Medical Student Interest in Straight-from-Medical-School Child and Adolescent Psychiatry Specialization

OBJECTIVE

The authors investigated fourth-year medical students' interest in straight-from-medical-school residency training resulting in specialization in child and adolescent psychiatry (CAP) and why students are interested in these options. They also examined factors influencing medical student choice of specialty.

METHODS

The authors distributed an online survey to two consecutive classes of fourth-year students at an urban, public, allopathic medical school. Students were asked about interest in 3-, 4-, and 5-year tracks resulting in board certification in CAP only or CAP and general psychiatry,  factors impacting their interest and CAP-related experiences.

RESULTS

Of 397 students surveyed, 168 (42.3%) responded. Twenty-two students (14.3%) reported psychiatry as a first-choice specialty and 18 (13.1%) reported Pediatrics. Fifty of the students (30%) indicated interest in at least one of the CAP tracks, with those interested in Psychiatry more likely to be interested in all track options. Students interested in Pediatrics were more likely to indicate interest in the 3-year CAP-only track (p < 0.05). Students interested in family medicine were more likely to indicate interest in the 4-year adult and CAP residency track (p < 0.05). Among all students, the 4-year combined CAP and adult track was the most popular.

CONCLUSION

In this pilot survey, medical students in their 4th year of training, especially those interested in applying to psychiatry, were interested in residencies allowing for specialization in CAP in fewer years. Medical students whose first choice specialty was Pediatrics or Family Medicine also expressed interest. Given the CAP workforce shortage, creation of this type warrants further investigation.

Lifelong reductions of PKMζ in ventral hippocampus of nonhuman primates exposed to early-life adversity due to unpredictable maternal care

Protein kinase Mζ (PKMζ) maintains long-term potentiation (LTP) and long-term memory through persistent increases in kinase expression. Early-life adversity is a precursor to adult mood and anxiety disorders, in part, through persistent disruption of emotional memory throughout life. Here we subjected 10- to 16-wk-old male bonnet macaques to adversity by a maternal variable-foraging demand paradigm. We then examined PKMζ expression in their ventral hippocampi as 7- to 12-yr-old adults. Quantitative immunohistochemistry reveals decreased PKMζ in dentate gyrus, CA1, and subiculum of subjects who had experienced early-life adversity due to the unpredictability of maternal care. Adult animals with persistent decrements of PKMζ in ventral hippocampus express timid rather than confrontational responses to a human intruder. Persistent down-regulation of PKMζ in the ventral hippocampus might reduce the capacity for emotional memory maintenance and contribute to the long-lasting emotional effects of early-life adversity.

173 Early Results of a Variable-Angle Volar Locking Plate for Distal Radius Fractures: A Bi-Centre Study

Introduction

This study examines the clinical, functional and radiological outcomes of distal radius fracture fixation with the Aptus® (Medartis, Pennsylvania) locking plate in order to determine its efficacy and to identify notable findings related to treatment variations.

Method

This is a retrospective bi-centre study collecting patient details from a District General Hospital and a Regional Hand Unit. We assessed 61 consecutive patients with distal radius fractures (AO grade A = 19, B = 9, C = 33) fixed using Aptus® plate with a minimum of six months follow-up. Outcome measures included the DASH score, wrist range of movement and grip strength, and complications. Radiographs were reviewed to assess restoration of anatomy and union.

Results

All but two fractures united within six weeks. Mean ranges of movement were only mildly restricted compared to the normal wrist (flexion/extension = 102°; radial/ulna deviation = 53°; pronation/supination = 169°). Mean postoperative grip strength was 23.8kg which was comparable to the contralateral side at 31.5kg. The mean DASH score was 18.2. Seven patients had screws misplaced outside the distal radius although three of these remained asymptomatic.

Conclusions

Variable-angle locking systems benefit from flexibility of implant positioning and may allow enhanced inter-fragmentary reduction for accurate fixation of intra-articular fractures.

Role legitimacy, comfort and confidence providing tobacco, alcohol and other drug care: a cross-sectional study of Australian early-career general practitioners

