Does routine postoperative contrast radiography improve outcomes for patients with perforated peptic ulcer? A multicenter retrospective cohort study

BACKGROUND

Perforated peptic ulcer is a morbid emergency general surgery condition. Best practices for postoperative care remain undefined. Surgical dogma preaches practices such as peritoneal drain placement, prolonged nil per os, and routine postoperative enteral contrast imaging despite a lack of evidence. We aimed to evaluate the role of postoperative enteral contrast imaging in postoperative perforated peptic ulcer care. Our primary objective was to assess effects of routine postoperative enteral contrast imaging on early detection of clinically significant leaks.

METHODS

We conducted a multicenter retrospective cohort study of patients who underwent repair of perforated peptic ulcer between July 2016 and June 2018. We compared outcomes between those who underwent routine postoperative enteral contrast imaging and those who did not.

RESULTS

Our analysis included 95 patients who underwent primary/omental patch repair. The mean age was 60 years, and 54% were male. Thirteen (14%) had a leak. Eighty percent of patients had a drain placed. Nine patients had leaks diagnosed based on bilious drain output without routine postoperative enteral contrast imaging. Use of routine postoperative enteral contrast imaging varied significantly between institutions (30%-87%). Two late leaks after initial normal postoperative enteral contrast imaging were confirmed by imaging after a clinical change triggered the second study. Two patients had contained leaks identified by routine postoperative enteral contrast imaging but remained clinically well. Duration of hospital stay was longer in those who received routine postoperative enteral contrast imaging (12 vs 6 days, median; P = .000).

CONCLUSION

Routine postoperative enteral contrast imaging after perforated peptic ulcer repair likely does not improve the detection of clinically significant leaks and is associated with increased duration of hospital stay.

Performance Characteristics of a High-Throughput Automated Transcription-Mediated Amplification Test for SARS-CoV-2 Detection

The COVID-19 pandemic caused by the new SARS-CoV-2 coronavirus has imposed severe challenges on laboratories in their effort to achieve sufficient diagnostic testing capability for identifying infected individuals. In this study, we report the analytical and clinical performance characteristics of a new, high-throughput, fully automated nucleic acid amplification test system for the detection of SARS-CoV-2. The assay utilizes target capture, transcription-mediated amplification, and acridinium ester-labeled probe chemistry on the automated Panther system to directly amplify and detect two separate target sequences in the open reading frame 1ab (ORF1ab) region of the SARS-CoV-2 RNA genome. The probit 95% limit of detection of the assay was determined to be 0.004 50% tissue culture infective dose (TCID50)/ml using inactivated virus and 25 copies/ml (c/ml) using synthetic in vitro transcript RNA targets. Analytical sensitivity (100% detection) was confirmed to be 83 to 194 c/ml using three commercially available SARS-CoV-2 nucleic acid controls. No cross-reactivity or interference was observed with testing of six related human coronaviruses, as well as 24 other viral, fungal, and bacterial pathogens, at high titers. Clinical nasopharyngeal swab specimen testing (n = 140) showed 100%, 98.7%, and 99.3% positive, negative, and overall agreement, respectively, with a validated reverse transcription-PCR nucleic acid amplification test (NAAT) for SARS-CoV-2 RNA. These results provide validation evidence for a sensitive and specific method for pandemic-scale automated molecular diagnostic testing for SARS-CoV-2.

The evolution of emergency general surgery: its time for a dedicated program manager

BACKGROUND

Emergency general surgery (EGS) is emerging as a distinct sub-specialty of acute care surgery but continues to exist without essential processes that drive modern trauma programs. An EGS-specific quality program was created with service-based Advanced Practice Provider (SB APP) administrative oversight, thus validating the need for a dedicated EGS program manager.

METHODS

In 2017, a quality structure was formalized with primary focus on scheduled quality meetings, peer review and outcomes review. All admission, service-specific dashboards, and readmission data were manually audited by SB APPs to confirm accuracy and identify opportunities for process improvement.

