Enteric viruses replicate in salivary glands and infect through saliva

Enteric viruses like norovirus, rotavirus and astrovirus have long been accepted as spreading in the population through fecal-oral transmission: viruses are shed into feces from one host and enter the oral cavity of another, bypassing salivary glands (SGs) and reaching the intestines to replicate, be shed in feces and repeat the transmission cycle1. Yet there are viruses (for example, rabies) that infect the SGs2,3, making the oral cavity one site of replication and saliva one conduit of transmission. Here we report that enteric viruses productively and persistently infect SGs, reaching titres comparable to those in the intestines. We demonstrate that enteric viruses get released into the saliva, identifying a second route of viral transmission. This is particularly significant for infected infants, whose saliva directly transmits enteric viruses to their mothers' mammary glands through backflow during suckling. This sidesteps the conventional gut-mammary axis route4 and leads to a rapid surge in maternal milk secretory IgA antibodies5,6. Lastly, we show that SG-derived spheroids7 and cell lines8 can replicate and propagate enteric viruses, generating a scalable and manageable system of production. Collectively, our research uncovers a new transmission route for enteric viruses with implications for therapeutics, diagnostics and importantly sanitation measures to prevent spread through saliva.

Acceptability and barriers to adopting physical therapy and rehabilitation as standard of care in hernia disease: a prospective national survey of providers and preliminary data

PURPOSE

Physical therapy (PT) and rehabilitation are widely utilized in a variety of disease processes to improve function, return to activities of daily living (ADLs), and promote overall recovery. However, hernia repair has struggled to adopt this practice despite operations occurring in one of the most dynamic parts of the body - the abdominal core. This study sought to understand perspectives and perceived barriers regarding the incorporation of PT and rehabilitation in hernia care.

METHODS

A standardized rehabilitation protocol was developed by the Abdominal Core Health Quality Collaborative (ACHQC), a national quality improvement initiative specific to hernia disease, and launched in 2019. Empiric data from the ACHQC was then obtained to describe preliminary utilization. A prospective electronic survey was then deployed to all surgeons participating in the ACHQC to aid in interpreting the identified trends. The survey included questions regarding the current use of PT in their practice, as well as further opinions on the functionality, benefit, and barriers to its use.

RESULTS

We identified 1,544 patients who were listed as receiving some form of postoperative rehabilitation, of which 992 (64.2%) had a primary diagnosis of ventral hernia and 552 (35.8%) had an inguinal hernia. Among patients who had a ventral hernia, 863 (87.0%) received self-directed rehabilitation exercises compared to 488 (88.4%) of inguinal hernia patients. The subsequent survey exploring these trends was completed by 46 ACHQC surgeons (10.2%). More than half (52%) reported using PT for hernia patients, primarily in abdominal wall reconstruction cases (92%). Of those who did not report using PT, 50% cited unknown clinical benefit and another 27% cited unknown PT resources. PT utilization was typically concentrated to the postoperative period (58%), while 42% reported also using it preoperatively. Despite 72% of respondents citing a perceived benefit of PT in hernia patients, overall use of PT was primarily reported as 'occasional' by 42%, with another 27% reporting 'rarely.' Perceived benefits of PT included increased core strength, stability, mobility, patient satisfaction, education, independence, earlier return to work and ADLs, overall improved recovery, and decreased risk of postoperative issues. Reported barriers to implementing PT in practice or adapting the ACHQC Rehabilitation Protocol included lack of education, lack of evidence of clinical benefit, and difficulties operationalizing the protocol.

CONCLUSION

A national survey of hernia surgeons demonstrated willingness to adopt PT and rehabilitation protocols in their clinical practices and noted a high perceived benefit to patients. However, lack of education and evidence regarding the protocol may represent important barriers to overcome in widely disseminating these resources to patients. These gaps can be addressed through dedicated educational venues and additional studies establishing PT and rehabilitation as critical future adjuncts for the recovery of hernia repair patients.

Non-standard insensitivity

The paper takes a closer look at some insensitivity results which are not contained in the class of insensitive generalised semi-Markov schemes. Based on a study of a special insensitive queue, a conjecture is proposed which covers all known results on insensitive equilibrium distributions. When insensitive events are also included, a study of the G/G/1 queue shows that the conjecture does not always hold.

Insensitivity of processes with interruptions

The theory of insensitivity within generalised semi-Markov processes is extended to cover classes of models in which the generally distributed lifetimes can be terminated prematurely by the deaths of negative exponentially distributed lifetimes. As a consequence of this approach it is shown that there exist classes of processes which are insensitive with respect to characteristics of the general distributions other than the mean. Two examples are given. The first is an analysis of networks of queues in which the generally distributed service times can be interrupted with resulting changes in routing probabilities. The second is a model for the effect of disturbances on the evolution of a vegetation community.

A correspondence between product-form batch-movement queueing networks and single-movement networks

A number of recent papers have exhibited classes of queueing networks, with batches of customers served and routed through the network, which have generalised product-form equilibrium distributions. In this paper we look at these from a new viewpoint. In particular we show that, under standard assumptions, for a network to possess an equilibrium distribution that factorises into a product form over the nodes of the network for all possible transition rates, it is necessary and sufficient that it be equivalent to a suitably-defined single-movement network. We consider also the form of the state space for such networks.

