Longitudinal Impacts of Precision Greenness on Alzheimer's Disease

BACKGROUND

The potential for greenness as a novel protective factor for Alzheimer's disease (AD) requires further exploration.

OBJECTIVES

This study assesses prospectively and longitudinally the association between precision greenness - greenness measured at the micro-environmental level, defined as the Census block - and AD incidence.

DESIGN

Older adults living in consistently high greenness Census blocks across 2011 and 2016 were compared to those living in consistently low greenness blocks on AD incidence during 2012-2016.

SETTING

Miami-Dade County, Florida, USA.

PARTICIPANTS

230,738 U.S. Medicare beneficiaries.

MEASUREMENTS

U.S. Centers for Medicare and Medicaid Services Chronic Condition Algorithm for AD based on ICD-9 codes, Normalized Difference Vegetation Index, age, sex, race/ethnicity, neighborhood income, and walkability.

RESULTS

Older adults living in the consistently high greenness tertile, compared to those in the consistently low greenness tertile, had 16% lower odds of AD incidence (OR=0.84, 95% CI: 0.76-0.94, p=0.0014), adjusting for age, sex, race/ethnicity, and neighborhood income. Age, neighborhood income and walkability moderated greenness' relationship to odds of AD incidence, such that younger ages (65-74), lower-income, and non-car dependent neighborhoods may benefit most from high greenness.

CONCLUSIONS

High greenness, compared to low greenness, is associated with lower 5-year AD incidence. Residents who are younger and/or who reside in lower-income, walkable neighborhoods may benefit the most from high greenness. These findings suggest that consistently high greenness at the Census block-level, may be associated with reduced odds of AD incidence at a population level.

Multisystem inflammatory syndrome in children during the first two years of the COVID-19 pandemic in Luxembourg

Objective

Estimate the incidence of multisystem inflammatory syndrome (MIS-C) in children (0-15 years), the role of SARS-CoV-2 variants during the first two years of COVID-19 pandemic in Luxembourg; and describe the demographic, biological and clinical characteristics of the patients.

Method

Observational retrospective cohort study. Cases between March 2020 and February 2022 were ascertained from the national registry of MIS-C cases by a retrospective review of medical records. Reported SARS-CoV-2 infections were obtained from the national COVID-19 surveillance system. We calculated monthly MIS-C incidence, the ratio between MIS-C and SARS-CoV-2 infections and associated rate ratios by the periods corresponding to the circulation of different variants.

Results

18 children were diagnosed with MIS-C among 35,200 reported infections. The incidence rate of MIS-C was 7.2 [95% confidence interval (CI) 4.5-11.4] per 1,000,000 person-months. A higher incidence of MIS-C was observed between September and December 2021, corresponding to the circulation of the Delta variant than during the first year of the pandemic (RR 3.6, 95% CI, 1.1-12.3). The lowest rate of MIS-C per infection was observed during the Omicron (RR 0.17, 95% CI, 0.03-0.82). Median age at diagnosis was 6.5 years. Previously healthy children made up 88% of MIS-C cases, none were vaccinated against SARS-CoV-2. 33% required intensive care. All patients recovered fully.

Conclusions

MIS-C incidence and MIS-C risk per infection changed significantly over time during the first two years of COVID-19 pandemic. Monitoring of MIS-C incidence in future SARS-CoV-2 waves will be essential to guide public health interventions and vaccination policies for children.

Reasonable requests: echocardiography referral forms as a measure of coherent clinical communication

BACKGROUND

Well performed clinical communication is a cornerstone of collaborative care in medicine but may be confounded by inconsistent intentions of the messenger and biased interpretation by the recipient. A comparison of the findings of electronic echocardiography reports with clinician-completed standardised request forms provided an opportunity to assess communication quality.

AIM

The study aimed to determine clinician aptitude to complete written echocardiography referral forms by assessing the completeness, appropriateness, accuracy, and coherency of the reported clinical findings, conclusions and requests made on the referral forms. The study explored factors that may influence the quality of communication through this referral medium.

METHODS

A retrospective cohort study was conducted on patients who underwent trans-thoracic echocardiography imaging at Cecilia Makiwane Hospital in East London over 26 months. Paper echocardiography request forms that recorded the requesting clinician's findings on examination, the provisional clinical diagnosis, and the specific echocardiographic information sought, were compared with the actual findings on echocardiography.