RESULTS

Surgical quality metrics including patient volume, mortality, complications, readmission and infection prevention indicators, were reviewed by SBAPPs. Annual EMR data for all EGS patients was compared to data collected via manual review with a novel registry logic. Comparison of EMR generated data versus EGS registry data identified under-representation of total admissions: in 2016, the EMR identified 130 admissions with registry logic identifying 625 actual EGS admissions. The EMR identified 515 admissions in 2017 and 485 admission in 2018 with registry logic identifying 777 and 712, respectively. Review of readmission data revealed an error of 14 patients in 2017 and 11 patients in 2018.

CONCLUSIONS

The quest to improve quality of care for the EGS patient requires timely review of high-quality, accurate data by dedicated and trained personnel. Our process revealed the vital functions of an EGS PM are crucial in the evolution of the EGS specialty.

LEVEL OF EVIDENCE

Level IV economic and value-based evaluations.

Service-Based Advanced Practice Providers: The Surgeon's Perspective

The ACGME work hour restrictions facilitated increased utilization of service-based advanced practice providers (APPs) to offset reduced general surgery resident work hours. Information regarding attending surgeon perceptions of APP impact is limited. The aim of this survey was to gauge these perceptions with respect to workload, length of stay (LOS), safety, best practice, level of function, and clinical judgment. Attending surgeons on surgical teams that employ service-based APPs at an urban tertiary referral center responded to a survey at the completion of academic year 2016. Perceptions regarding APP impact on workload, LOS, safety, best practice, level of function, and clinical judgment were examined. Twenty-two attending surgeons (40%) responded. Respondents agreed that APPs always/usually decrease their workload (77%), decrease LOS (64%), improve safety (68%), contribute to best practice (82%), and decrease near misses (71%). They also agreed that APPs decrease resident workload (87%), but fewer agreed that APPs contribute to resident education (68%). The majority perceived APPs function at the PGY1/2 (43%) or PGY3 (39%) level and always/usually trust their clinical judgment (72%), and felt there was variability in level of function among APPs (56%). This single-center study illustrates that attending surgeons perceive a positive impact on patient care by service-based APPs.

Service-Based Advanced Practice Providers: The Surgeon's Perspective

The ACGME work hour restrictions facilitated increased utilization of service-based advanced practice providers (APPs) to offset reduced general surgery resident work hours. Information regarding attending surgeon perceptions of APP impact is limited. The aim of this survey was to gauge these perceptions with respect to workload, length of stay (LOS), safety, best practice, level of function, and clinical judgment. Attending surgeons on surgical teams that employ service-based APPs at an urban tertiary referral center responded to a survey at the completion of academic year 2016. Perceptions regarding APP impact on workload, LOS, safety, best practice, level of function, and clinical judgment were examined. Twenty-two attending surgeons (40%) responded. Respondents agreed that APPs always/usually decrease their workload (77%), decrease LOS (64%), improve safety (68%), contribute to best practice (82%), and decrease near misses (71%). They also agreed that APPs decrease resident workload (87%), but fewer agreed that APPs contribute to resident education (68%). The majority perceived APPs function at the PGY1/2 (43%) or PGY3 (39%) level and always/usually trust their clinical judgment (72%), and felt there was variability in level of function among APPs (56%). This single-center study illustrates that attending surgeons perceive a positive impact on patient care by service-based APPs.

The impact of advanced practice providers on the surgical resident experience: Agree to disagree?

BACKGROUND

We examined and compared APP versus surgical resident perceptions of the role of APPs in surgical subspecialty teams.

METHODS

Residents/first year surgical critical care fellows and inpatient service-specific APPs responded to a survey that examined perceptions about the APP-resident/fellow relationship. Statistical analysis compared responses using a Pearson chi-square test.