A solution of the carrier-borne epidemic

An alternative approach to the derivation of a general class of results in carrier-borne epidemic theory is presented. Some insight can be gained into the basic structure of carrier-borne epidemics and the method indicates which other problems of a similar type could yield to analysis.

Some new results on queueing networks with batch movement

Product-form equilibrium distributions in networks of queues in which customers move singly have been known since 1957, when Jackson derived some surprising independence results. A product-form equilibrium distribution has also recently been shown to be valid for certain queueing networks with batch arrivals, batch services and even correlated routing.

This paper derives the joint equilibrium distribution of states immediately before and after a batch of customers is released into the network. The results are valid for either discrete- or continuous-time queueing networks: previously obtained results can be seen as marginal distributions within a more general framework. A generalisation of the classical ‘arrival theorem' for continuous-time networks is given, which compares the equilibrium distribution as seen by arrivals to the time-averaged equilibrium distribution.

Queueing networks by negative customers and negative queue lengths

A number of papers have recently appeared in the literature in which customers, in moving from node to node in the network arrive as either a positive customer or as a batch of negative customers. A positive customer joining its queue increases the number of customers at the queue by 1 and each negative customer decreases the queue length by 1, if possible. It has been shown that the equilibrium distribution for these networks assumes a geometric product form, that certain partial balance equations prevail and that the parameters of the geometric distributions are, as in Jackson networks, the service facility throughputs of customers. In this paper the previous work is generalised by allowing state dependence into both the service and routing intensities and by allowing the possibility, although not the necessity, for negative customers to build up at the nodes.

Insensitivity and reversed Markov processes

This paper is concerned with the relationship between insensitivity in a certain class of Markov processes and properties of that process when time is reversed. Necessary and sufficient conditions for insensitivity are established and linked to already proved results. A number of examples of insensitive systems are given.

State-dependent signalling in queueing networks

It has recently been shown that networks of queues with state-dependent movement of negative customers, and with state-independent triggering of customer movement have product-form equilibrium distributions. Triggers and negative customers are entities which, when arriving to a queue, force a single customer to be routed through the network or leave the network respectively. They are ‘signals' which affect/control network behaviour. The provision of state-dependent intensities introduces queues other than single-server queues into the network.

This paper considers networks with state-dependent intensities in which signals can be either a trigger or a batch of negative customers (the batch size being determined by an arbitrary probability distribution). It is shown that such networks still have a product-form equilibrium distribution. Natural methods for state space truncation and for the inclusion of multiple customer types in the network can be viewed as special cases of this state dependence. A further generalisation allows for the possibility of signals building up at nodes.

Discrete-time queueing networks with geometric release probabilities

This note is concerned with the continuing misconception that a discrete-time network of queues, with independent customer routing and the number of arrivals and services in a time interval following geometric and truncated geometric distributions respectively, has a product-form equilibrium distribution.

Insensitivity with age-dependent routing

The theory of insensitivity is extended to include processes where some of the routing probabilities of the process are made dependent upon the length of time the generally distributed variables have been alive. Examples of such systems are given, including networks of queues with age-dependent routing.

Connecting internally balanced quasi-reversible Markov processes

We provide a general framework for interconnecting a collection of quasi-reversible nodes in such a way that the resulting process exhibits a product-form invariant measure. The individual nodes can be quite general, although some degree of internal balance will be assumed. Any of the nodes may possess a feedback mechanism. Indeed, we pay particular attention to a class of feedback queues, characterized by the fact that their state description allows one to maintain a record of the order in which events occur. We also examine in some detail the problem of determining for which values of the arrival rates a node does exhibit quasi-reversibility.

The Utility of a Personal Values Report for Medical Decision-Making

Our aim was to determine if a patient's Personal Values Report (PVR) has a positive impact on a doctor's decisions regarding treatment. We conducted a prospective cohort study delivering a short, web-based hypothetical case-centred questionnaire to intensive care doctors practising in Australia and New Zealand. One hundred and twenty-four intensive care consultants and registrars agreed to participate in an online questionnaire in two routine mailings between November 2013 and February 2014. We evaluated the effect of a PVR on clinical decision-making in a case-based scenario. In addition, participants rated the utility of the PVR on their decision-making process. Participants were presented with a difficult scenario in a frail elderly man where death was almost inevitable without aggressive support but survival with severe disability was possible with significant intervention. Most doctors (52.4%) elected to continue ventilation and admit to ICU. After the PVR was made available, only 8.1% of doctors continued to choose to admit the patient to the ICU. In all cases where admission to the ICU was chosen after seeing the PVR, the admission to the ICU was stated to be to permit family to arrive before withdrawing support (an approach which was consistent with the values stated in the PVR). One hundred and twenty-one of the 124 participants (97.6%) agreed or strongly agreed that the PVR helped them get an understanding of the patient's wishes, whereas none of the participants (0%) were unsure, disagreed or strongly disagreed with this statement. The remaining 2.4% did not answer the question. It is surmised that PVRs pre-written by patients are potentially an effective and valuable tool for use in helping doctors make decisions regarding patient care.