RESULTS

Of 613 request forms reviewed, 97 cases were excluded due to illegibility or because they lacked analysable information or requester details, leaving 516 forms suitable for study. No pathology was found on echocardiography in 31%. Of the murmurs expected from the echocardiography findings, only half were recorded on the request form (sensitivity and positive predictive value both 52%.). Only 35% of request forms that mentioned a mitral systolic murmur gave a working diagnosis of mitral regurgitation and only 38% of request forms that mentioned an aortic systolic murmur considered aortic stenosis. Clinically suspected cardiomyopathy (CMO) had a PPV of 43% and echocardiographic CMO was missed clinically in 41%. Apex beat displacement reported clinically was not associated with echocardiographic LV dilatation in 65% of cases. One-third (34%) of forms reporting murmurs did not request valve function assessment and 17% considering cardiomyopathy did not request left ventricular function assessment.

CONCLUSION

Echocardiography request forms highlight vulnerabilities in clinical communication. Specifically, important clinical features were missing and more concerningly, included when unlikely to be present. There was a lack of concordance between recorded clinical findings and postulated diagnoses. Clinicians sometimes appeared unclear about the value or appropriateness of the requested assistance. Greater emphasis on teaching examination and communication skills may foster safer and more efficient use of scarce resources.

Cumulative incidence of SARS-CoV-2 and associated risk factors among healthcare workers: a cross-sectional study in the Eastern Cape, South Africa

OBJECTIVES

This study assesses the cumulative incidence of SARS-CoV-2 infection among healthcare workers (HCWs) during South Africa's first wave and examines the associated demographic, health-related and occupational risk factors for infection.

METHODS

Multistage cluster sampling was used in a cross-sectional study to recruit 1309 HCWs from two academic hospitals in the Eastern Cape, South Africa over 6 weeks in November and December 2020. Prior test results for SARS-CoV-2 PCR and participants' characteristics were recorded while a blood sample was drawn for detection of IgG antibodies against SARS-CoV-2 nucleocapsid protein. The primary outcome measure was the SARS-CoV-2 cumulative incidence rate, defined as the combined total of positive results for either PCR or IgG antibodies, divided by the total sample. The secondary outcome was significant risk factors associated with infection.

RESULTS

Of the total participants included in the analysis (n=1295), the majority were women (81.5%), of black race (78.7%) and nurses (44.8%). A total of 390 (30.1%) HCWs had a positive SARS-CoV-2 PCR result and SARS-CoV-2 antibodies were detected in 488 (37.7%), yielding a cumulative incidence of 47.2% (n=611). In the adjusted logistic regression model, being overweight (adjusted OR (aOR)=2.15, 95% CI 1.44 to 3.20), obese (aOR=1.37, 95% CI 1.02 to 1.85) and living with HIV (aOR=1.78, 95% CI 1.38 to 2.08) were independently associated with SARS-CoV-2 infection. There was no significant difference in infection rates between high, medium and low COVID-19 exposure working environments.

CONCLUSIONS

The high SARS-CoV-2 cumulative incidence in the cohort was surprising this early in the epidemic and probably related to exposure both in and outside the hospitals. To mitigate the impact of SARS-CoV-2 among HCWs, infection prevention and control strategies should target community transmission in addition to screening for HIV and metabolic conditions.

Longitudinal impacts of greenness on cardiovascular disease conditions

Introduction

Environmental determinants of health, such as greenness, play an increasing role in our understanding of cardiovascular disease, and can inform how to address geographic cardiovascular disparities. This study assesses the impact of greenness and changes in greenness on cardiovascular disease.

Purpose

The purpose of this study is to investigate the impact of greenness and changes in greenness on cardiovascular disease diagnoses.

Methods

The sample for this prospective, longitudinal study was comprised of 243,558 U.S. Medicare beneficiaries 65 years or older, residing on the same Census Block from 2011 through 2016, and who had a Miami-Dade residential 9-digit zip code. Analyses examined the impact of greenness, measured by mean block-level Normalized Difference Vegetation index (NDVI) from satellite imagery to incidence of new cardiovascular conditions including: acute myocardial infarction, atrial fibrillation, heart failure, ischemic heart disease, hypertension, and stroke/ transient ischemic attack. Zero-inflated poisson regression was used to model the odds of developing any new cardiovascular disease and number of new cardiovascular conditions based on block level greenness while adjusting for individual age, gender, race/ethnicity, number of baseline cardiovascular conditions, and neighborhood characteristics including income and walkability.

Results

Living in a higher greenness Census Block was associated with lower odds of having at least one new cardiovascular condition and having a small number of new conditions, adjusting for individual and neighborhood level characteristics. When compared to individuals living in the lowest tertile of greenness throughout the study, those individuals living in the highest tertile of greenness throughout the study had a 16% lower odds of having any new cardiovascular conditions (OR=0.84, 95% CI: 0.79–0.90, p<0.001) and among individuals developing at least one new cardiovascular disease, 4% fewer new cardiovascular conditions (OR=0.96, 95% CI: 0.92–0.99, p<0.05). When compared to individuals living in the lowest tertile of greenness throughout the study, those individuals living in areas that increased their greenness from the lowest tertile to the highest tertile of greenness had a 15% lower odds of having any new cardiovascular conditions (OR=0.85, 95% CI: 0.75–0.97, p<0.001) and among individuals developing at least one new cardiovascular disease, 9% fewer new cardiovascular conditions (OR=0.91, 95% CI: 0.83–0.99, p<0.05).