RESULTS

Thirty-two resident/fellows (48%) and 10 APPs (42%) responded. There was consensus that having an APP on service decreases workload, contributes to continuity of care and enhances resident-patient coordination education and agreement that there was clear communication and adequate collaboration. Both groups differed with respect to APPs contribution to resident/fellow clinical education, role definition and chain of command. The majority of trainees felt that APPs function at a PGY2 level (51.7%) compared to APPs, who felt that they functioned at a PGY4/5 (22%) or Fellow (44%) level.

CONCLUSION

APPs and resident/fellows agree that APPs impact resident workload, continuity of care and patient-coordination education.

Viral morphogenesis and morphological changes in human neuronal cells following Tioman and Menangle virus infection

Tioman virus (TioPV) and Menangle virus (MenPV) are two antigenically and genetically related paramyxoviruses (genus: Rubulavirus, family: Paramyxoviridae) isolated from Peninsular Malaysia (2001) and Australia (1997), respectively. Both viruses are potential zoonotic agents. In the present study, the infectivity, growth kinetics, morphology and morphogenesis of these two paramyxoviruses in a human neuronal cell (SK-N-SH) line were investigated. Sub-confluent SK-N-SH cells were infected with TioPV and MenPV at similar multiplicity of infection. These cells were examined by conventional and immunoelectron microscopy, and virus titres in the supernatants were assayed. Syncytia were observed for both infections in SK-N-SH cells and were more pronounced during the early stages of TioPV infection. The TioPV titre increased consistently (10(1)) every 12 h after infection. In MenPV-infected cells, cellular material was frequently observed within budding virions, and microfilaments and microtubules were abundant. Viral budding was common, and extracellular MenPVs tended to be more pleomorphic compared to TioPVs, which appeared to be more spherical in appearance. The MenPV cytoplasmic viral inclusion appeared to be comparatively smaller, loose and interspersed with randomly scattered circle-like particles, whereas huge tubule-like cytoplasmic inclusions were observed in TioPV-infected cells. Both viruses also displayed different cellular pathology in the SK-N-SH cells. The intracellular ultrastructural characteristics of these two viruses in infected neuronal cells may allow them to be differentiated by electron microscopy.

A randomised controlled trial examining the longer-term outcomes of standard versus new antiepileptic drugs. The SANAD trial

OBJECTIVES

To compare clinicians' choice of one of the standard epilepsy drug treatments (carbamazepine or valproate) versus appropriate comparator new drugs.

DESIGN

A clinical trial comprising two arms, one comparing new drugs in carbamazepine and the other with valproate.

SETTING

A multicentre study recruiting patients with epilepsy from hospital outpatient clinics.

PARTICIPANTS

Patients with an adequately documented history of two or more clinically definite unprovoked epileptic seizures within the last year for whom treatment with a single antiepileptic drug represented the best therapeutic option.

INTERVENTIONS

Arm A was carbamazepine (CBZ) versus gabapentin (GBP) versus lamotrigine (LTG) versus oxcarbazepine (OXC) versus topiramate (TPM). Arm B valproate (VPS) versus LTG versus TPM.

MAIN OUTCOME MEASURES

Time to treatment failure (withdrawal of the randomised drug for reasons of unacceptable adverse events or inadequate seizure control or a combination of the two) and time to achieve a 12-month remission of seizures. Time from randomisation to first seizure, 24-month remission of seizures, incidence of clinically important adverse events, quality of life (QoL) outcomes and health economic outcomes were also considered.