Site specific nematode management-development and success in cotton production in the United States

Variability in edaphic factors such as clay content, organic matter, and nutrient availability within individual fields is a major obstacle confronting cotton producers. Adaptation of geospatial technologies such global positioning systems (GPS), yield monitors, autosteering, and the automated on-and-off technology required for site-specific nematicide application has provided growers with additional tools for managing nematodes. Multiple trials in several states were conducted to evaluate this technology in cotton. In a field infested with Meloidogyne spp., both shallow (0 to 0.3 m) and deep (0 to 0.91 m) apparent electrical conductivity (ECa) readings were highly correlated with sand content. Populations of Meloidogyne spp. were present when shallow and deep EC values were less than 30 and 90 mS/m, respectively. Across three years of trials in production fields in which verification strips (adjacent nematicide treated and untreated rows across all soil zones) were established to evaluate crop response to nematicide application, deep EC values from 27.4-m wide transects of verification strips were more predictive of yield response to application of 1,3-dichloropropene than were shallow EC values in one location and both ECa values equally effective at predicting responses at the second location. In 2006, yields from entire verification strips across three soil zones in four production fields showed that nematicide response was greatest in areas with the lowest EC values indicating highest content of sand. In 2008 in Ashley and Mississippi Counties, AR, nematicide treatment by soil zone resulted in 36% and 42% reductions in the amount of nematicide applied relative to whole-field application. In 2007 in Bamberg County, SC, there was a strong positive correlation between increasing population densities of Meloidogyne incognita and increasing sand content. Trials conducted during 2007 and 2009 in South Carolina against Hoplolaimus columbus showed a stepwise response to increasing rates of aldicarb in zone 1 but not in zones 2 and 3. Site-specific application of nematicides has been shown to be a viable option for producers as a potential management tool against several nematode pathogens of cotton.

Quasi-monoenergetic laser-plasma acceleration of electrons to 2 GeV

Laser-plasma accelerators of only a centimetre’s length have produced nearly monoenergetic electron bunches with energy as high as 1 GeV. Scaling these compact accelerators to multi-gigaelectronvolt energy would open the prospect of building X-ray free-electron lasers and linear colliders hundreds of times smaller than conventional facilities, but the 1 GeV barrier has so far proven insurmountable. Here, by applying new petawatt laser technology, we produce electron bunches with a spectrum prominently peaked at 2 GeV with only a few per cent energy spread and unprecedented sub-milliradian divergence. Petawatt pulses inject ambient plasma electrons into the laser-driven accelerator at much lower density than was previously possible, thereby overcoming the principal physical barriers to multi-gigaelectronvolt acceleration: dephasing between laser-driven wake and accelerating electrons and laser pulse erosion. Simulations indicate that with improvements in the laser-pulse focus quality, acceleration to nearly 10 GeV should be possible with the available pulse energy.

Laser-plasma accelerators can produce high-energy electron bunches over just a few centimetres of distance, offering possible table-top accelerator capabilities. Wang et al. break the current 1 GeV barrier by applying a petawatt laser to accelerate electrons nearly monoenergetically up to 2 GeV.

Demonstration of a 1.1 petawatt laser based on a hybrid optical parametric chirped pulse amplification/mixed Nd:glass amplifier

We present the design and performance of the Texas Petawatt Laser, which produces a 186 J 167 fs pulse based on the combination of optical parametric chirped pulse amplification (OPCPA) and mixed Nd:glass amplification. OPCPA provides the majority of the gain and is used to broaden and shape the seed spectrum, while amplification in Nd:glass accounts for >99% of the final pulse energy. Compression is achieved with highly efficient multilayer dielectric gratings.

Metal complexes of sporidesmin D and dimethylgliotoxin, investigated by electrospray ionisation mass spectrometry

Electrospray ionisation mass spectrometry (ES-MS) has been used to probe the coordination chemistry of metabolites such as sporidesmin D (spdD), found in the saprophytic fungus Pithomyces chartarum, and the related bisdethiobis(methylthio)gliotoxin (dimethylgliotoxin, Megtx). SpdD forms complexes of the type [spdD+M(MeCN)] and [2spdD+M]+ (M=Cu, Ag) and, at higher cone voltages, [spdD+M]+. The bis(ligand) ion [2spdD+M]+ was observed at very high cone voltages, indicating it has appreciable stability; the proposed structure of this species has a four-coordinate metal ion with two bidentate spdD ligands, coordinated through their SMe groups. 1H NMR titrations of spdD with K+, Ag+ and Cu+ provided additional evidence for complex formation with the soft metals. SpdD forms only relatively weak complexes with Zn2+, Cd2+, Co2+ and Mn2+, in keeping with the known reduced tendency of these metals to form stable thioether complexes. ES-MS studies of Megtx showed similar results to spdD, with stable adducts formed with Cu+ and Ag+ ions. The X-ray crystal structure of spdD is also reported.

