Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Community-based monitoring detects catastrophic earthquake and tsunami impacts on seagrass beds in the Solomon Islands

Tetepare Island in the Solomon Islands is the largest uninhabited island in the South Pacific and supports seagrass beds inside fringing reefs along its coastline. We monitored the diversity and abundance of seagrass species on Tetepare and nearby sparsely-populated Rendova Island over a 12 year period, 4 years before and up to 8 years after a major earthquake and tsunami event in January 2010. Both seagrass cover and diversity declined after the tsunami and had not reached pre-Tsunami levels after 8 years. Seagrass cover declined the fastest at sites on Rendova, closest to the epicentre, declining from 50% to <10% cover within 12 months of the earthquake. At sites within the Tetepare MPA, seagrass cover took longer to decline and dropped from an average of 50% to <10% within 2 years and became dominated by Halophila ovalis. Species richness declined from 9 to 4 species with some species such as Syringodium isoetifolium disappearing from monitoring sites. Community-based monitoring was an effective method of documenting long term changes in seagrass cover and long-term monitoring is required to determine if seagrass beds are permanently altered or return to pre-tsunami conditions.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Maternal cardiac output response to colloid preload and vasopressor therapy during spinal anaesthesia for caesarean section in patients with severe pre-eclampsia: a randomised, controlled trial

We examined the haemodynamic effects of colloid preload, and phenylephrine and ephedrine administered for spinal hypotension, during caesarean section in 42 women with severe early onset pre-eclampsia. Twenty patients with pre-delivery spinal hypotension were randomly allocated to receive an initial dose of either 50 μg phenylephrine or 7.5 mg ephedrine; the primary outcome was percentage change in cardiac index. After a 300-ml colloid preload, mean (SD) cardiac index increased from 4.9 (1.1) to 5.6 (1.2) l.min^-1 .m^-2 (p < 0.01), resulting from an increase in both heart rate, from 81.3 (17.2) to 86.3 (16.5) beats.min^-1 (p = 0.2), and stroke volume, from 111.8 (19.0) to 119.8 (17.9) ml (p = 0.049). Fourteen (33%) and 23 (54.8%) patients exhibited a stroke volume response > 10% and > 5%, respectively; a significant negative correlation was found between heart rate and stroke volume changes. Spinal hypotension in 20 patients was associated with an increase from baseline in cardiac index of 0.6 l.min^-1 .m^-2 (mean difference 11.5%; p < 0.0001). After a median [range] dose of 50 [50-150] μg phenylephrine or 15 [7.5-37.5] mg ephedrine, the percentage change in cardiac index during the measurement period of 150 s was greater, and negative, in patients receiving phenylephrine vs. ephedrine, at -12.0 (7.3)% vs. 2.6 (6.0)%, respectively (p = 0.0001). The percentage change in heart rate after vasopressor was higher in patients receiving phenylephrine, at -9.1 (3.4)% vs. 5.3 (12.6)% (p = 0.0027), as was the change in systemic vascular resistance, at 22.3 (7.5) vs. -1.9 (10.5)% (p < 0.0001). Phenylephrine effectively reverses spinal anaesthesia-induced haemodynamic changes in severe pre-eclampsia, if left ventricular systolic function is preserved.

The neuronal metabolite NAA regulates histone H3 methylation in oligodendrocytes and myelin lipid composition

The neuronal mitochondrial metabolite N-acetylaspartate (NAA) is decreased in the multiple sclerosis (MS) brain. NAA is synthesized in neurons by the enzyme N-acetyltransferase-8-like (NAT8L) and broken down in oligodendrocytes by aspartoacylase (ASPA) into acetate and aspartate. We have hypothesized that NAA links the metabolism of axons with oligodendrocytes to support myelination. To test this hypothesis, we performed lipidomic analyses using liquid chromatography-tandem mass spectrometry (LC-MS/MS) and high-performance thin-layer chromatography (HPTLC) to identify changes in myelin lipid composition in postmortem MS brains and in NAT8L knockout (NAT8L^-/-) mice which do not synthesize NAA. We found reduced levels of sphingomyelin in MS normal appearing white matter that mirrored decreased levels of NAA. We also discovered decreases in the amounts of sphingomyelin and sulfatide lipids in the brains of NAT8L^-/- mice compared to controls. Metabolomic analysis of primary cultures of oligodendrocytes treated with NAA revealed increased levels of α-ketoglutarate, which has been reported to regulate histone demethylase activity. Consistent with this, NAA treatment resulted in alterations in the levels of histone H3 methylation, including H3K4me3, H3K9me2, and H3K9me3. The H3K4me3 histone mark regulates cellular energetics, metabolism, and growth, while H3K9me3 has been linked to alterations in transcriptional repression in developing oligodendrocytes. We also noted the NAA treatment was associated with increases in the expression of genes involved in sulfatide and sphingomyelin synthesis in cultured oligodendrocytes. This is the first report demonstrating that neuronal-derived NAA can signal to the oligodendrocyte nucleus. These data suggest that neuronal-derived NAA signals through epigenetic mechanisms in oligodendrocytes to support or maintain myelination.