Australian general practitioners (GPs) see most Australians each year and, as tobacco, alcohol and other drug use (substance use) are common, GPs often see problematic, risky or dependent substance use. This study aimed to explore early-career GPs' role legitimacy, comfort and confidence managing patients with problematic use of tobacco, alcohol, psychoactive pharmaceutical or illicit substances.Using the '5A's framework: Ask, Assess, Advise, Assist and Arrange, we surveyed 251 early-career GPs (GP registrars) on role legitimacy, confidence managing patient substance use, and sources of clinical information, advice and support.There was strong agreement that managing substance use is a GP's role, with high levels of confidence 'Asking' (screening) about tobacco and alcohol use, which decreased across other substance classes. Early-career GPs reported lower levels of confidence 'Assessing' and 'Advising' (brief interventions); and much lower levels of confidence 'Assisting' (treating) and 'Arranging' (follow up and/or referral) for patients with substance issues across all substances, including tobacco. Participants were most likely to seek advice from senior colleagues in their practice.Early-career GPs reported lower than optimal levels of confidence for all substances. Our findings have important implications for educators globally. Education that improves confidence across all 5As for high-prevalence substances (tobacco and alcohol) while focusing on increasing comfort screening and improving understanding of referral pathway options for low-prevalence substances may improve early-career GPs' confidence. This could increase engagement in managing substance use issues potentially leading to better health and wellbeing outcomes for patients.

Urinary piperacillin/tazobactam pharmacokinetics in vitro to determine the pharmacodynamic breakpoint for resistant Enterobacteriaceae

Urinary tract infections caused by multidrug-resistant Enterobacteriaceae are a growing burden worldwide. Recent studies of urinary pharmacokinetics described high piperacillin/tazobactam (TZP) concentrations in urine, but it is unknown whether this results in treatment efficacy. This study investigated the pharmacodynamics of TZP in a static in vitro model for Enterobacteriaceae to determine the concentration-effect relationship and ultimately the required free (unbound) time above the minimum inhibitory concentration (fT_>MIC) required for bacterial killing. The static simulation model investigated TZP fT_>MIC between 0% and 100%. Resistant Escherichia coli and Klebsiella pneumoniae isolates with piperacillin/tazobactam MICs of 4096/512, 1024/128 and 128/16 mg/L were investigated; two of the three organisms were carbapenemase-producers. Clinical efficacy was determined as a 3-log reduction over the dosing interval by comparing interval growth with controls. TZP was observed to exhibit time dependence for all organisms. The fT_>MIC was determined to be 37.5%, 37.5% and 50% for MICs of 4096/512, 1024/128 and 128/16 mg/L, respectively. Linear regression identified the overall target to be 49.85 ± 16.9% fT_>MIC. In conclusion, bactericidal activity against TZP-resistant Enterobacteriaceae occurred at 49.85 ± 16.9% fT_>MIC. This suggests that highly resistant urinary organisms, including carbapenemase-producers, with MICs up to 4096/512 mg/L could be treated with TZP. Further investigations are required to elucidate urinary breakpoints and to explore the impact of different resistance mechanisms.

Weak effects of geolocators on small birds: A meta-analysis controlled for phylogeny and publication bias

Currently, the deployment of tracking devices is one of the most frequently used approaches to study movement ecology of birds. Recent miniaturization of light-level geolocators enabled studying small bird species whose migratory patterns were widely unknown. However, geolocators may reduce vital rates in tagged birds and may bias obtained movement data. There is a need for a thorough assessment of the potential tag effects on small birds, as previous meta-analyses did not evaluate unpublished data and impact of multiple life-history traits, focused mainly on large species and the number of published studies tagging small birds has increased substantially. We quantitatively reviewed 549 records extracted from 74 published and 48 unpublished studies on over 7,800 tagged and 17,800 control individuals to examine the effects of geolocator tagging on small bird species (body mass <100 g). We calculated the effect of tagging on apparent survival, condition, phenology and breeding performance and identified the most important predictors of the magnitude of effect sizes. Even though the effects were not statistically significant in phylogenetically controlled models, we found a weak negative impact of geolocators on apparent survival. The negative effect on apparent survival was stronger with increasing relative load of the device and with geolocators attached using elastic harnesses. Moreover, tagging effects were stronger in smaller species. In conclusion, we found a weak effect on apparent survival of tagged birds and managed to pinpoint key aspects and drivers of tagging effects. We provide recommendations for establishing matched control group for proper effect size assessment in future studies and outline various aspects of tagging that need further investigation. Finally, our results encourage further use of geolocators on small bird species but the ethical aspects and scientific benefits should always be considered.

Spinocerebellar ataxia type 11-associated alleles of Ttbk2 dominantly interfere with ciliogenesis and cilium stability

Spinocerebellar ataxia type 11 (SCA11) is a rare, dominantly inherited human ataxia characterized by atrophy of Purkinje neurons in the cerebellum. SCA11 is caused by mutations in the gene encoding the Serine/Threonine kinase Tau tubulin kinase 2 (TTBK2) that result in premature truncations of the protein. We previously showed that TTBK2 is a key regulator of the assembly of primary cilia in vivo. However, the mechanisms by which the SCA11-associated mutations disrupt TTBK2 function, and whether they interfere with ciliogenesis were unknown. In this work, we present evidence that SCA11-associated mutations are dominant negative alleles and that the resulting truncated protein (TTBK2^SCA11) interferes with the function of full length TTBK2 in mediating ciliogenesis. A Ttbk2 allelic series revealed that upon partial reduction of full length TTBK2 function, TTBK2^SCA11 can interfere with the activity of the residual wild-type protein to decrease cilia number and interrupt cilia-dependent Sonic hedgehog (SHH) signaling. Our studies have also revealed new functions for TTBK2 after cilia initiation in the control of cilia length, trafficking of a subset of SHH pathway components, including Smoothened (SMO), and cilia stability. These studies provide a molecular foundation to understand the cellular and molecular pathogenesis of human SCA11, and help account for the link between ciliary dysfunction and neurodegenerative diseases.