Luminescent visualization of latent fingerprints by direct reaction with a lanthanide shift reagent

The utilization of the lanthanide shift reagent tris (6,6,7,7,8,8,8-heptafluoro-2,2-dimethyl-3,5-octanedionato) europium (III) [Eu(fod)3] as a simple one-step reagent for the luminescent visualization of latent fingerprints has been investigated. UV excitation of Eu(fod)3-treated prints, achieved by using a hand-held UV lamp or a Polilight, results in an orange emission at 614 nm. Time-resolved imaging is not required for visualization. Visualization of latent fingerprints on paper under the conditions used, although good, was found to be inferior to that obtained by standard DFO (1,8-diazafluoren-9-one) treatment, whereas visualization of prints obtained on aluminum drink cans and galvanized iron proved superior to that obtained by Superglue/panacryl treatment. Eu(fod)3 treatment can also be used first without compromising subsequent ninhydrin or DFO treatment, making it a 'nothing-to-lose" reagent.

Detecting improvement in quality of life and symptomatology in schizophrenia

Instrument-based scores are often used as outcome measures. However, little is known about what changes in scores mean in terms of a clinical assessment of improvement or deterioration. The purpose of this report was to determine how much change in standard instrument scores represents a clinically detectable improvement or deterioration. The Veterans Affairs (VA) Cooperative Study of Clozapine in Refractory Schizophrenia evaluated 423 patients on clozapine or haloperidol. Symptoms and quality of life scales were completed at baseline; 6 weeks; and 3, 6, and 12 months. Among patients judged as "improved" by clinicians, the average percentage changes were a 21 percent decrease in Positive and Negative Syndrome Scale (PANSS) scores and a 26 percent increase in Quality of Life Scale (QLS) scores across all followup periods. The change in mean seven-point item scores were -0.46 (PANSS) and 0.23 (QLS). A major gain in clinically assessed improvement to "much better" was associated with a 45 percent decline in PANSS scores and 50 percent increase in QLS scores (change in mean seven-point item scores -0.88 and 0.92, respectively). Thus, modest changes in psychometric scales assessing symptoms and quality of life reflect clinically detectable improvement.

Percutaneous coronary intervention versus coronary artery bypass graft surgery for patients with medically refractory myocardial ischemia and risk factors for adverse outcomes with bypass: a multicenter, randomized trial. Investigators of the Department of Veterans Affairs Cooperative Study #385, the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME)

BACKGROUND

Percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG) are being applied to high-risk populations, but previous randomized trials comparing revascularization methods have excluded a number of important high-risk groups.

OBJECTIVES

This five-year, multicenter, randomized clinical trial was designed to compare long-term survival among patients with medically refractory myocardial ischemia and a high risk of adverse outcomes assigned to either a CABG or a PCI strategy, which could include stents.

METHODS

Patients from 16 Veterans Affairs Medical Centers were screened to identify myocardial ischemia refractory to medical management and the presence of one or more risk factors for adverse outcome with CABG, including prior open-heart surgery, age >70 years, left ventricular ejection fraction <0.35, myocardial infarction within seven days or intraaortic balloon pump required. Clinically eligible patients (n = 2,431) underwent coronary angiography; 781 were angiographically acceptable; 454 (58% of eligible) patients consented to random assignment between CABG and PCI.

RESULTS

A total of 232 patients was randomized to CABG and 222 to PCI. The 30-day survivals for CABG and PCI were 95% and 97%, respectively. Survival rates for CABG and PCI were 90% versus 94% at six months and 79% versus 80% at 36 months (log-rank test, p = 0.46).

CONCLUSIONS

Percutaneous coronary intervention is an alternative to CABG for patients with medically refractory myocardial ischemia and a high risk of adverse outcomes with CABG.

Metal complexes of the mycotoxins sporidesmin A and gliotoxin, investigated by electrospray ionisation mass spectrometry

The mycotoxin sporidesmin A (spdA), responsible for the intoxication of animals, causing facial eczema, has been investigated by electrospray ionisation mass spectrometry. Protonated [spdA+H](+) and deprotonated [spdA-H](-) ions are observed in positive and negative ion modes respectively. Reduced spdA, formed by cleavage of the disulfide bond by Na[BH(4)] gives an ion [spdA+H](-), and forms ions of the type [2spdA+M](2-) with a range of divalent metal ions M(2+)=Zn(2+), Cd(2+), Hg(2+), Sn(2+) and Fe(2+). Sodium-containing analogues [2spdA+M+Na](-) are observed, particularly at high cone voltages, where they are stable towards cone voltage-induced fragmentation, indicating appreciable stability of the (spdA)(2)M system. A competition experiment between Cd(2+) and Zn(2+) demonstrates that reduced spdA has a higher affinity for Cd(2+) ions. The related gliotoxin (gtx) forms analogous [2gtx+M](2-) and [2gtx+M+Na](-) ions. The reduction and metal complexation of spdA can be monitored by (1)H NMR spectroscopy, and results in chemical shift changes for those protons adjacent to the sulfur atoms. The isolation of a polymeric cadmium-spdA complex is also reported.