Conclusions

High greenness is associated with lower rates of cardiovascular conditions over time, both when greenness increases and when a Census Block maintains high greenness. It is remarkable that these effects appear in five years, a relatively short amount of time for a positive environmental impact; and that even for those who began in the lowest greenness tertile, an increase to the high greenness tertile had a significant effect.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Robert Wood Johnson Evidence for Action Grant

Acceptance of COVID-19 Vaccine among the Healthcare Workers in the Eastern Cape, South Africa: A Cross Sectional Study

BACKGROUND

This study assesses the perceptions and acceptance of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) vaccination. It also examines its influencing factors among the healthcare workers (HCWs) in the Eastern Cape, South Africa.

METHODS

In this cross-sectional study performed in November and December 2020, a total of 1308 HCWs from two large academic hospitals participated in the Eastern Cape Healthcare Workers Acquisition of SARS-CoV-2 (ECHAS) study. Validated measures of vaccine hesitancy were explored using a questionnaire. Logistic regression was used to identify the determinants of vaccine hesitancy.

RESULTS

The majority were nurses (45.2%), and at risk for unfavourable Covid-19 outcome, due to obesity (62.9%) and having direct contact with individuals confirmed to have Covid-19 (77.1%). The overall acceptance of SARS-CoV-2 vaccine was 90.1%, which differed significantly by level of education. Individuals with lower educational attainment (primary and secondary education) and those with prior vaccine refusal were less likely to accept the SARS-CoV-2 vaccine. However, positive perceptions about the SARS-CoV-2 vaccine were independently associated with vaccine acceptance.

CONCLUSIONS

The high level of acceptance of SARS-CoV-2 vaccine is reassuring; however, HCWs with a lower level of education and those with prior vaccine refusal should be targeted for further engagements to address their concerns and fears.

Cost-effectiveness analysis of flucytosine as induction therapy in the treatment of cryptococcal meningitis in HIV-infected adults in South Africa

Background

Cryptococcal meningitis in HIV-infected patients in sub-Saharan Africa accounts for three-quarters of the global cases and 135,000 deaths per annum. Current treatment includes the use of fluconazole and amphotericin B. Recent evidence has shown that the synergistic use of flucytosine improves efficacy and reduces toxicity, however affordability and availability has hampered access to flucytosine in many countries. This study investigated the evidence and cost implications of introducing flucytosine as induction therapy for cryptococcal meningitis in HIV-infected adults in South Africa.

Methods

A decision analytic cost-effectiveness and cost impact model was developed based on survival estimates from the ACTA trial and local costs for flucytosine as induction therapy in HIV-infected adults with cryptococcal meningitis in a public sector setting in South Africa. The model considered five treatment arms: (a) standard of care; 2-week course amphotericin B/fluconazole (2wk AmBd/Flu), (b) 2-week course amphotericin B/flucytosine (2wk AmBd/5FC), (c) short course; 1-week course amphotericin B/flucytosine (1wk AmBd/5FC) (d) oral course; 2-week oral fluconazole/flucytosine (oral) and e) 1-week course amphotericin B/fluconazole (1wk AmBd/Flu). A sensitivity analysis was conducted on key variables.

Results

The highest total treatment costs are in the 2-week AmBd/5FC arm followed by the 2-week oral regimen, the 1-week AmBd/5FC, then standard of care with the lowest cost in the 1-week AmBd/Flu arm. Compared to the lowest cost option the 1-week flucytosine course is most cost-effective at USD119/QALY. The cost impact analysis shows that the 1-week flucytosine course has an incremental cost of just over USD293 per patient per year compared to what is currently spent on standard of care. Sensitivity analyses suggest that the model is most sensitive to life expectancy and hospital costs, particularly infusion costs and length of stay.

Conclusions

The addition of flucytosine as induction therapy for the treatment of cryptococcal meningitis in patients infected with HIV is cost-effective when it is used as a 1-week AmBd/5FC regimen. Savings could be achieved with early discharge of patients as well as a reduction in the price of flucytosine.