Defects in primary cilia structure and function are linked to a number of recessive genetic disorders, now collectively referred to as ciliopathies. Most of the characteristics of these disorders arise from disruptions to embryonic development, with the requirements for primary cilia in adult tissues being less well-defined. We previously showed that a kinase associated with an adult-onset neurodegenerative condition is required for cilium assembly and ciliary signaling during development. Here, we show that the human disease-associated mutations act as mild dominant negatives, interfering with the function of the full-length protein in cilia formation and ciliary signaling.

Development, Evaluation and Implementation of Chief Complaint Groupings to Activate Data Collection: A Multi-Center Study of Clinical Decision Support for Children with Head Trauma

BACKGROUND

Overuse of cranial computed tomography scans in children with blunt head trauma unnecessarily exposes them to radiation. The Pediatric Emergency Care Applied Research Network (PECARN) blunt head trauma prediction rules identify children who do not require a computed tomography scan. Electronic health record (EHR) based clinical decision support (CDS) may effectively implement these rules but must only be provided for appropriate patients in order to minimize excessive alerts.

OBJECTIVES

To develop, implement and evaluate site-specific groupings of chief complaints (CC) that accurately identify children with head trauma, in order to activate data collection in an EHR.

METHODS

As part of a 13 site clinical trial comparing cranial computed tomography use before and after implementation of CDS, four PECARN sites centrally developed and locally implemented CC groupings to trigger a clinical trial alert (CTA) to facilitate the completion of an emergency department head trauma data collection template. We tested and chose CC groupings to attain high sensitivity while maintaining at least moderate specificity.

RESULTS

Due to variability in CCs available, identical groupings across sites were not possible. We noted substantial variability in the sensitivity and specificity of seemingly similar CC groupings between sites. The implemented CC groupings had sensitivities greater than 90% with specificities between 75-89%. During the trial, formal testing and provider feedback led to tailoring of the CC groupings at some sites.

CONCLUSIONS

CC groupings can be successfully developed and implemented across multiple sites to accurately identify patients who should have a CTA triggered to facilitate EHR data collection. However, CC groupings will necessarily vary in order to attain high sensitivity and moderate-to-high specificity. In future trials, the balance between sensitivity and specificity should be considered based on the nature of the clinical condition, including prevalence and morbidity, in addition to the goals of the intervention being considered.

A novel technique for the treatment of infected metalwork in orthopaedic patients using skin closure over irrigated negative pressure wound therapy dressings

Introduction

There has been recent interest in the use of negative pressure wound therapy (NWPT) as an adjunct to parenteral antibiotics in the treatment of infection in orthopaedic patients with metalwork in situ. To address some of the limitations of standard NPWT in this situation, the senior author has developed a modified method of treatment for infected metalwork (excluding arthroplasty) in orthopaedic patients that includes irrigation and skin closure over the standard NPWT dressing.

Methods

This retrospective study examined the outcome of a case series of 16 trauma and orthopaedic patients with deep infection involving metalwork in whom this modified form of NPWT was used. In conjunction with standard parenteral antibiotic therapy and a multidisciplinary approach, this modified technique included serial debridements in theatre, irrigation and negative pressure dressings over a white polyvinyl alcohol foam (KCI, Kidlington, UK) as well as closure of the skin over the foam.

Results

Among the 16 patients, there was a variety of upper and lower limb as well as spinal trauma and elective cases. In all 16 patients, there was successful resolution of the infection with no early or unplanned removal of any metalwork required.

Conclusions

Patients with infected metalwork are a heterogeneous group, and often suffer high morbidity and mortality. The modified NPWT technique shows potential as an adjunct in the treatment of complex orthopaedic patients with infected metalwork.

Is levomepromazine stable over time?

Levomepromazine (methotrimeprazine) is an anti-psychotic used at low dose for the control of nausea and vomiting. When levomepromazine hydrochloride as Nozinan® is diluted with 0.9% sodium chloride at concentrations ranging from 0.13 to 6.25 mg/ml, and stored in polypropylene syringes, the drug is stable for at least 14 days.