Hysterectomy in Veterans Affairs Medical Centers

OBJECTIVE

To examine the indications and surgical morbidity for women veterans who underwent hysterectomies in Department of Veterans Affairs Medical Centers (VAs).

METHODS

Data on hysterectomies performed in VAs from 1991 to 1997 were abstracted from a surgical quality improvement program.

RESULTS

Records of 1722 women who had hysterectomies in VAs over 6 years were examined. Women were predominately white (62%) and their average age was 42.5 years. Operations included abdominal (74%), vaginal (22%), and laparoscopic-assisted (4%) methods. The most common indications for surgery included uterine leiomyomas (31%), abnormal uterine bleeding (14%), and endometriosis (11%). Indications differed by race (P <.01); nonwhite women were most likely to have surgery for leiomyoma (51%), whereas white women had hysterectomies for leiomyomas (19%), abnormal bleeding (15%), endometriosis (13%), and genital prolapse (11%). The mean postoperative stay was significantly longer for abdominal hysterectomies (4.51 days) than either vaginal or laparoscopic-assisted hysterectomies (2.92 and 2.21 days, respectively; P <.001). The overall complication rate within 30 days was 9%, and the most frequent complication was urinary tract infection (3.3%).

CONCLUSION

Women who underwent hysterectomies in VAs had low complication rates, comparable to hysterectomy complication rates in the United States generally.

Validating risk-adjusted surgical outcomes: chart review of process of care

OBJECTIVE

The primary purpose of this study was to validate risk-adjusted surgical outcomes as indicators of the quality of surgical care at US Department of Veterans Affairs (VA) hospitals. The secondary purpose was to validate the risk-adjustment models for screening cases for quality review.

DESIGN

We compared quality of care, determined by structured implicit chart review, for patients from hospitals with higher and lower than expected operative mortality and morbidity (hospital-level tests) and between patients with high and low predicted risk of mortality and morbidity who died or developed complications (patient-level tests).

SUBJECTS

739 general, peripheral vascular and orthopedic surgery cases sampled from the 44 VA hospitals participating in the National VA Surgical Risk Study.

MAIN OUTCOME MEASURES

A global rating of quality of care based on chart review.

RESULTS

Ratings of overall quality of care did not differ significantly between patients from hospitals with higher and lower than expected mortality and morbidity. On some of the secondary measures, patient care was rated higher for hospitals with lower than expected operative mortality. At the patient level of analysis, those who died or developed complications and had a high predicted risk of mortality or morbidity were rated higher on quality of care than those with a low predicted risk of adverse outcome.

CONCLUSIONS

The absence of a relationship between most of our measures of process of care and risk-adjusted outcomes may be due to an insensitivity of chart reviews to hospital-level differences in quality of care. Site visits to National VA Surgical Risk Study hospitals with high and low risk-adjusted mortality and morbidity have detected differences on a number of dimensions of quality. The patient-level findings suggest that the risk-adjustment models are useful for screening adverse outcome cases for quality of care review.

Bioequivalence evaluation of lansoprazole 30-mg capsules (Lanfast and Lanzor) in healthy volunteers

The bioequivalence of two lansoprazole 30-mg capsules was determined in healthy human, adult volunteers after a single dose in a randomized cross-over study. The study was conducted at Pharmaconsult, Flemington Pharmaceutical Corp., New Jersey, USA. Reference (Lanzor, Laboratoires Houde, Paris, France) and test (Lanfast, Julphar, UAE) were administered to volunteers with 240 ml water after overnight fasting. Blood samples were collected at specified time intervals, plasma was separated and analyzed for lansoprazole using a validated HPLC method. The pharmacokinetic parameters AUC(0-t), AUC(0-~), C(max), T(max), T(1/2) and elimination rate constant were determined from plasma concentration-time profile of both formulations and found to be in good agreement with previously reported values. The calculated pharmacokinetic parameters were compared statistically to evaluate bioequivalence between the two brands, using the statistical modules recommended by the Food and Drug Administration. The analysis of variance (ANOVA) did not show any significant difference between the two formulations and 90% confidence intervals fell within the acceptable range (80-120%) for bioequivalence. Based on these statistical inferences it was concluded that the two formulations exhibited comparable pharmacokinetic profiles and that Julphar's Lanfast is bioequivalent to Lanzor of Lab. Houde.

Quality of life in schizophrenia: a comparison of instruments. Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia

Health-related quality of life in schizophrenia can be assessed by direct patient response or by a rating based on a structured interview. This study compares both types of instruments using a series of five standards: (1) sensitivity to change over time, (2) sensitivity to treatment effect, (3) correlation with symptom severity, (4) correlation with global clinical ratings, and (5) correlation with other measures of health-related quality of life. Four hundred and twenty-three inpatients with schizophrenia participating in a clinical trial comparing clozapine and haloperidol (VA Cooperative Study in Health Services #17) were evaluated using multiple measures of health-related quality of life (Lehman Quality of Life Interview; Heinrichs-Carpenter-Hanlon Quality of Life Scale; Strauss-Carpenter Level of Function scale, and clinical response.) The Quality of Life Interview showed less sensitivity to change and treatment effect, as well as lower correlations with all other measures than the Quality of Life Scale and the Level of Function scale. The latter scales showed high sensitivity to both change and treatment effect, and moderate-high correlations with other measures and with each other. The Quality of Life Scale and the Level of Function scale rater assessments appeared to be substantially more sensitive to subtle change and treatment effects than the patient-reported Quality of Life Interview for clinical trials. Health-related quality of life in schizophrenia is a more heterogeneous concept than previously appreciated.