Dynamics of culling for Jersey, Holstein, and Jersey × Holstein crossbred cows in large multibreed dairy herds

The objective of this observational study was to describe and compare the dynamics of reason-specific culling risk for the genetic groups Jerseys (JE), Holsteins (HO), and Jersey × Holstein crossbreds (JH), considering parity, stage of lactation, and milk yield, among other variables, in large multibreed dairy herds in Texas. The secondary objective was to analyze the association between survival and management factors, such as breeding and replacement policies, type of facilities, and use of cooling systems. After edits, available data included 202,384 lactations in 16 herds, ranging from 407 to 8,773 cows calving per year during the study period from 2007 to 2011. The distribution of lactation records by genetic group was 58, 36, and 6% for HO, JE, and JH crosses, respectively. Overall culling rates across breeds were 30.1, 32.1, and 35.0% for JH, JE, and HO, respectively. The dynamics of reason-specific culling were dependent on genetic group, parity, stage of lactation, milk yield, and herd characteristics. Early lactation was a critical period for "died" and "injury-sick" culling. The risk increased with days after calving for "breeding" and, in the case of HO, "low production" culling. Open cows had a 3.5 to 4.6 times greater risk for overall culling compared with pregnant cows. The odds of culling with reason "died" within the first 60 d in milk (DIM) were not significantly associated with genetic group. However, both JE and JH crosses had lower odds of live culling within the first 60 DIM compared with HO cows (OR=0.72 and 0.82, respectively). Other cow variables significantly associated with the risk of dying within the first 60 DIM were cow relative 305-d mature equivalent (305ME) milk yield, parity, and season of calving. Significant herd-related variables for death included herd size and origin of replacements. In addition to genetic group, the risk of live culling within 60 DIM was associated with cow-relative 305ME milk yield, parity, and season of calving. Significant herd-related variables for live culling included herd-relative 305ME milk yield, herd size, type of facility, origin of replacement, and type of maternity. Overall, reason-specific culling followed similar patterns across DIM in the 3 genetic groups.

Emergence of opiate-induced neonatal abstinence syndrome

Neonatal abstinence syndrome (NAS) is the clinical picture of infants withdrawing from in-utero substance exposure. The incidence of NAS rose in Dublin maternity hospitals in the 1970's and '80's in parallel with increasing in opiate abuse in that city. The purpose of this study was to determine if a similar pattern was emerging in Cork University Maternity Hospital. Data from the Erinville Hospital (2000-2007) and CUMH (2008-2011) were compared. Sixteen cases of NAS were identified, two at Erinville Hospital (22,987 deliveries; incidence = 0.09/1000 deliveries) and 14 at CUMH (37,414 deliveries; incidence = 0.38/1000 deliveries; p < 0.01). Five of the 16 mothers were using heroin, while ten were on methadone maintenance. All were multi-drug abusers. Newborns requiring pharmacotherapy for NAS (5/16) had prolonged hospitalisations compared to those requiring supportive care. NAS in Cork is increasing. Primary, secondary and tertiary preventative measures are warranted to prevent further escalation.

Mortality and incidence of new primary cancers in men with prostate cancer: a Danish population-based cohort study

BACKGROUND

Prostate cancer (PC) survivors may have an increased risk of new primary cancers (NPCs) due to shared risk factors or PC-directed treatments.

METHODS

Using Danish registries, we conducted a cohort study of men with (n=30,220) and without PC (n=151,100) (comparators), matched 1:5 on age and PC diagnosis/index date. We computed incidence rates of NPCs per 10,000 person years (PY) and associated 95% confidence intervals (CI), and used Cox proportional hazards regression to compute hazard ratios (HRs) and 95%CI, adjusting for comorbidities. In order to obviate any impact of shorter survival among prostate cancer patients, we censored comparator patients when the matched prostate cancer patient died or was censored.