No significant effect of uridine or pravastatin treatment for HIV lipoatrophy in men who have ceased thymidine analogue nucleoside reverse transcriptase inhibitor therapy: a randomized trial

BACKGROUND

Lipoatrophy can complicate thymidine analogue nucleoside reverse transcriptase inhibitor (tNRTI)-based antiretroviral therapy (ART). Lipoatrophy may be less likely with ART including ritonavir-boosted lopinavir (LPV/r). Small, placebo-controlled studies found that uridine (in tNRTI recipients) and pravastatin improved HIV lipoatrophy over 12 weeks. Today, most patients with lipoatrophy receive non-tNRTI-based ART; the effect of uridine in such patients is unknown.

METHODS

We performed a prospective, randomized trial in lipoatrophic adults with plasma HIV RNA<50 HIV-1 RNA copies/mL on tNRTI-sparing ART including LPV/r. Patients received uridine [36 g three times a day (tid) on 10 consecutive days per month; n=10], pravastatin [40 mg every night (nocte); n=12], uridine plus pravastatin (n=11) or neither (n=12) for 24 weeks. The primary endpoint was mean change in limb fat mass as assessed by dual-energy X-ray absorptiometry (DEXA). With 20 patients per intervention, the study had 80% power to detect a mean difference between a treatment and the control of 0.5 kg, assuming a standard deviation of 0.9 and an alpha threshold equal to 5% (two-sided).

RESULTS

Of 45 participants (all men, with median age 49.5 years and median limb fat 2.6 kg), two discontinued pravastatin and one participant stopped both pravastatin and uridine. The difference between the mean changes in limb fat mass for uridine vs. no uridine was 0.03 kg [95% confidence interval (CI) -0.35, +0.28; P=0.79]. The respective difference for pravastatin was -0.03 kg (95% CI -0.29, +0.34; P=0.84). Pravastatin slightly decreased total cholesterol (0.44 mmol/L; P=0.099). Visceral adipose tissue measured by computed tomography did not change significantly.

CONCLUSION

In this population and at the doses used, neither uridine nor pravastatin for 24 weeks significantly increased limb fat mass.

Quicksilver: a novel publish and subscribe clinical messaging platform

The authors introduce and describe the features of Quicksilver, a novel clinical messaging platform deployed in a multidisciplinary academic primary care clinic. The system follows a publication-subscription messaging paradigm employing dynamic role-based addressing. Quicksilver leverages the open-source XMPP, a powerful and extensible protocol for efficient asynchronous and synchronous communication commonly used in instant messaging applications.

Redefining the coronary care unit: an observational study of patients admitted to hospital in England and Wales in 2003

BACKGROUND

Coronary care units were developed in the 1960s as specially equipped and staffed areas where patients with acute myocardial infarction could be monitored and offered rapid resuscitation from life-threatening arrhythmias. Awareness of the morbidity and mortality of the wider spectrum of acute coronary ischaemia was unrecognized at that time.

AIM

To examine the relative frequencies with which thrombolytic treatment and resuscitation from cardiac arrest are provided for patients with myocardial infarction in cardiac care units (CCUs), emergency departments (EDs) and other medical wards.

DESIGN

Observational study.

METHODS

We analysed records from the National Audit of Myocardial Infarction Project (MINAP) for 61 688 patients admitted to 230 acute hospitals in England and Wales during 2003, and who received a final diagnosis of myocardial infarction, for locations of initiation of thrombolytic therapy and of first cardiac arrest within hospital.

RESULTS

Overall, 84% of 27 881 patients with ST-segment-elevation infarction, but only 42% of 30 382 patients with non-ST-elevation infarction, were admitted to a CCU. Of those receiving thrombolytic treatment for ST-elevation infarction, 68.3% of 21 595 did so in the ED. Within the first 4 h after arrival, the majority of episodes of cardiac arrest occurred in the ED: 709 (57%) vs. 488 (39%) in CCU, and 49 (4%) in medical wards.

DISCUSSION

The traditional role of the CCU in providing early resuscitation and thrombolytic treatment for patients with ST elevation infarction has largely been devolved to the ED. The role of the CCU should be re-evaluated, and the service re-designed to provide specialist care for all presentations of acute coronary syndrome.

Acidophiles of saline water at thermal vents of Vulcano, Italy

DNA was extracted from samples taken from close to acidic hydrothermal vents on shore of the Aeolian Island of Vulcano (Italy). RNA gene sequences were amplified by PCR, cloned, and sequenced. A sequence with an origin in samples at 35 degrees and 45 degrees C corresponded to that of a novel Acidithiobacillus species that was isolated from water close to the vents. Novel, iron-oxidizing mesophilic acidophiles were isolated through enrichment cultures with ferrous iron but were not represented in the clone banks of environmental rDNA. These acidophiles were related to Thiobacillus prosperus, which was isolated previously from Vulcano. The archaeal sequences that comprised a clone bank representing a high-temperature sample (75 degrees C) corresponded to those of Acidianus brierleyi and of thermophiles previously isolated from Vulcano, Thermoplasma volcanium and Acidianus infernus.