Effectiveness of team-managed home-based primary care: a randomized multicenter trial

CONTEXT

Although home-based health care has grown over the past decade, its effectiveness remains controversial. A prior trial of Veterans Affairs (VA) Team-Managed Home-Based Primary Care (TM/HBPC) found favorable outcomes, but the replicability of the model and generalizability of the findings are unknown.

OBJECTIVES

To assess the impact of TM/HBPC on functional status, health-related quality of life (HR-QoL), satisfaction with care, and cost of care.

DESIGN AND SETTING

Multisite randomized controlled trial conducted from October 1994 to September 1998 in 16 VA medical centers with HBPC programs.

PARTICIPANTS

A total of 1966 patients with a mean age of 70 years who had 2 or more activities of daily living impairments or a terminal illness, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD). Intervention Home-based primary care (n=981), including a primary care manager, 24-hour contact for patients, prior approval of hospital readmissions, and HBPC team participation in discharge planning, vs customary VA and private sector care (n=985).

MAIN OUTCOME MEASURES

Patient functional status, patient and caregiver HR-QoL and satisfaction, caregiver burden, hospital readmissions, and costs over 12 months.

RESULTS

Functional status as assessed by the Barthel Index did not differ for terminal (P=.40) or nonterminal (those with severe disability or who had CHF or COPD) (P=.17) patients by treatment group. Significant improvements were seen in terminal TM/HBPC patients in HR-QoL scales of emotional role function, social function, bodily pain, mental health, vitality, and general health. Team-Managed HBPC nonterminal patients had significant increases of 5 to 10 points in 5 of 6 satisfaction with care scales. The caregivers of terminal patients in the TM/HBPC group improved significantly in HR-QoL measures except for vitality and general health. Caregivers of nonterminal patients improved significantly in QoL measures and reported reduced caregiver burden (P=.008). Team-Managed HBPC patients with severe disability experienced a 22% relative decrease (0.7 readmissions/patient for TM/HBPC group vs 0.9 readmissions/patient for control group) in hospital readmissions (P=.03) at 6 months that was not sustained at 12 months. Total mean per person costs were 6.8% higher in the TM/HBPC group at 6 months ($19190 vs $17971) and 12.1% higher at 12 months ($31401 vs $28008).

CONCLUSIONS

The TM/HBPC intervention improved most HR-QoL measures among terminally ill patients and satisfaction among non-terminally ill patients. It improved caregiver HR-QoL, satisfaction with care, and caregiver burden and reduced hospital readmissions at 6 months, but it did not substitute for other forms of care. The higher costs of TM/HBPC should be weighed against these benefits.

Comparison of complications after radical and partial nephrectomy: results from the National Veterans Administration Surgical Quality Improvement Program

OBJECTIVE

To determine whether radical nephrectomy causes less morbidity, less mortality and is associated with a shorter hospital stay than is partial nephrectomy.

PATIENTS AND METHODS

A total of 1885 nephrectomies (1373 radical and 512 partial) conducted between 1991 and 1998 in the Department of Veterans Affairs (VA) National Surgical Quality Improvement Program were evaluated. Using multivariate analyses, outcomes were risk-adjusted based on 45 preoperative variables to compare mortality and morbidity rates.

RESULTS

The unadjusted 30-day mortality was 2.0% for radical and 1.6% for partial nephrectomy (P = 0.58). Risk-adjusting the two groups did not result in a statistically significant difference in mortality. The 30-day overall morbidity rate was 15% for radical and 16.2% for partial nephrectomy (P = 0.52); risk-adjusted morbidity rates were not statistically different. There were no statistically significant differences in the rates of postoperative progressive renal failure, acute renal failure, urinary tract infection, prolonged ileus, transfusion requirement, deep wound infection, or extended length of stay.

CONCLUSIONS

Partial nephrectomy carried out in the VA program has low morbidity and mortality rates, comparable with the complication rates after radical nephrectomy.

Clinical and psychopharmacologic factors influencing family burden in refractory schizophrenia. The Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia

BACKGROUND

This study compares the effect of clozapine and haloperidol and identifies other factors related to family burden as experienced by relatives of patients with refractory schizophrenia (DSM-III-R).

METHOD

Of 423 patients participating in a multisite randomized clinical trial, 221 identified a family member who was actively involved in their care and who agreed to complete a standardized measure of family burden at 6 weeks and 3, 6, 9, and 12 months after randomization, simultaneous with comprehensive patient assessments.