RESULTS

Follow-up spanned 113,487PY and 462,982PY in the PC and comparison cohorts, respectively. 65% of the cohorts were aged >70 years at diagnosis. Among PC patients, 51% had distant/unspecified stage, and 63% had surgery as primary treatment. The PC cohort had lower incidence of NPCs than their comparators. The adjusted HR of NPC among men with PC versus the comparators was 0.84 (95%CI=0.80, 0.88). Lowest HRs were among older men, those with distant stage, and were particularly evident for cancers of the brain, liver, pancreas, respiratory, upper gastrointestinal, and urinary systems.

CONCLUSIONS

We find no evidence of an increased risk of NPCs among men with PC. The deficit of NPCs among men with PC may be a true effect but is more likely due to lower levels of risk factors (e.g., smoking) in PC patients versus comparators, clinical consideration of cancers at new organs as metastases rather than new primaries, or under-recording/under-reporting of NPCs among PC patients.

Incidence, risk factors, and outcomes of osteonecrosis of the jaw: integrated analysis from three blinded active-controlled phase III trials in cancer patients with bone metastases

BACKGROUND

Osteonecrosis of the jaw (ONJ) has been reported in patients receiving bisphosphonates for metastatic bone disease. ONJ incidence, risk factors, and outcomes were evaluated in a combined analysis of three phase III trials in patients with metastatic bone disease receiving antiresorptive therapies.

PATIENTS AND METHODS

Patients with bone metastases secondary to solid tumors or myeloma were randomly assigned to receive either s.c. denosumab (120 mg) or i.v. zoledronic acid (4 mg) every 4 weeks. On-study oral examinations were conducted by investigators at baseline and every 6 months. Oral adverse events were adjudicated by an independent blinded committee of dental experts.

RESULTS

Of 5723 patients enrolled, 89 (1.6%) patients were determined to have ONJ: 37 (1.3%) received zoledronic acid and 52 (1.8%) received denosumab (P = 0.13). Tooth extraction was reported for 61.8% of patients with ONJ. ONJ treatment was conservative in >95% of patients. As of October 2010, ONJ resolved in 36.0% of patients (29.7% for zoledronic acid and 40.4% for denosumab).

CONCLUSIONS

In this combined analysis of three prospective trials, ONJ was infrequent, management was mostly conservative, and healing occurred in over one-third of the patients. Educating physicians about oral health before and during bone-targeted therapy may help reduce ONJ incidence and improve outcomes.

Infections in postmenopausal women with osteoporosis treated with denosumab or placebo: coincidence or causal association?

Serious adverse events of infections that occurred in subjects receiving denosumab or placebo in the Fracture Reduction Evaluation of Denosumab in Osteoporosis every 6 Months (FREEDOM) study were examined in detail. Serious adverse events of infections in denosumab subjects had heterogeneous etiology, with no clear clinical pattern to suggest a relationship to time or duration of exposure to denosumab.

INTRODUCTION

Denosumab reduces the risk for new vertebral, hip, and nonvertebral fractures compared with placebo. In the pivotal phase 3 fracture trial (FREEDOM), the overall safety profile and incidence of adverse events including adverse events of infections were similar between groups. Serious adverse events of erysipelas and cellulitis were more frequent in denosumab-treated subjects. In this report, we further evaluate the details of infectious events in FREEDOM to better understand if RANKL inhibition with denosumab influences infection risk.

METHODS

FREEDOM was an international multicenter, randomized, double-blind, placebo-controlled study in postmenopausal women with osteoporosis randomly assigned to receive placebo (n = 3,906) or denosumab 60 mg every 6 months (n = 3,902). The incidence of adverse events and serious adverse events categorized within the Medical Dictionary for Regulatory Activities system organ class, "Infections and Infestations," was compared between the placebo and denosumab groups by body systems and preferred terms. The temporal relationship between occurrence of serious adverse events of infections of interest and administration of denosumab was explored.

RESULTS

Serious adverse events of infections involving the gastrointestinal system, renal and urinary system, ear, and endocarditis were numerically higher in the denosumab group compared with placebo, but the number of events was small. No relationship was observed between serious adverse events of infections and timing of administration or duration of exposure to denosumab.

CONCLUSIONS

Serious adverse events of infections that occurred with denosumab treatment had heterogeneous etiology, with no clear clinical pattern to suggest a relationship to time or duration of exposure to denosumab.