Survival in epithelial ovarian cancer patients with prior breast cancer

Ovarian cancer patients who carry germ-line BRCA1 mutations may have improved survival compared with ovarian cancer patients without these mutations. To evaluate this hypothesis, the authors compared survival in ovarian cancer patients who had a history of prior breast cancer with that of patients without such a history. Specifically, they used data from the population-based US Surveillance, Epidemiology, and End Results (SEER) Program to assess time to death from ovarian cancer among ovarian cancer patients with and without a prior breast cancer. All 25,637 White women diagnosed with invasive epithelial ovarian cancer in SEER registries between 1973 and 1995 were included. Of these, 824 women had had a prior breast cancer diagnosis. The ovarian cancer death rate among women with prior breast cancer was significantly lower than that of women with ovarian cancer only, adjusted for age and stage at ovarian cancer diagnosis. The survival advantage was most pronounced among older women and among those whose ovarian cancers were more advanced at the time of diagnosis. These results lend indirect support to prior findings of improved ovarian cancer survival in BRCA1 mutation carriers.

Degradation of the cyanobacterial toxin cylindrospermopsin, from Cylindrospermopsis raciborskii, by chlorination

Cylindrospermopsin, a potent cyanobacterial toxin produced by Cylindrospermopsis raciborskii and other cyanobacteria, is regularly found in water supplies of Queensland, Australia. This study focussed on the effectiveness of chlorination as a water treatment procedure for cylindrospermopsin degradation. The results demonstrate that relatively low chlorine doses (<1 mg l(-1)) are sufficient for degradation of cylindrospermopsin, when the dissolved organic carbon content is low. However, if organic matter other than cylindrospermopsin is present in the solution, the effectiveness of chlorine for cylindrospermopsin degradation is reduced as other organic matter present consumes chlorine. Under the experimental conditions using samples with a solution pH of 6-9, a residual chlorine concentration of 0.5 mg l(-1)99% of cylindrospermopsin. Toxin degradation via chlorination occurs within the first minute and no difference was observable between degradation in an open system and in a closed system. With a decrease of the pH from 6 to 4 a reduction in the efficiency of chlorine for degradation of cylindrospermopsin was observable, a possible indication that cylindrospermopsin is more stable to chlorine degradation at lower pH. However, in normal water treatment this is not relevant since the pH is consistently higher than 6.

Discovery of Circularly Polarized Radio Emission from SS 433

We report the discovery of circularly polarized radio emission from the radio-jet X-ray binary SS 433 with the Australia Telescope Compact Array. The flux density spectrum of the circular polarization, clearly detected at four frequencies between 1 and 9 GHz, is of the form V~nu-0.9+/-0.1. Multiple components in the source and a lack of very high spatial resolution do not allow a unique determination of the origin of the circular polarization or of the spectrum of fractional polarization. However, we argue that the emission is likely to arise in the inner regions of the binary, possibly via propagation-induced conversion of linear to circular polarization, and the fractional circular polarization of these regions may be as high as 10%. Observations such as these have the potential to help us investigate the composition, whether pairs or baryonic, of the ejecta from X-ray binaries.

High-resolution HLA-A*0201 subtyping using directed heteroduplex analysis

HLA-A02* has become an important target for cytotoxic T lymphocyte-based immunotherapy reflecting the high prevalence of this allele in patient populations. There are at least 26 different A*02 alleles, and their subtype specificity has significant functional implications for T-cell-mediated recognition of immunologic targets. We have developed a novel method for HLA-A*02 allelic screening using directed heteroduplex analysis (DHDA). DNA samples from Epstein-Barr virus (EBV)-transformed B lymphoblastoid cell lines (EBV-B) representing 10 different HLA-A*02 alleles (0201, 0202, 0204, 0205, 0206, 0208, 0210, 0211, 0216, 0217) were prepared. In addition, DNA was prepared from 81 individuals representing a wide variety of A*02 subtypes previously determined by sequence specific primer (SSP) polymerase chain reaction (PCR) including individuals heterozygous for two A*02 specificities. Probes and samples were generated by PCR amplification using HLA-A*02 specific primers encompassing exons 2 and 3, where most of the functionally significant allelic polymorphism is clustered. DHDA was performed by generating heteroduplex molecules composed of a fluorescein-labeled allelic probe sequence and an unlabeled allelic PCR product. Gel retardation was consistent for allele-probe combinations. We were able to identify several A*02 alleles prepared from EBV-B cell lines that, when used as probes, had very impressive specificity and sensitivity. Combinations of two probes were identified (0205 + 0211 and 0208 + 0211) that allowed differentiation of A*0201 alleles from all other A*02 alleles tested. All samples typed by probe combinations had DHDA typing and SSP typing confirmed by DNA sequencing. This study expands the molecular typing repertoire available to the modern HLA laboratory, and shows that DHDA has significant promise as a reliable screening method for HLA A*02 subtyping.