Recurrent De Novo NAHR Reciprocal Duplications in the ATAD3 Gene Cluster Cause a Neurogenetic Trait with Perturbed Cholesterol and Mitochondrial Metabolism

Recent studies have identified both recessive and dominant forms of mitochondrial disease that result from ATAD3A variants. The recessive form includes subjects with biallelic deletions mediated by non-allelic homologous recombination. We report five unrelated neonates with a lethal metabolic disorder characterized by cardiomyopathy, corneal opacities, encephalopathy, hypotonia, and seizures in whom a monoallelic reciprocal duplication at the ATAD3 locus was identified. Analysis of the breakpoint junction fragment indicated that these 67 kb heterozygous duplications were likely mediated by non-allelic homologous recombination at regions of high sequence identity in ATAD3A exon 11 and ATAD3C exon 7. At the recombinant junction, the duplication allele produces a fusion gene derived from ATAD3A and ATAD3C, the protein product of which lacks key functional residues. Analysis of fibroblasts derived from two affected individuals shows that the fusion gene product is expressed and stable. These cells display perturbed cholesterol and mitochondrial DNA organization similar to that observed for individuals with severe ATAD3A deficiency. We hypothesize that the fusion protein acts through a dominant-negative mechanism to cause this fatal mitochondrial disorder. Our data delineate a molecular diagnosis for this disorder, extend the clinical spectrum associated with structural variation at the ATAD3 locus, and identify a third mutational mechanism for ATAD3 gene cluster variants. These results further affirm structural variant mutagenesis mechanisms in sporadic disease traits, emphasize the importance of copy number analysis in molecular genomic diagnosis, and highlight some of the challenges of detecting and interpreting clinically relevant rare gene rearrangements from next-generation sequencing data.

Severe malaria presenting to the ED: A collaborative approach utilizing exchange transfusion and artesunate

We describe the case of a previously healthy 33year-old male pilot recently arrived to the United States from Africa. The patient presented to our ED febrile and disoriented, with projectile coffee-ground emesis. He was later found to have severe malaria and cerebral parasitemia. Due to the severity of his illness, the patient received the anti-malarial medication Artesunate as well as several exchange transfusions. Within 48h his parasitic load was reduced from 42% to 0.4%. The following is an account of a collaborative effort that spans the specialties of emergency medicine, infectious disease, and critical care medicine.

WNT Signaling Perturbations Underlie the Genetic Heterogeneity of Robinow Syndrome

Locus heterogeneity characterizes a variety of skeletal dysplasias often due to interacting or overlapping signaling pathways. Robinow syndrome is a skeletal disorder historically refractory to molecular diagnosis, potentially stemming from substantial genetic heterogeneity. All current known pathogenic variants reside in genes within the noncanonical Wnt signaling pathway including ROR2, WNT5A, and more recently, DVL1 and DVL3. However, ∼70% of autosomal-dominant Robinow syndrome cases remain molecularly unsolved. To investigate this missing heritability, we recruited 21 families with at least one family member clinically diagnosed with Robinow or Robinow-like phenotypes and performed genetic and genomic studies. In total, four families with variants in FZD2 were identified as well as three individuals from two families with biallelic variants in NXN that co-segregate with the phenotype. Importantly, both FZD2 and NXN are relevant protein partners in the WNT5A interactome, supporting their role in skeletal development. In addition to confirming that clustered -1 frameshifting variants in DVL1 and DVL3 are the main contributors to dominant Robinow syndrome, we also found likely pathogenic variants in candidate genes GPC4 and RAC3, both linked to the Wnt signaling pathway. These data support an initial hypothesis that Robinow syndrome results from perturbation of the Wnt/PCP pathway, suggest specific relevant domains of the proteins involved, and reveal key contributors in this signaling cascade during human embryonic development. Contrary to the view that non-allelic genetic heterogeneity hampers gene discovery, this study demonstrates the utility of rare disease genomic studies to parse gene function in human developmental pathways.

Diagnosis of lethal or prenatal-onset autosomal recessive disorders by parental exome sequencing

OBJECTIVE

Rare genetic disorders resulting in prenatal or neonatal death are genetically heterogeneous, but testing is often limited by the availability of fetal DNA, leaving couples without a potential prenatal test for future pregnancies. We describe our novel strategy of exome sequencing parental DNA samples to diagnose recessive monogenic disorders in an audit of the first 50 couples referred.

METHOD

Exome sequencing was carried out in a consecutive series of 50 couples who had 1 or more pregnancies affected with a lethal or prenatal-onset disorder. In all cases, there was insufficient DNA for exome sequencing of the affected fetus. Heterozygous rare variants (MAF < 0.001) in the same gene in both parents were selected for analysis. Likely, disease-causing variants were tested in fetal DNA to confirm co-segregation.

RESULTS

Parental exome analysis identified heterozygous pathogenic (or likely pathogenic) variants in 24 different genes in 26/50 couples (52%). Where 2 or more fetuses were affected, a genetic diagnosis was obtained in 18/29 cases (62%). In most cases, the clinical features were typical of the disorder, but in others, they result from a hypomorphic variant or represent the most severe form of a variable phenotypic spectrum.

