting, establishing ES of WPV circulation is particularly crucial for early detection and containment of an outbreak.

Palliative care health professionals’ experiences of caring for patients with advance care directives

Objective To explore the health professionals’ (HPs) perceptions and experiences of advance care directives (ACDs) and advance care planning in Australian palliative care services. Methods A nationwide survey of 105 palliative care services was conducted, with two HPs from each service invited to participate. A qualitative analysis of open responses about advance care planning was undertaken. Results Sixty questionnaires were returned with open responses. Most responders were nurses (75%), aged ≥40 years (80%) and with a mean of 12 years palliative care experience. Data were grouped into four key themes: (1) the ACD; (2) the process of developing ACDs; (3) the process of using ACDs; and (4) the consequences of having ACDs. Participants were positive about advance care planning, commenting that ongoing communication about end-of-life care ensures mutual understanding between patients, family and HPs. Provision of care was considered easier and more efficient with an ACD in place. ACDs were perceived to reduce distrust and conflict between family, friends and HPs, and promote communication. Suboptimal documentation, clarity and explicitness limited the usefulness of ACDs when they were available. Conclusions Advance care planning benefits HPs, patients and their family. To maximise these benefits, ACDs need to be clear, comprehensive, medically relevant and transportable documents. What is known about the topic? Ideally, advance care planning encompasses the identification and documentation of a person’s preferences for future medical treatments and care in preparation for an occasion when the person cannot express their values and wishes. The uptake and practice of advance care planning is inconsistent, and the extent to which it is used by health professionals and patients is variable. Many people are cared for at the end of life in specialist palliative care services, but the intersection between palliative care and advance care planning remains under-researched. What does this paper adds? ACDs facilitate communication and advance care planning; help establish trust between health professionals, patients and their families; and make multiple aspects of care easier for HPs. Processes surrounding ACDs, particularly inadequate documentation, limit adherence and application. What are the implications for practitioners? Clear communication is necessary for effective ACD development and application. The presence of an ACD makes communication and advance care planning easier, and improves trust between HPs, patients and their family. To be useful, ACDs must be clear, comprehensive, medically relevant, transportable documents.

An intravaginal ring that releases the NNRTI MIV-150 reduces SHIV transmission in macaques

Microbicides may prevent HIV and sexually transmitted infections (STIs) in women; however, determining the optimal means of delivery of active pharmaceutical ingredients remains a major challenge. We previously demonstrated that a vaginal gel containing the non-nucleoside reverse transcriptase inhibitor MIV-150 partially protected macaques from SHIV-RT (simian/HIV reverse transcriptase) infection, and the addition of zinc acetate rendered the gel significantly protective. We test the activity of MIV-150 without the addition of zinc acetate when delivered from either ethylene vinyl acetate (EVA) or silicone intravaginal rings (IVRs). MIV-150 was successfully delivered, because it was detected in vaginal fluids and tissues by radioimmunoassay in pharmacokinetic studies. Moreover, EVA IVRs significantly protected macaques from SHIV-RT infection. Our results demonstrate that MIV-150-containing IVRs have the potential to prevent HIV infection and highlight the possible use of IVRs for delivering drugs that block HIV and other STIs.

Maps and missing malaria--if in doubt request a blood film

The severe sequelae of infection from the conventionally termed ‘benign’ forms of malaria are being increasingly recognised, and delayed diagnosis and treatment lead to worse outcomes. The clinical picture can be non-specific and malaria epidemiology is constantly changing, presenting challenges for the acute clinician. The most critical step in the diagnosis of patients presenting in the U.K. is the clinician’s awareness of the disease and its key presenting features. We describe a case of Plasmodium vivax malaria in a young man who presented with fever and diarrhoea, who had never travelled to a recognised malaria-endemic area.

The nonnucleoside reverse transcription inhibitor MIV-160 delivered from an intravaginal ring, but not from a carrageenan gel, protects against simian/human immunodeficiency virus-RT Infection