Impaired cardiac functional reserve in type 2 diabetic db/db mice is associated with metabolic, but not structural, remodelling

AIM

To identify the initial alterations in myocardial tissue associated with the early signs of diabetic cardiac haemodynamic dysfunction, we monitored changes in cardiac function, structural remodelling and gene expression in hearts of type 2 diabetic db/db mice.

METHODS

Cardiac dimensions and function were determined echocardiographically at 8, 12, 16 and 18 weeks of age. Left ventricular pressure characteristics were measured at 18 weeks under baseline conditions and upon dobutamine infusion.

RESULTS

The db/db mice were severely diabetic already at 8 weeks after birth, showing elevated fasting blood glucose levels and albuminuria. Nevertheless, echocardiography revealed no significant changes in cardiac function up to 18 weeks of age. At 18 weeks of age, left ventricular pressure characteristics were not significantly different at baseline between diabetic and control mice. However, dobutamine stress test revealed significantly attenuated cardiac inotropic and lusitropic responses in db/db mice. Post-mortem cardiac tissue analyses showed minor structural remodelling and no significant changes in gene expression levels of the sarcoplasmic reticulum calcium ATPase (SERCA2a) or beta1-adrenoceptor (beta1-AR). Moreover, the phosphorylation state of known contractile protein targets of protein kinase A (PKA) was not altered, indicating unaffected cardiac beta-adrenergic signalling activity in diabetic animals. By contrast, the substantially increased expression of uncoupling protein-3 (UCP3) and angiopoietin-like-4 (Angptl4), along with decreased phosphorylation of AMP-activated protein kinase (AMPK) in the diabetic heart, is indicative of marked changes in cardiac metabolism.

CONCLUSION

db/db mice show impaired cardiac functional reserve capacity during maximal beta-adrenergic stimulation which is associated with unfavourable changes in cardiac energy metabolism.

Magnetic Resonance Imaging quantification of breast density in BRCA carriers following gonadotropin releasing hormone agonist (GnRHA)-based hormonal chemoprevention

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Background: Breast tissue density limits the usefulness of mammography as a surveillance tool in young women. Breast Magnetic Resonance Imaging (MRI) provides high tissue contrast and three-dimensional structural information not impaired by high breast density. We developed a volumetric “MR density” measure of breast structural composition that may be complementary to mammographic breast density. We tested this MR density measure in unaffected women with known high risk of breast cancer due to a BRCA gene mutation (or empiric risk > 30% lifetime), who were recruited in a phase II trial to study the effects of a hormonal chemoprevention regimen. Methods: Nine premenopausal high-risk women age 21 to 48 were treated with intranasal GnRHA (deslorelin), low-dose estradiol, and testosterone daily for 10 months. All patients underwent one contrast-enhanced breast MRI exam before and after treatment. We measured MR density as the ratio of fibroglandular tissue volume to total volume of the breast, at both time points. Our technique involved the semi-automated delineation of the breast and the automated segmentation of fibroglandular from adipose tissue. An “MR index” was also defined to quantify partial voluming effects due to the presence of adipose/fibroglandular edges in the MR data. Results: Eight out of nine patients showed a reduction in MR density (p = 0.026) with treatment. Three patients had less than 5% MR density at baseline, making it difficult to quantitate a change with treatment. All of the remaining six patients had reduced MR density after treatment (mean reduction 35.5%; p = 0.035). Conclusions: We have demonstrated the use of breast MR density as a robust volumetric quantitative measure of breast tissue composition. Our findings suggest that MR could be used to measure hormonal chemoprevention effects in BRCA carriers.

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Connective tissue growth factor and cardiac fibrosis

Cardiac fibrosis is a major pathogenic factor in a variety of cardiovascular diseases and refers to an excessive deposition of extracellular matrix components in the heart, which leads to cardiac dysfunction and eventually overt heart failure. Evidence is accumulating for a crucial role of connective tissue growth factor (CTGF) in fibrotic processes in several tissues including the heart. CTGF orchestrates the actions of important local factors evoking cardiac fibrosis. The central role of CTGF as a matricellular protein modulating the fibrotic process in cardiac remodelling makes it a possible biomarker for cardiac fibrosis and a potential candidate for therapeutic intervention to mitigate fibrosis in the heart.

Antibiotic prophylaxis for percutaneous endoscopic gastrostomy--a prospective, randomised, double-blind trial

BACKGROUND

Peristomal infection can sometimes complicate percutaneous endoscopic gastrostomy (PEG) placement. Antibiotic prophylaxis has, in some studies, been shown to reduce the incidence. However, the use of prophylaxis varies widely, possibly because the design and findings of the studies have differed, making their relevance to clinical practice difficult to interpret.