CONCLUSION

We conclude that exome sequencing of parental samples is a powerful strategy with high clinical utility for the genetic diagnosis of lethal or prenatal-onset recessive disorders. © 2017 The Authors Prenatal Diagnosis published by John Wiley & Sons Ltd.

Epstein-Barr viral loads do not predict post-transplant lymphoproliferative disorder in pediatric lung transplant recipients: A multicenter prospective cohort study

Prediction of PTLD after pediatric lung transplant remains difficult. Use of EBV VL in WB has been poorly predictive, while measurement of VL in BAL fluid has been suggested to have enhanced utility. The NIH-sponsored Clinical Trials in Organ Transplantation in Children (CTOTC-03) prospectively obtained serial quantitative measurements of EBV PCR in both WB and BAL fluid after pediatric lung transplantation. Descriptive statistics, contingency analyses, and Kaplan-Meier analyses evaluated possible association between EBV and PTLD. Of 61 patients, 34 (56%) had an EBV+PCR (at least once in WB or BAL). EBV donor (D)+patients more often had a positive PCR (D+/recipient (R)-: 13/18; D+/R+: 14/23) compared to EBV D- patients (6/17). Several D-/R- (5/12) patients developed EBV, but none developed PTLD. All four PTLD patients were D+/R- with EBV+PCR. Neither the time to first EBV+PCR nor the CT for PCR positivity in BAL or WB was statistically different between those with and without PTLD. Having an EBV-seropositive donor was associated with increased risk of EBV+PCR in WB. EBV load in BAL was not predictive of PTLD.

An enhanced method for targeted next generation sequencing copy number variant detection using ExomeDepth

Copy number variants (CNV) are a major cause of disease, with over 30,000 reported in the DECIPHER database. To use read depth data from targeted Next Generation Sequencing (NGS) panels to identify CNVs with the highest degree of sensitivity, it is necessary to account for biases inherent in the data. GC content and ambiguous mapping due to repetitive sequence elements and pseudogenes are the principal components of technical variability. In addition, the algorithms used favour the detection of multi-exon CNVs, and rely on suitably matched normal dosage samples for comparison. We developed a calling strategy that subdivides target intervals, and uses pools of historical control samples to overcome these limitations in a clinical diagnostic laboratory. We compared our enhanced strategy with an unmodified pipeline using the R software package ExomeDepth, using a cohort of 109 heterozygous CNVs (91 deletions, 18 duplications in 26 genes), including 25 single exon CNVs. The unmodified pipeline detected 104/109 CNVs, giving a sensitivity of 89.62% to 98.49% at the 95% confidence interval. The detection of all 109 CNVs by our enhanced method demonstrates 95% confidence the sensitivity is ≥96.67%, allowing NGS read depth analysis to be used for CNV detection in a clinical diagnostic setting.

Polycystic Kidney Disease with Hyperinsulinemic Hypoglycemia Caused by a Promoter Mutation in Phosphomannomutase 2

Hyperinsulinemic hypoglycemia (HI) and congenital polycystic kidney disease (PKD) are rare, genetically heterogeneous disorders. The co-occurrence of these disorders (HIPKD) in 17 children from 11 unrelated families suggested an unrecognized genetic disorder. Whole-genome linkage analysis in five informative families identified a single significant locus on chromosome 16p13.2 (logarithm of odds score 6.5). Sequencing of the coding regions of all linked genes failed to identify biallelic mutations. Instead, we found in all patients a promoter mutation (c.-167G>T) in the phosphomannomutase 2 gene (PMM2), either homozygous or in trans with PMM2 coding mutations. PMM2 encodes a key enzyme in N-glycosylation. Abnormal glycosylation has been associated with PKD, and we found that deglycosylation in cultured pancreatic β cells altered insulin secretion. Recessive coding mutations in PMM2 cause congenital disorder of glycosylation type 1a (CDG1A), a devastating multisystem disorder with prominent neurologic involvement. Yet our patients did not exhibit the typical clinical or diagnostic features of CDG1A. In vitro, the PMM2 promoter mutation associated with decreased transcriptional activity in patient kidney cells and impaired binding of the transcription factor ZNF143. In silico analysis suggested an important role of ZNF143 for the formation of a chromatin loop including PMM2 We propose that the PMM2 promoter mutation alters tissue-specific chromatin loop formation, with consequent organ-specific deficiency of PMM2 leading to the restricted phenotype of HIPKD. Our findings extend the spectrum of genetic causes for both HI and PKD and provide insights into gene regulation and PMM2 pleiotropy.