RESULTS

Arm A recruited 1721 patients (88% with symptomatic or cryptogenic partial epilepsy and 10% with unclassified epilepsy). Arm B recruited 716 patients (63% with idiopathic generalised epilepsy and 25% with unclassified epilepsy). In Arm A LTG had the lowest incidence of treatment failure and was statistically superior to all drugs for this outcome with the exception of OXC. Some 12% and 8% fewer patients experienced treatment failure on LTG than CBZ, the standard drug, at 1 and 2 years after randomisation, respectively. The superiority of LTG over CBZ was due to its better tolerability but there is satisfactory evidence indicating that LTG is not clinically inferior to CBZ for measures of its efficacy. No consistent differences in QoL outcomes were found between treatment groups. Health economic analysis supported LTG being preferred to CBZ for both cost per seizure avoided and cost per quality-adjusted life-year gained. In Arm B for time to treatment failure, VPS, the standard drug, was preferred to both TPM and LTG, as it was the drug least likely to be associated with treatment failure for inadequate seizure control and was the preferred drug for time to achieving a 12-month remission. QoL assessments did not show any between-treatment differences. The health economic assessment supported the conclusion that VPS should remain the drug of first choice for idiopathic generalised or unclassified epilepsy, although there is a suggestion that TPM is a cost-effective alternative to VPS.

CONCLUSIONS

The evidence suggests that LTG may be a clinical and cost-effective alternative to the existing standard drug treatment, CBZ, for patients diagnosed as having partial seizures. For patients with idiopathic generalised epilepsy or difficult to classify epilepsy, VPS remains the clinically most effective drug, although TPM may be a cost-effective alternative for some patients. Three new antiepileptic drugs have recently been licensed in the UK for the treatment of epilepsy (levetiracetam, zonisamide and pregabalin), therefore these drugs should be compared in a similarly designed trial.

The SANAD study of effectiveness of carbamazepine, gabapentin, lamotrigine, oxcarbazepine, or topiramate for treatment of partial epilepsy: an unblinded randomised controlled trial

BACKGROUND

Carbamazepine is widely accepted as a drug of first choice for patients with partial onset seizures. Several newer drugs possess efficacy against these seizure types but previous randomised controlled trials have failed to inform a choice between these drugs. We aimed to assess efficacy with regards to longer-term outcomes, quality of life, and health economic outcomes.

METHODS

SANAD was an unblinded randomised controlled trial in hospital-based outpatient clinics in the UK. Arm A recruited 1721 patients for whom carbamazepine was deemed to be standard treatment, and they were randomly assigned to receive carbamazepine, gabapentin, lamotrigine, oxcarbazepine, or topiramate. Primary outcomes were time to treatment failure, and time to 12-months remission, and assessment was by both intention to treat and per protocol. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN38354748.

FINDINGS

For time to treatment failure, lamotrigine was significantly better than carbamazepine (hazard ratio [HR] 0.78 [95% CI 0.63-0.97]), gabapentin (0.65 [0.52-0.80]), and topiramate (0.64 [0.52-0.79]), and had a non-significant advantage compared with oxcarbazepine (1.15 [0.86-1.54]). For time to 12-month remission carbamazepine was significantly better than gabapentin (0.75 [0.63-0.90]), and estimates suggest a non-significant advantage for carbamazepine against lamotrigine (0.91 [0.77-1.09]), topiramate (0.86 [0.72-1.03]), and oxcarbazepine (0.92 [0.73-1.18]). In a per-protocol analysis, at 2 and 4 years the difference (95% CI) in the proportion achieving a 12-month remission (lamotrigine-carbamazepine) is 0 (-8 to 7) and 5 (-3 to 12), suggesting non-inferiority of lamotrigine compared with carbamazepine.

INTERPRETATION

Lamotrigine is clinically better than carbamazepine, the standard drug treatment, for time to treatment failure outcomes and is therefore a cost-effective alternative for patients diagnosed with partial onset seizures.

The SANAD study of effectiveness of valproate, lamotrigine, or topiramate for generalised and unclassifiable epilepsy: an unblinded randomised controlled trial

BACKGROUND

Valproate is widely accepted as a drug of first choice for patients with generalised onset seizures, and its broad spectrum of efficacy means it is recommended for patients with seizures that are difficult to classify. Lamotrigine and topiramate are also thought to possess broad spectrum activity. The SANAD study aimed to compare the longer-term effects of these drugs in patients with generalised onset seizures or seizures that are difficult to classify.