RESULTS

Patient factors most consistently correlated with greater family burden were symptom severity, days living in the community (i.e., not in the hospital), and frequency of family contact. Among family members, clozapine was associated with significantly (p = .048) greater reduction in feelings of dissatisfaction related to providing support to the patient, but not in objective measures of support, amount of worry the patient engendered, or days of missed employment or household activity. Although clozapine reduces symptoms, thus lowering family burden, it also increases days living in the community, which tends to increase family burden, perhaps canceling out the benefit to families of reduced symptoms.

CONCLUSION

Clozapine has a small but significant effect on the experience of families of patients. This is the first study to demonstrate that effective pharmacotherapy may be of some benefit to families as well as to patients.

ABTS: a safe alternative to DAB for the enhancement of blood fingerprints

The use of 2,2'-azino-di-[3-ethylbenzthiazolinesulfonate(6)] diammonium salt (ABTS) for the enhancement of fingerprints in blood has been investigated. Optimal pH conditions and H2O2 concentrations have been determined using UV/Vis spectroscopy. ABTS is an effective and safe noncarcinogenic (though more expensive) alternative to the presently used 3,3'-diaminobenzidine (DAB) for the development of blood fingerprints, especially on porous surfaces. The bright green color of the oxidized ABTS is an advantage on certain colored surfaces where the dark brown color of DAB does not stand out well from the background. Development with ABTS does not interfere with subsequent DAB treatment, making ABTS a "nothing-to-lose" reagent. ABTS can be used after ninhydrin treatment, but the reverse is not the case.

How long to wait for a response to clozapine: a comparison of time course of response to clozapine and conventional antipsychotic medication in refractory schizophrenia

This study compared the time course to clinical improvement with clozapine and with conventional antipsychotic medications. A double-blind trial compared clozapine and haloperidol in patients with schizophrenia who were refractory to conventional antipsychotic medication and were hospitalized for 30 to 364 days at 15 Veteran Affairs medical centers during the year before study entry. Patients in the original study were randomly assigned to haloperidol or clozapine and followed for 12 months, at maximum tolerable doses. Patients who completed a full year of treatment with clozapine (n = 122), or with either haloperidol or another conventional antipsychotic medication (n = 123) and who also completed the 9- or 12-month assessment were included. Response to treatment was defined as 20 percent improvement on standard scales of symptoms and quality of life at the latter of the 9- or 12-month interviews. More patients assigned to clozapine achieved 20 percent improvement in symptoms at each followup. Among patients who did not improve at 6 weeks, 3 months, or 6 months, there were no significant differences between clozapine and comparison patients in outcomes at 1 year. Among patients who did improve, maintenance of that improvement also did not differ between the groups at 1 year on symptom measures. Maintenance of improvement in quality of life at 1 year was significantly greater for clozapine patients who had improved at 6 months (p < 0.04). Significant differential symptom response to clozapine occurred exclusively during the first 6 weeks of treatment.

Quantum-critical conductivity scaling for a metal-insulator transition

Temperature (T)- and frequency (omega)-dependent conductivity measurements are reported here in amorphous niobium-silicon alloys with compositions (x) near the zero-temperature metal-insulator transition. There is a one-to-one correspondence between the frequency- and temperature-dependent conductivity on both sides of the critical concentration, thus establishing the quantum-critical nature of the transition. The analysis of the conductivity leads to a universal scaling function and establishes the critical exponents. This scaling can be described by an x-, T-, and omega-dependent characteristic length, the form of which is derived by experiment.

The respiratory effects of volatile organic compounds

Volatile organic compounds (VOCs) have been implicated as causative agents in asthma and building-related illness. To determine whether a mixture of VOCs could impair lung function or cause airway inflammation among subjects without bronchial hyperresponsiveness, the authors conducted a randomized, crossover-design trial of controlled human exposures to filtered air for four hours, VOCs at 25 mg/m(3) for four hours, and VOCs at 50 mg/m(3) for four hours, using a VOC mixture based on sampling of indoor environments. VOC exposures caused dose-related increases in lower respiratory, upper respiratory, and non-respiratory symptoms, with no significant change in lung function (FEV(1);, FVC, or FEF(25-75), nasal lavage cellularity or differential cell counts, induced sputum cellularity or differential cell counts, or biomarkers of airway inflammation, including IL-8, LTB(4), or albumin in nasal lavage or induced sputum samples. Atopic individuals had significantly reduced FEE(25-75 following exposure to VOCs at 50 mg/m(3), suggesting that these individuals may be more sensitive to the health effects of VOCs. The authors conclude that reductions in levels of VOCs to substantially less than 25 mg/m(3) are required if a "non-irritating" work environment is desired.