Mechanical properties of several nickel-titanium alloy wires in three-point bending tests

The purpose of this study was to clarify the mechanical properties of 42 brands of nickel-titanium alloy orthodontic wires from 9 manufacturers by conducting three-point bending tests under uniform testing conditions. Manufacturers included A-Company, Hoya Medical, Lancer, Ormco, Rocky Mountain, Sankin, Tomy (GAC), TP, and 3M/Unitek. Cobalt-chrome, and titanium-molybdenum alloy wires were also tested as a reference for comparison of force levels. All reported data were recorded during the unloading process to simulate the force that a wire exerts on a tooth as it is moved into the dental arch from a position of malocclusion. The following results were obtained for the nickel-titanium wires tested. (1) Among the 0.016 inch round wires tested under a maximum deflection of 1.5 mm, the difference between the smallest (Copper nickel-titanium 35) and the largest (Aline) load values was 136 g. For the 0.016 x 0.022 inch rectangular wires tested, the difference between the smallest (Copper nickel-titanium 40) and the largest (Aline) load values was 337 g. (2) The change in load between 1.5 and 0.5 mm of deflection was examined to clarify the superelastic properties of the wires tested. For the 0.016 inch wires, 17 wire brands produced a load difference of less than 100 g, and two brands produced a difference of at least 100 g (Aline and Titanal = 100 g). For the 0.016 x 0.022 inch wires, 15 brands produced a load difference of less than 100 g, and eight brands produced a difference of over 100 g. The smallest and largest load differences were 3 g (Copper nickel-titanium 35) and 200 g (Aline). (3) The majority of the samples with a smaller load difference between deflections of 1.5 mm and 0.5 mm in the unloading process were found among super-elastic wires, while samples with a larger load difference were predominantly found among work-hardened wires. Compared with cobalt-chrome and TMA wires, nickel-titanium alloy wires exert significantly less force. However, the amount of force varies greatly from brand to brand. Consequently, when using nickel-titanium alloy wires, brands must be selected carefully by taking into consideration the severity of the malocclusion and the stage of orthodontic treatment in each case. It is the intent of this study to offer clinicians an unbiased guide for the selection of appropriate nickel-titanium alloy wires.

Molecular evidence of cryptic speciation in planktonic foraminifers and their relation to oceanic provinces

The fossil record of planktonic foraminifers is a key source of data on the biodiversity and evolution of marine plankton. One of the most distinctive foraminiferal taxa, Orbulina universa, widely used as a stratigraphic and paleoclimatic index, has always been regarded as a single species. Here we present a phylogenetic analysis of Orbulina small subunit rDNA sequences from 25 pelagic stations covering 100 degrees latitude in the Atlantic Ocean. The genetic data reveal the presence of three cryptic species, whose distribution is clearly correlated to hydrographic provinces, and particularly to sea-surface total chlorophyll a concentration. Our results, together with previous studies, suggest that a considerable part of the diversity among planktonic foraminifers has been overlooked in morphological taxonomies. Our data also support the idea that planktonic foraminifers, even if adapted to particular hydrographic conditions, are high-dispersal organisms whose speciation may be similar to that of other high-dispersal taxa in which reproductive mechanisms and behavior, rather than just geographic barriers to dispersal, play key roles in species formation and maintenance.

Pulmonary infiltrates in the surgical ICU: prospective assessment of predictors of etiology and mortality

A prospective cohort study of 129 consecutive patients developing pulmonary infiltrates in the surgical ICU was conducted to determine the predictors and outcome of pulmonary infiltrates. Most common etiologies of pulmonary infiltrates were pneumonia (30%), pulmonary edema (29%), acute lung injury (15%), and atelectasis (13%). Enteral nutrition was associated with a significantly lower incidence of acute lung injury as compared with pneumonia (22% vs 58%, p = 0.012). Patients with liver disease were significantly more likely to have pulmonary infiltrates due to acute lung injury as compared with other etiologies (p = 0.02). Clinical pulmonary infection score (Pugin score) > 6 virtually excluded acute lung injury, pulmonary edema, or atelectasis as etiologies of pulmonary infiltrates. Nosocomial Haemophilus/pneumococcal pneumonia occurred significantly earlier in the ICU as compared with Gram-negative (p = 0.05) or methicillin-resistant Staphylococcus aureus pneumonia (p = 0.01). Pneumonia in trauma patients was significantly more likely to be due to Haemophilus/pneumococcus as compared with all other ICU patients (54% vs 0%, p = 0.0004). These data have implications for treatment of patients with nosocomial pneumonia in the ICU.