AIM

To determine the efficacy of antibiotics, either prophylaxis or concurrent antibiotics at the time of the procedure, in reducing peristomal infection after PEG insertion in the context of a study designed to reflect current practice.

METHODS

One hundred and forty-one patients undergoing PEG placement were randomised to group one to receive either a single dose of 750 mg of intravenous cefuroxime (n=50) or placebo (n=51) 30 min before PEG insertion. Forty patients who, for various reasons, were already receiving antibiotics were allocated to group two. The peristomal site was evaluated on day 3, 5 and 7 following insertion. Erythema and exudate were scored on a scale from 0 to 4; induration was scored on a scale of 0-3. A maximum combined score of 8 or higher or the presence of pus was criteria for infection. The primary outcome measure was the occurrence of a peristomal wound infection at any time within one week of PEG insertion.

RESULTS

Peristomal wound infection was significantly reduced in patients who received antibiotics either as a single dose of cefuroxime [one of 33 (3%)], or in those on antibiotics for prior indications [one of 36 (3%)], compared with placebo [six of 33 (18%)], P=0.04 and 0.03, respectively.

CONCLUSION

Antibiotics, either prophylaxis or concurrent, reduce the incidence of peristomal wound infection after PEG placement.

Ambivalence of primary health care professionals towards the South African guidelines for hypertension and diabetes

BACKGROUND

Consensus-derived guidelines for hypertension and diabetes management were introduced by the National Department of Health to improve quality of care. However, the incorporation of guidelines into clinical practice is largely dependent on the attitudes of health professionals.

OBJECTIVE

To audit the responses and examine the attitudes of health professionals in primary care towards the diabetes and hypertension care guidelines.

DESIGN

Qualitative focus group, in-depth discussions and clinic observations.

SETTING

Four community health centres (CHCs) in the Western Cape.

SUBJECTS

Fifteen doctors and 10 professional nurses.

METHODS

The responses of health professionals to the guidelines were audited. Their attitudes were evaluated at a single pilot CHC using focus group discussions and in-depth interviews. Semi-structured interviews based on these themes were conducted at 3 other CHCs. Clinic consultations were observed to validate the responses.

RESULTS

The guidelines were not systematically implemented at local CHCs and individual doctors consulted the guidelines infrequently. Several themes were identified as barriers to the application of the guidelines, including the consultation process by which the guidelines were developed, time constraints, scepticism about durability of the guidelines, conflict with local practices, health system problems, and patient beliefs.

CONCLUSION

The usefulness of passive dissemination of guidelines to health professionals in primary care should be reviewed as several attitudinal barriers to implementation may exist. Guidelines may be adopted more readily if these barriers are addressed.

The National Outcomes Management Project: a benchmarking collaborative

Traditional evaluation of health care quality usually involves the measurement of the structure, process, and outcome of care. Most quality improvement programs involve a cycle that includes a setting of goals, a measurement of either process or outcomes, and a real-time or retrospective feedback of the results of data measurement. Benchmarking, a well-known efficient business technology, can lead to practice innovations necessary to survive in an environment that has a need for decreasing cost and increasing quality. The purpose of this article is to present a novel use of benchmarking in managed ambulatory behavioral health care and its application in a model collaborative outcome management project at more than 16 sites and nine states in the United States.

Identification of two-dimensionally separated human cerebrospinal fluid proteins by N-terminal sequencing, matrix-assisted laser desorption/ionization--mass spectrometry, nanoliquid chromatography-electrospray ionization-time of flight-mass spectrometry, and tandem mass spectrometry