METHODS

SANAD was an unblinded randomised controlled trial in hospital-based outpatient clinics in the UK. Arm B of the study recruited 716 patients for whom valproate was considered to be standard treatment. Patients were randomly assigned to valproate, lamotrigine, or topiramate between Jan 12, 1999, and Aug 31, 2004, and follow-up data were obtained up to Jan 13, 2006. Primary outcomes were time to treatment failure, and time to 1-year remission, and analysis was by both intention to treat and per protocol. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN38354748.

FINDINGS

For time to treatment failure, valproate was significantly better than topiramate (hazard ratio 1.57 [95% CI 1.19-2.08]), but there was no significant difference between valproate and lamotrigine (1.25 [0.94-1.68]). For patients with an idiopathic generalised epilepsy, valproate was significantly better than both lamotrigine (1.55 [1.07-2.24] and topiramate (1.89 [1.32-2.70]). For time to 12-month remission valproate was significantly better than lamotrigine overall (0.76 [0.62-0.94]), and for the subgroup with an idiopathic generalised epilepsy 0.68 (0.53-0.89). But there was no significant difference between valproate and topiramate in either the analysis overall or for the subgroup with an idiopathic generalised epilepsy.

INTERPRETATION

Valproate is better tolerated than topiramate and more efficacious than lamotrigine, and should remain the drug of first choice for many patients with generalised and unclassified epilepsies. However, because of known potential adverse effects of valproate during pregnancy, the benefits for seizure control in women of childbearing years should be considered.

Prion-removal capacity of chromatographic and ethanol precipitation steps used in the production of albumin and immunoglobulins

BACKGROUND AND OBJECTIVES

Although there is no epidemiological evidence to suggest that classical Creutzfeldt-Jakob disease (CJD) is transmitted through blood or blood products, the variant form (vCJD) has been implicated in transmission via packed red blood cells. The potential threat of the infectious agent contaminating plasma pools has led to manufacturing processes being examined for capacity to remove prions. The objective of these studies was to examine the prion-removal potential of the chromatographic purification and ethanol precipitation steps used to fractionate immunoglobulins and albumin from human plasma.

MATERIALS AND METHODS

Western blot assay was used to examine the partitioning of proteinase K-resistant scrapie prion protein (PrPsc) over DEAE Sepharose, CM Sepharose and Macro-Prep High Q chromatographic columns, utilizing microsomal scrapie 263K spiked into each scaled down feedstream and assayed after each chromatographic step. In further studies, bioassay in C57 black mice was used and spikes of 10 000 g clarified brain homogenate of scrapie ME7 were added to feedstreams before sequences of scaled down chromatographic or Cohn fractionation process steps.

RESULTS

The microsomal spiking study with Western blot detection demonstrated substantial partitioning of PrPsc away from the target proteins in all ion exchange chromatographic steps examined. The log10 reduction factors (LRF) across DEAE Sepharose and CM Sepharose columns for albumin were > or = 4.0 and > or = 3.0 respectively. The reductions across DEAE Sepharose and Macro-Prep High Q for intravenous immunoglobulin were 3.3 and > or = 4.1 respectively. Bioassay demonstrated LRFs of >or = 5.6 across the combination of DEAE Sepharose and CM Sepharose columns in the albumin process and > or = 5.4 across the combination of DEAE Sepharose and Macro-Prep High Q columns in the intravenous immunoglobulin process. Bioassay studies also demonstrated a LRF of > or = 5.6 for immunoglobulin produced by Cohn fractionation.

CONCLUSIONS

Using rodent-adapted scrapie as a model, the studies indicated that ion exchange chromatography, as well as Cohn immunoglobulin fractionation have the potential to effectively reduce the load of TSE agents should they be present in plasma pools.