Adhesion, internalization and metabolism of calcium oxalate monohydrate crystals by renal epithelial cells

The interaction between crystals that nucleate in the nephron lumen and tubular cells could be an important determinant of renal calcification. Kidney epithelial cells in monolayer culture (BSC-1 line), used to model the tubule, rapidly bound and internalized crystals of calcium oxalate monohydrate (COM), the most common constituent of renal stones. Transmission and scanning electron microscopy, enzyme histochemistry, and kinetic analysis of [14C]-labeled crystals were used to study the interaction between renal cells and COM crystals. Electron microscopy revealed that adherent crystals on the apical cell surface can serve as sites for aggregation of additional crystals. Enhanced binding of exogenous crystals to plasma membrane domains overlying internalized crystals was observed for at least 24 hours after the initial cell-crystal interaction. Following internalization, crystals appeared to dissolve within lysosomal inclusion bodies during the ensuing five to seven weeks. Over this time, many cells still containing crystals clustered together in the monolayer. These observations suggest that adhesion and internalization can promote crystal retention in the nephron, whereas intracellular dissolution of crystals may serve as an important, hitherto unrecognized defense against pathologic renal calcification.

Adhesion of hydroxyapatite crystals to anionic sites on the surface of renal epithelial cells

Adhesion of microcrystals that nucleate in tubular fluid to the apical surface of renal tubular cells could be a critical step in the formation of kidney stones, 20% of which contain hydroxyapatite (HA). HA crystals bound rapidly to monolayer cultures of monkey kidney epithelial cells (BSC-1 line), used to model the surface of the nephron, in a concentration-dependent manner. Adhesion was blocked by diverse polyanions including heparin, pentosan polysulfate, polyaspartate, and polyglutamate, as well as many found in tubular fluid such as chondroitin sulfates A and B, heparan sulfate, citrate, nephrocalcin, and osteopontin. The polycations cetylpyridinium chloride and cationized ferritin, as well as the cationic dyes alcian blue, polyethylenimine, and brilliant blue R, also inhibited adhesion of HA crystals, as did specific lectins including Triticum vulgaris (wheat germ agglutinin). Anions that inhibited adhesion of crystals appeared to act on the crystal surface, whereas cations and lectins exerted their effect on the cell. Treatment of cells with neuraminidase inhibited binding of crystals, suggesting that anionic cell surface sialic acid residues function as HA crystal receptor sites that can be blocked by specific cations or lectins. Adherence of HA crystals to cells of another renal line (MDCK) and, to 3T3 fibroblasts was also inhibited by heparin, polyaspartate, alcian blue, and T vulgaris lectin, suggesting that these crystals bind to analogous molecules on the surface of different types of cells. These results suggests that the structure, quantity, and/or function of soluble anions in tubular fluid, as well as those anchored to the cell surface, could be critical determinants of HA crystal retention in the nephron and the subsequent formation of a renal stone.

How mental health and developmental disabilities staff prioritize training and development needs

This paper contrasts a staff training needs assessment distributed to three groups: staff serving persons with mental health needs in the community, staff serving persons with mental health needs in state hospitals, and staff serving persons with developmental disabilities in the community. Analyses revealed that all three groups rated team-related training as the area in greatest need of development. Further analyses suggested that community staff serving persons with developmental disabilities reported significantly less need for training on direct client care compared to community and inpatient staff who serve persons with mental health needs. The community staff serving persons with mental health needs did not differ significantly from the inpatient staff on any of the surveyed training areas. Results suggest that future development efforts should begin with team building skills.

Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration

We carried out a systematic overview using individual patient data from the seven randomised trials that have compared a strategy of initial coronary artery bypass graft (CABG) surgery with one of initial medical therapy to assess the effects on mortality in patients with stable coronary heart disease (stable angina not severe enough to necessitate surgery on grounds of symptoms alone, or myocardial infarction). 1324 patients were assigned CABG surgery and 1325 medical management between 1972 and 1984. The proportion of patients in the medical treatment group who had undergone CABG surgery was 25% at 5 years, 33% at 7 years, and 41% at 10 years: 93.7% of patients assigned to the surgery group underwent CABG surgery. The CABG group had significantly lower mortality than the medical treatment group at 5 years (10.2 vs 15.8%; odds ratio 0.61 [95% CI 0.48-0.77], p = 0.0001), 7 years (15.8 vs 21.7%; 0.68 [0.56-0.83], p < 0.001), and 10 years (26.4 vs 30.5%; 0.83 [0.70-0.98]; p = 0.03). The risk reduction was greater in patients with left main artery disease than in those with disease in three vessels or one or two vessels (odds ratios at 5 years 0.32, 0.58, and 0.77, respectively). Although relative risk reductions in subgroups defined by other baseline characteristics were similar, the absolute benefits of CABG surgery were most pronounced in patients in the highest risk categories. This effect was most evident when several prognostically important clinical and angiographic risk factors were integrated to stratify patients by risk levels and the extension of survival at 10 years was examined (change in survival -1.1 [SE 3.1] months in low-risk group, 5.0 [4.2] months in moderate-risk group, and 8.8 [5.4] months in high-risk group; p for trend < 0.003). A strategy of initial CABG surgery is associated with lower mortality than one of medical management with delayed surgery if necessary, especially in high-risk and medium-risk patients with stable coronary heart disease. In low-risk patients, the limited data show a non-significant trend towards greater mortality with CABG.

Postpartum multivessel coronary dissection

A 29-year-old woman had an acute myocardial infarction 5 days after giving birth. Serial coronary angiography showed multiple progressive coronary artery dissections, which eventually involved both the right and left coronary trees. Persistent cardiogenic shock necessitated emergent orthotopic heart transplantation. Examination of the cardiectomy specimen confirmed the presence of multiple myocardial infarctions, coronary artery dissection, and fibromuscular dysplasia of the coronary arteries. Fibromuscular dysplasia combined with changes in the arterial ground substance and hormonal milieu attributable to pregnancy or parturition are proposed as possible causes of coronary artery dissection in this case.

Measurement of dothiepin and its major metabolites in plasma by high-performance liquid chromatography

This paper describes a reversed-phase high-performance liquid chromatographic method which will simultaneously measure dothiepin and its three major metabolites (northiaden, northiaden-S-oxide and dothiepin-S-oxide) in plasma using trimipramine as internal standard. Sample preparation involved a basic extraction using diethyl ether followed by an acid back-extraction. The method we report is linear over the range 50-1000 ng/ml (r = 0.999), for all analytes. Total imprecision is less than 11% (coefficient of variation) and accuracy is greater than 94% (n = 20). Recovery of analytes varied considerably from 51.7% for northiaden-S-oxide to 90.2% for dothiepin-S-oxide.

Silent ischemia in rehabilitation patients: limited clinical utility of electrocardiographic monitoring

In a prospective blinded trial, 24-hour continuous electrocardiographic monitoring for silent ischemia was used to try to identify rehabilitation patients at risk for cardiac complications. Five of 42 patients had episodes of silent ischemia, none of which occurred during physical therapy sessions. One of these patients had syncope while wearing the Holter; none of the other four patients had significant cardiac complications during their rehabilitation, and all were discharged home. None of the patients without ischemia on the monitor had complications, but two patients of 14 whose ECGs precluded monitoring for ischemia had complications. In addition, six patients had episodes of nonsustained asymptomatic ventricular tachycardia, 12 had episodes of supraventricular tachycardia, and four had significant ventricular ectopy, all without clinical significance. Despite the apparent high sensitivity and specificity of the technique, the positive predictive value of monitoring eligible patients for silent ischemia was 20%. We conclude that ambulatory electrocardiographic monitoring for silent ischemia or ectopy has limited clinical utility in the rehabilitation population.

The effects of physical activity and exercise training on psychological stress and well-being in an adolescent population

To determine whether participating in physical activity affects psychological well-being in an adolescent population, 147 adolescents completed self-reports of exercise and psychological stress and well-being. Analysis revealed that those who reported greater physical activity also reported less stress and lower levels of depression. Adolescents who experienced a higher incidence of life events also demonstrated a strong association between stress and anxiety/depression/hostility. To investigate the effects of exercise training on psychological well-being, adolescents were assigned to either high or moderate intensity aerobic training, flexibility training or a control group. The training groups met twice per week for 25-30 min. Aerobic fitness levels, heart rate, blood pressure and self-report of stress and well-being were measured prior to and following 10 weeks of training. Post-training fitness measures confirmed the effectiveness of the high intensity aerobic exercise and between groups differences for physiological and some psychological measures were found. Subjects undergoing high intensity exercise reported significantly less stress than subjects in the remaining three groups. The relationship between stress and anxiety/depression/hostility for the high intensity group was considerably weakened at the end of the training period. For the remaining subjects, however, this relationship was, if anything, strengthened. This experiment provides evidence to suggest that in an adolescent population, high intensity aerobic exercise has positive effects on well-being.