Long-Term Follow-up of a Successfully Treated Case of Congenital Pyridoxine-Dependent Epilepsy

Autosomal recessive disorders affecting pyridoxine (vitamin B6) metabolism are a rare but well-recognized cause of neonatal seizures. Antiquitin deficiency, caused by mutations in ALDH7A1, is a disorder of the lysine degradation pathway causing accumulation of an intermediate that complexes with pyridoxal phosphate. Reports of long-term follow-up of neonatal pyridoxine-dependent seizures (PDS) remain scarce and prognostic information is varied. We report a case of PDS in a 47-year-old lady who originally presented shortly after birth in 1964. Pyridoxine replacement was successful and diagnostic confirmation was obtained later in life, initially by biochemical analysis of serum pipecolic acid. Subsequently we organized genetic analysis of ALDH7A1, which revealed compound heterozygous mutations. To our knowledge, this represents the longest duration of follow-up published to date.

The many faces of hydatid disease

No abstact

A review of internal medicine re-admissions in a peri-urban South African hospital

OBJECTIVE

To measure the re-admission rate and the number of preventable re-admissions in a secondary-level South African hospital, and to identify factors predictive of re-admission.

METHOD

The admission register for the medical wards at Cecilia Makiwane Hospital (CMH) was used to identify re-admitted patients, whose folders were then reviewed. A comparison group of patients who were not re-admitted was randomly generated from the same register.

RESULTS

The re-admission rate for the 7 months ending October 2006 was 8.5% (262/3 083). Patients who were more likely to be re-admitted had chronic respiratory disease (odds ratio (OR) 4.2, 95% confidence interval (CI) 1.2 - 14.6), HIV infection (OR 5.0, CI 2.1 - 12.0), were older than 50 years (OR 5.2, CI 2.5 - 10.9), had a first admission of more than 8 days (OR 3.2, CI 1.5 - 6.6) or a booked medical outpatients followup (OR 5.1, CI 2.6 - 10.3). Age distribution of re-admissions was bimodal, with HIV-positive individuals (27.4% overall) accounting for 50% of all admissions younger than 50 years, but only 9.1% of those 50 years or older. In individuals older than 50 years, 42.1% of admissions were due to chronic cardiorespiratory illnesses. Half of re-admissions were judged to be potentially preventable, mainly through improved patient education.

CONCLUSION

One in 12 general medical patients was readmitted. Chronic diseases and inadequate patient education and discharge planning accounted for the largest group of re-admissions in older patients. Re-admission of HIV/AIDS patients has generated a second peak in younger individuals, and the impact of the antiretroviral roll-out on admission rates warrants further scrutiny.

Insulin mutation screening in 1,044 patients with diabetes: mutations in the INS gene are a common cause of neonatal diabetes but a rare cause of diabetes diagnosed in childhood or adulthood

OBJECTIVE

Insulin gene (INS) mutations have recently been described as a cause of permanent neonatal diabetes (PND). We aimed to determine the prevalence, genetics, and clinical phenotype of INS mutations in large cohorts of patients with neonatal diabetes and permanent diabetes diagnosed in infancy, childhood, or adulthood.

RESEARCH DESIGN AND METHODS

The INS gene was sequenced in 285 patients with diabetes diagnosed before 2 years of age, 296 probands with maturity-onset diabetes of the young (MODY), and 463 patients with young-onset type 2 diabetes (nonobese, diagnosed <45 years). None had a molecular genetic diagnosis of monogenic diabetes.

RESULTS

We identified heterozygous INS mutations in 33 of 141 probands diagnosed at <6 months, 2 of 86 between 6 and 12 months, and none of 58 between 12 and 24 months of age. Three known mutations (A24D, F48C, and R89C) account for 46% of cases. There were six novel mutations: H29D, L35P, G84R, C96S, S101C, and Y103C. INS mutation carriers were all insulin treated from diagnosis and were diagnosed later than ATP-sensitive K(+) channel mutation carriers (11 vs. 8 weeks, P < 0.01). In 279 patients with PND, the frequency of KCNJ11, ABCC8, and INS gene mutations was 31, 10, and 12%, respectively. A heterozygous R6C mutation cosegregated with diabetes in a MODY family and is probably pathogenic, but the L68M substitution identified in a patient with young-onset type 2 diabetes may be a rare nonfunctional variant.

CONCLUSIONS

We conclude that INS mutations are the second most common cause of PND and a rare cause of MODY. Insulin gene mutation screening is recommended for all diabetic patients diagnosed before 1 year of age.

Permanent neonatal diabetes caused by dominant, recessive, or compound heterozygous SUR1 mutations with opposite functional effects

Heterozygous activating mutations in the KCNJ11 gene encoding the pore-forming Kir6.2 subunit of the pancreatic beta cell K(ATP) channel are the most common cause of permanent neonatal diabetes (PNDM). Patients with PNDM due to a heterozygous activating mutation in the ABCC8 gene encoding the SUR1 regulatory subunit of the K(ATP) channel have recently been reported. We studied a cohort of 59 patients with permanent diabetes who received a diagnosis before 6 mo of age and who did not have a KCNJ11 mutation. ABCC8 gene mutations were identified in 16 of 59 patients and included 8 patients with heterozygous de novo mutations. A recessive mode of inheritance was observed in eight patients with homozygous, mosaic, or compound heterozygous mutations. Functional studies of selected mutations showed a reduced response to ATP consistent with an activating mutation that results in reduced insulin secretion. A novel mutational mechanism was observed in which a heterozygous activating mutation resulted in PNDM only when a second, loss-of-function mutation was also present.