Analysis of speech-related variance in rapid event-related fMRI using a time-aware acquisition system

Speech production introduces signal changes in fMRI data that can mimic or mask the task-induced BOLD response. Rapid event-related designs with variable ISIs address these concerns by minimizing the correlation of task and speech-related signal changes without sacrificing efficiency; however, the increase in residual variance due to speech still decreases statistical power and must be explicitly addressed primarily through post-processing techniques. We investigated the timing, magnitude, and location of speech-related variance in an overt picture naming fMRI study with a rapid event-related design, using a data acquisition system that time-stamped image acquisitions, speech, and a pneumatic belt signal on the same clock. Using a spectral subtraction algorithm to remove scanner gradient noise from recorded speech, we related the timing of speech, stimulus presentation, chest wall movement, and image acquisition. We explored the relationship of an extended speech event time course and respiration on signal variance by performing a series of voxelwise regression analyses. Our results demonstrate that these effects are spatially heterogeneous, but their anatomic locations converge across subjects. Affected locations included basal areas (orbitofrontal, mesial temporal, brainstem), areas adjacent to CSF spaces, and lateral frontal areas. If left unmodeled, speech-related variance can result in regional detection bias that affects some areas critically implicated in language function. The results establish the feasibility of detecting and mitigating speech-related variance in rapid event-related fMRI experiments with single word utterances. They further demonstrate the utility of precise timing information about speech and respiration for this purpose.

The cleavage activation and sites of glycosylation in the fusion protein of Hendra virus

Hendra virus (HeV) is an unclassified member of the Paramyxoviridae family that causes systemic infections in humans, horses, cats, guinea pigs and flying foxes. The fusion protein (F(0)) of members of the Paramyxoviridae family that cause systemic infections in vivo contains a basic amino acid-rich region at which the protein is activated by cleavage into two subunits (F(1) and F(2)). HeV F(0) lacks such a domain. We have determined the cleavage site in HeV F(0) by sequencing the amino terminus of the F(1) subunit and in view of the potential effect of glycosylation on the cleavage process have ascertained the sites at which F(0) is glycosylated. The results indicate that unlike other members of the family that replicate in cultured cells and cause systemic infections in vivo, cleavage of HeV F(0) occurs at a single lysine (reside 109) in the sequence Asp-Val-Lys- downward arrow-Leu. Although HeV genotypically resembles members of the Respirovirus and Rubulavirus genera in having potential N-linked glycosylation sites in both the F(1) and F(2) subunits, we show that phenotypically HeV may more closely resemble members of the Morbillivirus genus that contain N-linked glycans only in the F(2) subunit.

Nipah virus: a recently emergent deadly paramyxovirus

A paramyxovirus virus termed Nipah virus has been identified as the etiologic agent of an outbreak of severe encephalitis in people with close contact exposure to pigs in Malaysia and Singapore. The outbreak was first noted in late September 1998 and by mid-June 1999, more than 265 encephalitis cases, including 105 deaths, had been reported in Malaysia, and 11 cases of encephalitis or respiratory illness with one death had been reported in Singapore. Electron microscopic, serologic, and genetic studies indicate that this virus belongs to the family Paramyxoviridae and is most closely related to the recently discovered Hendra virus. We suggest that these two viruses are representative of a new genus within the family Paramyxoviridae. Like Hendra virus, Nipah virus is unusual among the paramyxoviruses in its ability to infect and cause potentially fatal disease in a number of host species, including humans.

Distal scaphoid resection arthroplasty for the treatment of degenerative arthritis secondary to scaphoid nonunion

Nineteen patients with chronic scaphoid nonunion and associated degenerative arthritis between the distal fragment and the radial styloid were treated by resection of the distal fragment. All patients had a dorsal intercalated segment instability wrist collapse pattern with an average radiolunate angle of -32 degrees and a 10% reduction in the carpal height, both of which changed minimally during the follow-up period. The duration of the nonunion averaged 12 years and the follow-up period averaged 49 months. Range of motion improved 85% and grip improved 134%. Thirteen of the patients experienced complete pain relief. One patient required additional surgery and elected wrist arthrodesis. Resection of the distal fragment is not recommended for patients with capitolunate arthritis. Two of the 4 patients with capitolunate arthritis had persistent symptoms; 3 had progressive degenerative changes.