We previously showed that a carrageenan (CG) gel containing 50 μM MIV-150 (MIV-150/CG) reduced vaginal simian/human immunodeficiency virus (SHIV)-RT infection of macaques (56%, p>0.05) when administered daily for 2 weeks with the last dose given 8 h before challenge. Additionally, when 100 mg of MIV-150 was loaded into an intravaginal ring (IVR) inserted 24 h before challenge and removed 2 weeks after challenge, >80% protection was observed (p<0.03). MIV-160 is a related NNRTI with a similar IC(50), greater aqueous solubility, and a shorter synthesis. To objectively compare MIV-160 with MIV-150, herein we evaluated the antiviral effects of unformulated MIV-160 in vitro as well as the in vivo protection afforded by MIV-160 delivered in CG (MIV-160/CG gel) and in an IVR under regimens used with MIV-150 in earlier studies. Like MIV-150, MIV-160 exhibited potent antiviral activity against SHIV-RT in macaque vaginal explants. However, formulated MIV-160 exhibited divergent effects in vivo. The MIV-160/CG gel offered no protection compared to CG alone, whereas the MIV-160 IVRs protected significantly. Importantly, the results of in vitro release studies of the MIV-160/CG gel and the MIV-160 IVR suggested that in vivo efficacy paralleled the amount of MIV-160 released in vitro. Hundreds of micrograms of MIV-160 were released daily from IVRs while undetectable amounts of MIV-160 were released from the CG gel. Our findings highlight the importance of testing different modalities of microbicide delivery to identify the optimal formulation for efficacy in vivo.

A single dose of a MIV-150/Zinc acetate gel provides 24 h of protection against vaginal simian human immunodeficiency virus reverse transcriptase infection, with more limited protection rectally 8-24 h after gel use

Previously we showed that repeated vaginal application of a MIV-150/zinc acetate carrageenan (MIV-150/ZA/CG) gel and a zinc acetate carrageenan (ZA/CG) gel significantly protected macaques from vaginal simian human immunodeficiency virus reverse transcriptase (SHIV-RT) infection. Gels were applied either daily for 2 weeks or every other day for 4 weeks, and the animals were challenged 4-24 h later. Herein, we examined the effects of a single vaginal dose administered either before or after virus challenge. Encouraged by the vaginal protection seen with MIV-150/ZA/CG, we also tested it rectally. Vaginal applications of MIV-150/ZA/CG, ZA/CG, and CG gel were performed once 8-24 h before, 1 h after, or 24 h before and 1 h after vaginal challenge. Rectal applications of MIV-150/ZA/CG and CG gel were performed once 8 or 24 h before rectal challenge. While vaginal pre-challenge and pre/post-challenge application of MIV-150/ZA/CG gel offered significant protection (88%, p<0.002), post-challenge application alone did not significantly protect. ZA/CG gel reduced infection prechallenge, but not significantly, and the effect was completely lost post-challenge. Rectal application of MIV-150/ZA/CG gel afforded limited protection against rectal challenge when applied 8-24 h before challenge. Thus, MIV-150/ZA/CG gel is a highly effective vaginal microbicide that demonstrates 24 h of protection from vaginal infection and may demonstrate efficacy against rectal infection when given close to the time of HIV exposure.

Spin Interactions in bcc and fcc Fe beyond the Heisenberg Model

Usually, the adiabatic magnetic exchange-energy hypersurface is parametrized in terms of the bilinear Heisenberg interactions in pairs of atoms. For general magnetic configurations, this model is not complete even if it includes pairs with up to infinite interatomic distances. In contrast, the modeling by an in principle infinite spin-cluster expansion is complete for all conceivable magnetic configurations. In the present Letter, it is shown for bcc and fcc iron that a very accurate representation can be reached with a finite expansion with 20 terms which include biquadratic or multispin non-Heisenberg interactions.

Microbiological Survey of Adirondack Lakes with Various pH Values

Nine high-altitude oligotrophic Adirondack lakes in upstate New York having water of pH 4.3 to 7.0 were surveyed for total bacterial numbers and possible adaptation of the microbial communities to environmental pH. The number of heterotrophic bacteria from water samples recoverable on standard plate count agar were low (10 to 10 per ml) for most of the lakes. Acridine orange direct counts were approximately two orders of magnitude higher than plate counts for each lake. Sediment aerobic heterotrophs recovered on standard plate count agar ranged from 1.4 x 10 to 1.3 x 10 per g of sediment. Direct epifluorescence counts of bacteria in sediment samples ranged from 3.0 x 10 to 1.4 x 10 per g. Low density values were consistent with the oligotrophic nature of all the lakes surveyed. There were no apparent differences in numbers of bacteria originally isolated at pH 5.0 and pH 7.0 between circumneutral lakes (pH > 6.0) and acidic lakes (pH < 5.0). Approximately 1,200 isolates were recultured over a range of pH from 3.0 to 7.0. Regardless of the original isolation pH (pH 5.0 or pH 7.0), less than 10% of the isolates grew at pH < 5.0. Those originally isolated at pH 5.0 also grew at pH 6.0 and 7.0. Those originally isolated at pH 7.0 preferred pH 7.0, with 98% able to grow at pH 6.0 and 44% able to grow at pH 5.0. A chi-square contingency test clearly showed (P < 0.005) that two distinct heterotrophic populations had been originally isolated at pH 5.0 and pH 7.0, although there is undoubtedly some overlap between the two populations.