Activation of estrogen signaling pathways collaborates with loss of Brca1 to promote development of ERalpha-negative and ERalpha-positive mammary preneoplasia and cancer

BRCA1 can regulate estrogen receptor-alpha (ERalpha) activity. This study tested the hypotheses that Brca1 loss in mammary epithelium alters the estrogenic growth response and that exposure to increased estrogen or ERalpha collaborates with Brca1 deficiency to accelerate preneoplasia and cancer development. Longer ductal extension was found in mammary glands of Brca1(f/f;MMTV-Cre) mice during puberty as compared to wild-type mice. Terminal end bud differentiation was impaired in Brca1 mutant mice with preservation of prolactin-induced alveolar differentiation. Exogenous estrogen stimulated an abnormal sustained increase in mammary epithelial cell proliferation and the appearance of ERalpha-negative preneoplasia in postpubertal Brca1 mutant mice. Carcinogenesis was investigated using Brca1(f/f;MMTV-Cre) mice hemizygous for p53. Exogenous estrogen increased the percentage of mice with multiple hyperplastic alveolar nodules. Targeted conditional ERalpha overexpression in mammary epithelial cells of mice that were Brca1 mutant and hemizygous for p53 increased the percentage of mice exhibiting multiple hyperplastic nodules, invasive mammary cancers and cancer multiplicity. Significantly more than half of the preneoplasia and cancers were ERalpha negative even as their initiation was promoted by ERalpha overexpression.

Women's health in prison must be improved

The challenges encompassing the care and control of prisoners have stretched the minds and intellect of many from areas as diverse as politicians, professionals, lay people and academics. Providing good quality health care is an ongoing struggle for any multidisciplinary team in prison health care. The complexity of the relationship between professionals and the patient is amplified because of the unique environment and the prison culture.

Sodium arsenite enhances AP-1 and NFkappaB DNA binding and induces stress protein expression in precision-cut rat lung slices

Arsenic is a known human carcinogen. These studies were designed to examine the impact of low arsenite concentrations on immediate early gene expression in precision-cut rat lung slices. Precision-cut lung slices are a versatile in-vitro system for toxicity studies, as they preserve the architecture and cellular heterogeneity of the lung. Since 0.1-100 microM arsenite did not compromise slice viability at 4 hours, effects of arsenite on the expression of c-jun/AP-1, NFkappaB, HSP 32, HSP 72, HSP 60, and HSP 90 were studied, using these concentrations of arsenite at 4 h. Nuclear c-jun was increased by 10 and 100 microM arsenite, while NFkappaB was not affected. Gel-shift assays indicated that 10 microM arsenite resulted in an enhanced DNA-binding activity of both AP-1 and NFkappaB. Confocal microscopic analysis of AP-1 indicated nuclear localization of this transcription factor, mainly in type-II epithelial cells and alveolar macrophages. Nuclear localization of NFkappaB was lower than that observed for AP-1, while most of the NFkappaB was localized to cytoplasm of type-II epithelial cells and alveolar macrophages. HSP 32 was increased by 1.0 and 10 microM arsenite, while HSP 72 was increased by only 100 microM arsenite. HSP 60 and HSP 90 were not changed by arsenite. These studies indicate that noncytotoxic concentrations of arsenite are capable of affecting signal transduction pathways and gene expression in the lung.

Prison health care: is it a crisis waiting to break?

Anew report from the British Medical Association on prison health care, entitled Prison Medicine: A Crisis Waiting to Break, is an excellent exposition of the difficulties and challenges facing doctors and other healthcare staff as they carry out their duties when working in prisons (British Medical Association, 2001).

The prison healthcare service: a workforce committed to change

This article discusses the changes that are needed in the prison healthcare service, outlining the move to a multidisciplinary team approach, away from the outdated, medically dominated service which prevails today. This article supports the partnership arrangements put forward in 'The Future Organization of Prison Health Care' (Department of Health (DoH), 1999) and suggests how this can be achieved locally, calling on nurses working in the prison environment to be proactive and forge links with colleagues in local NHS services. The need for clinical governance to be firmly established and regular reports to be submitted to prison governors on the quality and provision of services is highlighted.