Describing traumatic responses and distress of community residents directly and indirectly exposed to an aircraft crash

This study described the traumatic responses and the extent of psychological distress among residents who had been exposed directly or indirectly to an aircraft crash in Coventry, U.K. The direct exposure group consisted of 62 residents who were on the housing estate at the time of the accident and 20 who were not. They were interviewed on their subjective responses to the crash and then asked to fill in two distress measures: the Impact of Event Scale (IES) and the General Health Questionnaire (GHQ). The results showed a contrast between the responses of the two groups at the time of the crash. They also showed that the direct exposure group had a significantly higher score in the IES item of avoidance, the IES total, the GHQ items of somatization, social dysfunction, and the total score than the indirect exposure group had. Associations were then made between subjective responses and distress measures. Stepwise multiple regression analyses showed that for the direct exposure residents, the IES total was predicted by "whether they received professional help" and "whether they were worried about their safety after the crash." The GHQ total of the direct exposure residents was predicted by "anger about what had happened to them." For the indirect exposure residents, the IES total was predicted by "their present feelings when they heard planes flying over." There were no predictions found between responses and the GHQ total.

Prenatal alcohol exposure and communication, behavior, and nonverbal intelligence of 3 school-age children

Associations of prenatal alcohol exposure in speech, language, behavioral, and intellectual development were investigated in three school-aged children diagnosed with Fetal Alcohol Syndrome, accompanied by Attention Deficit Hyperactivity Disorder. Each child showed similar patterns of moderate-to-severe dysfunctional behavior; however, their scores on speech, language and nonverbal intellectual measures were highly variable.

Distinct molecular events during secretory granule biogenesis revealed by sensitivities to brefeldin A

The biogenesis of peptide hormone secretory granules involves a series of sorting, modification, and trafficking steps that initiate in the trans-Golgi and trans-Golgi network (TGN). To investigate their temporal order and interrelationships, we have developed a pulse-chase protocol that follows the synthesis and packaging of a sulfated hormone, pro-opiomelanocortin (POMC). In AtT-20 cells, sulfate is incorporated into POMC predominantly on N-linked endoglycosidase H-resistant oligosaccharides. Subcellular fractionation and pharmacological studies confirm that this sulfation occurs at the trans-Golgi/TGN. Subsequent to sulfation, POMC undergoes a number of molecular events before final storage in dense-core granules. The first step involves the transfer of POMC from the sulfation compartment to a processing compartment (immature secretory granules, ISGs): Inhibiting export of pulse-labeled POMC by brefeldin A (BFA) or a 20 degrees C block prevents its proteolytic conversion to mature adrenocorticotropic hormone. Proteolytic cleavage products were found in vesicular fractions corresponding to ISGs, suggesting that the processing machinery is not appreciably activated until POMC exits the sulfation compartment. A large portion of the labeled hormone is secreted from ISGs as incompletely processed intermediates. This unregulated secretory process occurs only during a limited time window: Granules that have matured for 2 to 3 h exhibit very little unregulated release, as evidenced by the efficient storage of the 15-kDa N-terminal fragment that is generated by a relatively late cleavage event within the maturing granule. The second step of granule biogenesis thus involves two maturation events: proteolytic activation of POMC in ISGs and a transition of the organelle from a state of high unregulated release to one that favors intracellular storage. By using BFA, we show that the two processes occurring in ISGs may be uncoupled: although the unregulated secretion from ISGs is impaired by BFA, proteolytic processing of POMC within this organelle proceeds unaffected. The finding that BFA impairs constitutive secretion from both the TGN and ISGs also suggests that these secretory processes may be related in mechanism. Finally, our data indicate that the unusually high levels of unregulated secretion often associated with endocrine tumors may result, at least in part, from inefficient storage of secretory products at the level of ISGs.