A multicenter, randomized trial of percutaneous coronary intervention versus bypass surgery in high-risk unstable angina patients. The AWESOME (Veterans Affairs Cooperative Study #385, angina with extremely serious operative mortality evaluation) investigators from the Cooperative Studies Program of the Department of Veterans Affairs

This multicenter, prospective randomized trial was designed to test the hypotheses that percutaneous coronary intervention (PCI) is a safe and effective alternative to coronary artery bypass grafting (CABG) for patients with refractory ischemia and high risk of adverse outcomes. As a comparison of revascularization strategies, the trial specifically allows surgeons and interventionists to use new techniques as they become clinically available. After 42 months of this 72-month trial, 17,624 patients have been screened and 2022 met eligibility requirements: 341 have been randomized to either CABG or PCI, and the remaining 1681 are being prospectively followed in a registry. The 3-year overall survival of patients in the registry and randomized trial is comparable. To enhance accrual into the randomized trial, site visits were conducted, a few low-accruing hospitals were put on probation and/or replaced, eligibility criteria were reviewed at annual meetings of investigators, and the accrual period was extended by 1 year. These data demonstrate that a prospective randomized trial and registry of coronary revascularization for medically refractory high-risk patients is feasible.

Sulfasalazine treatment for rheumatoid arthritis: a metaanalysis of 15 randomized trials

OBJECTIVE

To assess the efficacy and safety of sulfasalazine (SSZ) compared to placebo and other disease modifying drugs.

METHODS

A metaanalysis was performed on 15 randomized clinical trials of rheumatoid arthritis (RA) that included SSZ (2 g/day average dose, 36 weeks average followup) as a treatment. Eight trials included a placebo group (PL), 2 hydroxychloroquine (HCQ) (350 mg/day average dose), 3 D-penicillamine (D-Pen) (667 mg/day average dose), and 4 gold sodium thiomalate or aurothioglucose (GST) (25 mg, 1 g/wk).

RESULTS

Compared to PL, SSZ was superior for improvement in erythrocyte sedimentation rate (ESR) (SSZ 37%, PL 14%; p < 0.0001), morning stiffness duration (SSZ 61%, PL 33%; p = 0.008), pain visual analog scale (SSZ 42%, PL 15%; p < 0.0001), articular index (SSZ 46%, PL 20%; p < 0.0001), number of swollen joints (SSZ 51%, PL 26%; p < 0.0001), number of painful joints (SSZ 59%, PL 33%; p = 0.004), and patient global assessment (SSZ 26%, PL 14%; p = 0.02). Withdrawals from study because of adverse drug reactions were increased (SSZ 24%, PL 7%; p < 0.0001), but lack of efficacy dropouts were decreased (SSZ 8%, PL 21%; p < 0.0001). Compared to HCQ, SSZ tended to have fewer lack of efficacy dropouts (SSZ 5%, HCQ 15%; p = 0.055) and improved ESR (SSZ 43%, HCQ 26%; p = 0.10) and morning stiffness duration (SSZ 59%, HCQ 40%; p = 0.09). Compared to GST, adverse drug reaction dropouts were significantly fewer (SSZ 12%, GST 29%; p < 0.0001), while withdrawals due to lack of efficacy were greater (SSZ 13%, GST 4%; p = 0.006). More patients tended to complete treatment taking SSZ (SSZ 69%, GST 61%; p = 0.09).

CONCLUSION

Over all, the metaanalysis provides data that support the effectiveness of SSZ as a treatment for RA.

Relationship between caregiver burden and health-related quality of life

This study tested the cross-sectional relationship between caregiver burden and health-related quality of life (HRQOL) among 1,594 caregivers of veterans identified to qualify for formal home care. A two-stage model found that familial relationship, coresidence, and low income predicted objective burden. Coresidence also predicted subjective burden, whereas being African American was protective. In the full model, spousal relationship, low income, and burden were associated with poor HRQOL scores. Total variance explained in HRQOL ranged from 14% to 29%, with objective burden contributing more than subjective burden. These findings suggest a direct effect of objective burden on caregiver HRQOL, indicating a need among caregivers for assistance in caring for disabled family members.

Enhanced access to primary care for patients with congestive heart failure. Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission

OBJECTIVE

To determine whether enhanced access to primary care affects the diagnostic evaluation, pharmacologic management, or health outcomes of patients hospitalized with congestive heart failure (CHF).

DESIGN

Multisite randomized, controlled trial.

SETTING

Nine Veterans Affairs medical centers.

PATIENTS

443 patients who were hospitalized with a diagnosis of CHF.

INTERVENTION

Enhanced access to primary care, including assignment of a primary care nurse and physician, increased telephone contact, additional outpatient visits, and patient education.

MAIN OUTCOME MEASURES

Diagnostic evaluation, pharmacologic management, health-related quality of life, and hospital readmission rates.

RESULTS

About 80% of patients who had enhanced access to care and patients receiving usual care underwent recommended evaluation of left ventricular ejection fraction. Among the subset of patients for whom an angiotensin-converting enzyme (ACE) inhibitor was recommended (i.e., ejection fraction < 40%), three quarters of the patients in both the enhanced access and usual care groups received the drug (75% vs. 73%; P > 0.2). Enhanced access to primary care did not improve quality of life and increased hospital readmissions, with an average of 1.5 +/- SD 2.0 readmissions per 6 months of follow-up for patients who had enhanced access compared with 1.1 +/- SD 1.8 for those who received usual care (P = 0.02).

CONCLUSIONS

Compliance with recommended CHF testing and treatment guidelines was equally high in both study groups. Enhanced access to primary care did not improve patients' self-reported health status and was associated with more frequent hospitalizations.