Prison health care: work environment and the nursing role

This article, the first in a new series on prison nursing, gives an overview of the world of prison nursing and the environmental factors that make it so different from other types of nursing. It welcomes the recommendation in the report 'Patient or Prisoner: A New Strategy for Health Care in Prisons' (HM Chief Inspector of Prisons for England and Wales, 1996) that the NHS should be responsible for providing health care for prisoners and the recent publication of the report of the Joint Prison Service/NHS Executive Working Group 'Future Organization of Prison health Care' (Department of Health, 1999), which endorses a formal partnership between the NHS and prison service. The article highlights the benefits that this will have for prison nurses who often feel professionally isolated. The role of the nurse working in the prison healthcare environment is outlined. The work of prison nurses differs from the role of nurses working in other healthcare situations as it is controlled by environmental factors associated with regimes, security and the prison culture. However, changes are taking place and a closer link with local services is envisaged. These changes are an excellent opportunity for nurses and nursing to establish a clear role in prisons and to develop further healthcare standards in the prison service.

Prison nursing: working at the cutting edge

At present there is a shortfall of skilled nursing staff within the NHS. This shortage also affects the prison healthcare service (Home Office, 1998a,b). Recruitment in this area is often made more difficult by a lack of understanding of the prison healthcare service and, in particular, the role of nurses practising within it.

Ah receptor-independent induction of CYP1A2 gene expression in genetically inbred mice

Acenaphthylene is a tricyclic aromatic hydrocarbon which induces hepatic methoxyresorufin O-demethylase (MROD) activity and CYP1A2 mRNA levels in 2 week-old male B6C3F1 mice. In the present study, this induction response was further investigated in genetically-inbred mice which differ in their aryl-hydrocarbon (Ah)-responsiveness. Acenapthylene (300 mg/kg) induced a 5- to 23-fold induction of MROD activity in Ah-nonresponsive (DBA and SJL) and responsive (C3H, C57/BL6, A/J, CBA and B6C3F1) mice. The highest induction response was observed in the DBA strain in which there was a 23- and 15-fold increase in activity in males and females, respectively. Acenaphthylene also caused a 2-fold increase in CYP1A2 mRNA and immunoreactive protein levels in 2 week-old DBA mice; however, this induction response was not observed in 6 week-old animals. For example, MROD activity in 6 week-old DBA mice was induced <2-fold by acenaphthylene, mainly as a consequence of increased basal CYP1A2 expression and MROD activity which, at the age of 6 weeks, approached levels induced by acenaphthylene in the 2 week-old mice. This was also observed by immunohistochemical staining with CYP1A2 antibodies of 2 and 6 week-old hepatic tissue from treated and control mice which also showed that CYP1A2 induction was dependent on the age of the animals.

Exploring the NHS executive document Signposts for Success

The recent document 'Signposts for Success' (Department of Health (DoH), 1988a) offers an extensive blueprint for the strategic development of services for people with a learning disability in the next decade. This article discusses the key issues raised and some of the controversial aspects that have to be addressed.

Equity and access to health care for women with learning disabilities

The increased expectation for women with learning disabilities to become more autonomous and independent is generally a positive and dynamic force. However, care must be taken to ensure that, within this environment, women with learning disabilities are not isolated or lack support as this increases their vulnerability. These issues exist for all women within our society, but women with learning disabilities are more vulnerable because of their lack of voice both individually and politically. Within this new culture of independence and rights for women with learning disabilities, nurses must ensure that they address their own accountability and responsibility.

New deal for people with learning difficulties

It is not often that service users, carers, and people involved with learning difficulties services can get excited, and it is certainly unusual to get news such as the Health Secretary's announcement of new guidance and advice for the NHS on how best to improve health care for people with learning difficulties (Department of Health (DoH), 1997).

Future directions for learning disability nursing

Over the past decade learning disability nurses have had to make many changes in the way they practice. Changes in attitude towards the way in which people with learning disabilities are cared for has meant that nurses have had to adjust their practice to address different expectations in the way these services are delivered. Nursing now provides opportunities for people with learning disabilities to express themselves and become involved in decision-making that affects their lives. For nurses this is a totally new way of working with this client group. Learning disability nurses have risen to the challenge that has resulted from moving into community care and forming links with primary healthcare teams.

Learning disability nursing and primary healthcare

This article addresses the issues surrounding the role of learning disability nurses and their relationship with primary healthcare colleagues. It highlights opportunities in general practice for the learning disability nurse who has become a key player in shaping services for this client group as services swing towards primary healthcare. The NHS Executive document NHS Priorities and Planning Guidance 1997-98 is explored and the opportunities that this gives the community learning disability nurse are discussed. The article stresses the need for learning disability nurses to obtain quality research-based evidence on effective caring interventions. The importance of clinical audit and outcome measurements from interventions are highlighted. Finally, the importance of good communication and being able to respond to this client group's needs is emphasized.