When crises collide: how intimate partner violence and poverty intersect to shape women's mental health and coping?

Until recently, the connection between intimate partner violence (IPV) and persistent poverty had been largely ignored. Recent research indicates, however, that the two phenomena cooccur at high rates; produce parallel effects; and, in each other's presence, constrain coping options. Therefore, both external situational, and internal psychological difficulties are missed when women contending with both poverty and IPV are viewed through the lens of just one or just the other. This article describes mental health consequences for women who contend with both partner violence and poverty. It proposes that the stress, powerlessness, and social isolation at the heart of both phenomena combine to produce posttraumatic stress disorder, depression, and other emotional difficulties. The article also introduces the term ''survival-focused coping'' to describe women's methods of coping with IPV in the context of poverty and highlights the role that domestic violence advocates, mental health providers, and researchers can play in addressing these tightly intertwined phenomena.

A new invasion score for determining the resectability of pancreatic carcinomas with contrast-enhanced multidetector computed tomography

OBJECTIVE

It was the aim of this study to evaluate a new infiltration score to determine the resectability of pancreatic carcinomas in preoperative planning.

MATERIALS AND METHODS

Eighty patients with suspected pancreatic tumor were examined prospectively using 16-row spiral CT. The scans were evaluated for the presence of pancreatic carcinoma, peripancreatic tumor extension and vascular invasion using a standardized questionnaire. Invasion of the surgically relevant vessels was evaluated using a new invasion score. The operative and histological findings and the clinical follow-up served as the gold standard.

RESULTS

Forty patients had a pancreatic carcinoma, 5 had metastasis of a different primary tumor, and in 35 patients, there was no malignant pancreatic disease. The sensitivity for tumor detection was 100%, with a specificity of 88% for differentiating between malignant and benign pancreatic tumors. Invasion of the surrounding vessels was evaluated correctly using the invasion score, with a sensitivity of 89% and a specificity of 99%. In evaluation of resectability, a sensitivity of 94% and a specificity of 89% were achieved.

CONCLUSION

Using 16-row spiral CT, the invasion score is a valid tool for correctly assessing invasion in relevant vessels in cases of pancreatic carcinoma and for determining resectability.

Challenges and perspectives of computer-assisted instruction in medical education: lessons learned from seven years of experience with the CAMPUS system

OBJECTIVES

In this paper we discuss solutions to the problem that medical teachers and students do not use modern computer-assisted instruction systems in medical education as much as expected by their developers.

METHODS

As an example for a modern problem-based CAI system we introduce the CAMPUS shell system for case-based training in medicine.

RESULTS

CAMPUS has received several awards and positive evaluation results. Nevertheless, the usage of such systems in courses and for self-study could be increased.

CONCLUSIONS

Curricular integration of CAI as well as further improvements on existing CAI systems to increase the usage in medical education is essential.

[Autoimmune pancreatitis--a surgical disease?]

The term autoimmune pancreatitis (AIP) describes a nonalcoholic, chronic lymphoplasmocytic pancreatitis. The lymphoplasmocytic infiltration is characterized by periductal localization of predominantly CD4-positive T cells, fibrosis, and acinar atrophy, frequently resulting in stenosis of the main pancreatic and distal common bile ducts. Imaging studies often reveal a diffuse narrowing of the pancreatic main duct and swelling of the pancreatic head wrongly suggesting the presence of a malignant tumor. Clinical signs include mild abdominal pain, jaundice, recurrent episodes of acute pancreatitis, and even new-onset diabetes mellitus. Additionally, AIP can be associated with other autoimmune diseases such as Sjögren's syndrome, primary sclerosing cholangitis, chronic inflammatory bowel diseases, and retroperitoneal fibrosis. Serological markers include autoantibodies and increased levels of gamma globulin and especially IgG4. Steroids seem to be effective in improving clinical symptoms as well as in the resolution of pancreatic and bile duct narrowing. This distinguishes AIP from other forms of pancreatitis and from pancreatic neoplasms. Further studies of the underlying pathophysiologic mechanisms, prognosis, and new diagnostic tools are needed to provide adequate and effective treatment in the future. In this article, we summarize the current knowledge about AIP and present 17 cases that underwent surgical resection at our institution from 2003 to 2004.