Optimal application of biological mass spectrometry (MS) in combination with two-dimensional polyacrylamide gel electrophoresis (2-D PAGE) of human cerebrospinal fluid (CSF) can lead to the identification of new potential biological markers of neurological disorders. To this end, we analyzed a number of 2-D PAGE protein spots in a human CSF pool using spot co-localization, N-terminal sequencing, matrix-assisted laser desorption/ionization-mass spectrometry (MALDI-MS) and nanoliquid chromatography-electrospray ionization-time of flight-mass spectrometry (nanoLC-ESI-TOF-MS) with tandem MS switching. Our constructed CSF master contained 469 spots after image analysis and processing of 2-D gels. Upon visual inspection of our CSF master with the CSF pattern available on the ExPASy server, it was possible to locate and annotate 15 proteins. N-terminal sequence analysis and MALDI-MS peptide mass fingerprint analysis of both silver- and Coomassie Brilliant Blue (CBB) G-250-stained protein spots after in situ trypsin digest not only confirmed nine of the visually annotated spots but additionally resolved the identity of another 13 spots. Six of these proteins were not annotated on the 2-D ExPASy map: complement C3 alpha-chain (1321-1663), complement factor B, cystatin C, calgranulin A, hemoglobin beta-chain, and beta-2-microglobulin. It was clear that MALDI-MS identification from CBB G-250-stained, rather than from silver-stained, spots was more successful. In cases where no N-terminal sequence and/or no clear MALDI-MS result was available, nanoLC-ESI-TOF-MS and tandem MS automated switching was used to clarify and/or identify these protein spots by generating amino acid sequence tags. In addition, enrichment of the concentration of low-abundant proteins on 2-D PAGE was obtained by removal of albumin and immunoglobulins from the CSF pool using affinity chromatography. Subsequent analysis by 2-D PAGE of the fractionated CSF pool showed various new silver-stainable protein spots, of which four were identified by nanoLC-ESI-TOF-MS and tandem MS switching. No significant homology was found in either protein or DNA databases, indicating than these spots were unknown proteins.

Hsp72 antigen expression in the proliferative compartment of involved psoriatic epidermis

Oxidative damage to growth regulatory proteins has been implicated in the aetiology of psoriasis. However, the transient synthesis of heat shock proteins has been shown to protect cells against the adverse effects of oxidative and other forms of physiological stress. This study has used an hsp72 monoclonal antibody to measure inducible 72 kDa heat shock protein expression in heat stressed normal human skin and established plaque psoriasis. Hsp72 was detected in the basal and suprabasal layer cells of heat-stressed normal skin, and in 12 involved psoriasis lesions. Hsp72 expression was not detected in unstressed normal skin or in 12 cases of uninvolved psoriasis. Immunoprecipitation and Western blotting of cell lysates from heat stressed normal skin and involved psoriasis lesions confirmed the presence of a 72 kDa polypeptide with hsp72 immunoreactivity. The MIB-1 monoclonal antibody was used to determine the proliferative fraction of normal and involved psoriastic epidermis. The Ki67 antigen was localised to the nuclei of basal and suprabasal layer cells of normal and involved psoriatic epidermis. Involved psoriatic epidermis contained a higher number of proliferating keratinocytes when compared with normal skin. The study has also demonstrated a strong correlation between hsp72 expression and keratinocyte proliferation in involved psoriatic epidermis (r=0.864, p<0.001). We believe that the 72 kDa inducible heat shock protein performs a protective function in the proliferative compartment of normal and involved psoriatic skin.

Blood pressure and social support observations from Mamre, South Africa, during social and political transition

OBJECTIVE

Social support, by moderating cardiovascular reactivity, has been demonstrated to attenuate the effects of stress on blood pressure in American communities. This is the first report to examine the relationship between social support and blood pressure in a South African context, during a period of infrastructure modernisation and political change.

METHODS

A total of 1240 residents (542 men, 698 women) of mixed ethnic origin, older than 14 years and stratified by age and sex, participated in a survey to determine risk factors for hypertension and cardiovascular diseases. Social support was assessed by a questionnaire developed in consultation with the community. It was defined by interactions that may threaten family harmony (score 1) and by networking between relatives, friends, colleagues and neighbours (score 2).

RESULTS

Mean blood pressure of the sample was 130/79 mm Hg (s.d. 25/14 mm Hg). Hypertension prevalence was 26.9%. Only 36% of women compared to 57.3% of men (P < 0.0001) were employed. More women (29%) than men (22%) reported threats to family harmony, but social support networks were similarly perceived by both sexes. Systolic and diastolic blood pressure correlated weakly with score 1 (r = 0.096, P < 0.0007) but no association was observed with score 2. Score 1 was not associated with blood pressure by multiple regression analysis, that included confounding by age, sex, BMI, alcohol consumption and smoking status.

CONCLUSIONS

Neither threats to family harmony nor networking between relatives, friends or neighbours, significantly influences blood pressure in this community. Measures of social support thought to moderate blood pressure may have limited cross-cultural application. Attitudinal changes during socio-political transition may impact on the generalisability of instruments for measurement.

Ambulance visits for severe hypoglycaemia in insulin-treated diabetes

AIM

To determine, in insulin-treated diabetes the incidence and risk factors for severe hypoglycaemia requiring ambulance visits.

METHODS

A cross-sectional, questionnaire survey was made of patients with type 1 diabetes, who received help for severe hypoglycaemia from Ambulance Association personnel, during the period 1/6/95 to 31/5/96.

RESULTS

The ambulance service made 386 emergency visits to 247 persons with type 1 diabetes. Of these, 128 respondents (52%) completed a questionnaire detailing personal and diabetes history, usual diabetes care practices and hypoglycaemia management. Two or more visits for severe hypoglycaemia were made to 26.3% of patients, who reported a longer duration of diabetes than those who required only one visit (28 vs 20 years, p<0.03). Self-blood-glucose monitoring was performed by 98.4% of respondents and 66.4% self-adjusted insulin doses. Intensively treated patients (> or = 3 insulin injections daily) reported less awareness of hypoglycaemia than standard therapy patients (< or = 2 insulin injections daily) (p<0.05). Fifty-four per cent of respondents had glucagon available for emergency use, but those who lived alone and in general practitioner care only (27%) were less likely to have glucagon (p<0.05) compared to those with companions and in shared-care arrangements (62%). Hypoglycaemia management was influenced by the availability of glucagon. Oral glucose was used by 82% before injecting glucagon, whereas 40% of patients without glucagon called for the ambulance when severe symptoms were present even before initiating treatment with oral glucose.

CONCLUSION

This survey determined the minimum frequency of severe hypoglycaemia requiring the ambulance at 1.6 episodes patient(-1) year(-1). Precipitating factors and a lack of coping skills and behaviours that might prevent severe hypoglycaemia and ambulance calls were identified.

Standardized screening of elderly patients' needs for social work assessment in primary care: use of the SF-36

Fewer hospitalizations and decreased lengths of stay in the hospital have resulted in an increased need for extensive support services and continuing care planning for elderly people in primary care. Early identification of elderly patients needing community and hospital nonmedical services is necessary so that timely appropriate services can be delivered. This study addresses the issue of whether a standardized health-related quality of life questionnaire, the SF-36, can be used independently as a screen predicting primary care elderly patients' needs for social work assessment. In addition, the question of what scales on the SF-36 a social worker would use to screen patients in need of assessment is explored.

Cost and value of performance indicators. Results from IBH's (Institute for Behavioral Healthcare) National Leadership Council

Consumer Reports style report cards are becoming commonplace in our industry and will emerge as a necessary component of 21st century behavioral healthcare. As a result, health plans and providers are increasingly required to invest in and maintain an infrastructure for comparative performance measurement and reporting. Policymakers and accrediting agencies must be careful to require reporting about the most cost-effective indicators in order to minimize the extra cost burden imposed upon health plans and providers by this effort. The Institute for Behavioral Healthcare's National Leadership Council evaluated "real life" performance indicators already in use in health plans, facility-based provider settings, community mental health centers, and behavioral group practices. This study shows which performance indicators are most worth measuring and those which are not, and why. Significant implications for policy and accrediting organizations, and for the behavioral healthcare field, are discussed.

Quality assessment and improvement standards for behavioral group practices

Behavioral group practices have agreed on performance indicators and have established national benchmarking standards. Collaborative study, led by the Institute for Behavioral Healthcare's Council of Behavioral Group Practices (CBGP), facilitates practice pattern evaluation, trend analysis, and clinical quality improvement. The study reports the benchmarking standards for quality assessment and improvement standards in behavioral group practices in the comprehensive 1995 and 1996 CBGP Performance Indicator Reports.

alpha 1-antitrypsin deficiency and idiopathic pulmonary fibrosis in a family

Idiopathic pulmonary fibrosis (IPF) is an interstitial lung disease of unknown etiology with an estimated prevalence of 3 to 5 per 100,000. We describe a patient with a family history of both IPF and alpha 1-antitrypsin (AAT) deficiency. The patient had a 6-month history of worsening dyspnea when first seen, and he later died of multisystem organ failure and recalcitrant hypoxemia. He had IPF and AAT deficiency, with the phenotype PiSZ. His father and younger brother died of respiratory failure due to IPF. Other family members are heterozygous for AAT deficiency. A variety of inflammatory diseases have been associated with AAT deficiency, and an association between heterozygous AAT deficiency and IPF has been reported in the literature. Most current theories on the pathogenesis of IPF suggest an aberrant inflammatory response to some stimulus. This family cluster and another reported in the literature suggest that AAT deficiency may be a factor predisposing to inflammatory lung disease manifested by interstitial fibrosis.

Self-care burden in women with human immunodeficiency virus

The authors of this descriptive study used Orem's Theory of Self-Care to assess perceived demand for or change in universal and health-deviation self-care activity and the degree of difficulty ascribed to meeting that demand. Perceived demand or change in self-care and difficulty in self-care were measured using the Self-Care Burden Scale (Oberst, Hughes, Chang & McCubbin, 1991) and a structured interview. A convenience sample of 10 English or Spanish-speaking women with HIV infection utilizing a city hospital's outpatient immunodeficiency clinic were recruited. Of the health deviation self-care items, home medical/nursing treatments, special diet, and obtaining resources were the most burdensome categories. Universal self-care tasks with the highest burden scores were caring for children, physical activity, and work.

SAPPHIRE: scenarios, architecture, and process

General Medical Practice (GMP) information systems within the UK are becoming more sophisticated and more complex and are widely available from numerous suppliers. Although such systems are viewed as being important, they are problematic in terms of interpreting and assessing their usefulness, and their impact upon work and the organisation (G. Walsham, Interpreting Information Systems in Organizations (Wiley, Chichester, 1993)). In particular, it is difficult for any who have an interest in these systems to apply existing technical specifications to a specific situation, and to match individual requirements with the supplier's products. The research project SAPPHIRE seeks to inform the decision making of stakeholders, e.g. GPs, facilitators and suppliers, with respect to procurement, update, design and supply of GMP systems by developing the means of evaluating such systems, and by facilitating an accreditation process through that evaluation. This extended paper introduces the multi-faceted approach, scenarios, architecture and process of SAPPHIRE.

Renal cisplatin chemoembolization with Angiostat, Gelfoam, and Ethiodol in the rabbit: renal platinum distributions

Renal platinum distributions were determined in rabbits after administration of 0.4 mL of 1 mg/mL cisplatin by intravenous infusion, by injections into the left renal artery with aqueous contrast material and with lipid contrast material (Ethiodol), and by chemoembolization of the left renal artery with concurrent administration of various concentrations of two collagen carriers, Angiostat collagen for embolization and Gelfoam gelatin. Renal platinum concentration was measured in tissue homogenates at 2 1/2 hours with atomic absorption spectrometry. Target-kidney platinum levels were 5.4 and 6.9 times the contralateral-kidney levels after intraarterial infusion of aqueous and lipid contrast media, respectively. With Angiostat and Gelfoam chemoembolization, renal platinum retention and collagen concentration were linearly related (r = .87 and .81, P less than .001). Target-kidney-contralateral-kidney platinum ratios were 57:1 for 30 mg/mL Gelfoam and 220:1 for 10 mg/mL Angiostat. The difference in regional drug retention for Angiostat versus Gelfoam reflects the stable fiber integrity of Angiostat.

Computer held chronic disease registers in general practice: a validation study

Lists of patients receiving repeat prescriptions for epilepsy, diabetes, thyroid disease and asthma were compared with chronic disease registers stored on seven practice computers. Diabetes was the most accurately recorded disease: the names of 72% of patients receiving medication for this condition appeared on the relevant disease registers. Agreement between the two data sources was 68% for thyroid disease, 58% for asthma and 49% for epilepsy. The levels of accuracy are not yet high enough for the computerised chronic disease registers to provide an accurate estimate of the prevalence of these conditions, but new system developments suggest a more optimistic outlook for the future.

Effect of antimicrobial protection on tolerance to hepatic chemoembolization with a fibrous collagen carrier

The effect of antimicrobial prophylaxis on tolerance to hepatic embolization and chemoembolization with collagen particles was examined in porcine liver. Embolization in the 36 animals consisted of hepatic artery injection of 3 mL of collagen (10 mg/mL) alone or combined with one to three drugs (cisplatin, mitomycin, and doxorubicin). Embolization was performed with or without antimicrobial protection, and the animals were killed at 5 days for gross and histologic evaluation of liver and for bacterial culture. When present, liver damage consisted of focal to whole-lobe necrosis. Liver damage was correlated with positive bacterial culture (P less than .002) and was reduced by antimicrobial protection. Vessel recanalization was inhibited by addition of drug to collagen (P less than .001) and by lack of antimicrobial protection (P less than .001). Perivascular necrosis was directly related to vessel size (P = .0001). Antimicrobial prophylaxis is recommended to enhance hepatic chemoembolization safety.