Decision and attribution bias in neurorehabilitation

OBJECTIVE

Examine neurorehabilitation therapists' clinical predictions and attributions for outcomes.

DESIGN

Single sample, repeated measures.

PARTICIPANTS

A sample of 51 neurorehabilitation therapists selected from representative disciplines including occupational therapy, physical therapy, speech therapy, and recreation therapy.

MAIN OUTCOME MEASURES

Self-report questionnaire on factors related to positive and negative outcomes in neurorehabilitation. Rank order listing of factors influencing outcome in neurorehabilitation.

RESULTS

Without cuing, therapists did not identify injury severity as factor in outcome (p < .0001). Therapists also made internal attributions for positive outcomes and external attributions for negative outcomes (p < .0001).

CONCLUSIONS

Neurorehabilitation therapists tend to ignore injury severity as factor in outcome unless encouraged to do so. Therapists accept personal responsibility for positive outcomes, but not for negative outcomes. Neurorehabilitation teams may benefit from education on factors affecting prognosis and attribution bias found in clinical practice.

Mortality among laboratory workers employed at the U.S. Department of Agriculture

We evaluated the mortality of 835 white male and 36 female laboratory workers employed by the U.S. Department of Agriculture who died between January 1, 1970, and December 31, 1979. For males, the mortality odds ratio for all cancers was 1.0 (95% confidence interval = 0.8-1.2). Colon cancer, lymphosarcoma and reticulosarcoma, nonmalignant diseases of the blood and blood-forming organs, and suicide showed elevated mortality odds ratios. Only colon cancer showed an association with duration of employment as a laboratory worker. In an accompanying case-control study, the risk of colon cancer rose to 3.2 among those who had 20 or more years of employment as a laboratory worker. Among females, breast cancer was elevated (mortality odds ratio = 5.3; 95% confidence interval = 2.8-10.1).

Mortality among forest and soil conservationists

The mortality of forest conservationists and soil conservationists in the United States Department of Agriculture (USDA) who died during January 1, 1970-December 31, 1979 (N = 1,411 white males) while actively employed or while receiving a pension was evaluated. The proportionate mortality analysis was used to identify cancers that might be elevated in this occupational group compared to the total U.S. white male population, whereas case-control analyses more rigorously evaluated the disease association with occupation. Controls were selected from employees at USDA who died of any cause of death other than that cause of death represented by the case. In case-control analyses, non-Hodgkin's lymphoma (NHL) and colon cancer demonstrated a statistically significant linear trend (p less than .05) with duration of employment as either a forest or soil conservationist, which suggests an occupational etiology for both diseases. Soil conservationists who were last employed after 1960 experienced significantly elevated risks for NHL (OR = 2.6) and colon cancer (OR = 1.8), whereas those last employed before 1960 were not at an increased risk. Among forest conservationists, the risk for both NHL and colon cancer appeared to be elevated before and after 1960.

The Family physician and the Terminally Ill Elderly

Palliative care rests on the three pillars of symptom control, communication, and family support. As our patient population ages, we family doctors will be increasingly involved in the care of the terminally ill elderly at home. Terminal illnesses are much more common in the elderly, and often death can be predicted. Family doctors have a most important role in co-ordinating the home-support services, in providing comfort care, and in supporting the family members who are caring for the terminally ill elderly at home.

Mortality among agricultural extension agents

The mortality experience of agricultural extension agents in the Cooperative Extension Service (CES) of the U.S. Department of Agriculture who died during the period January 1, 1970-December 31, 1979 (n = 1,495 white males) was evaluated in proportionate-mortality and case-control studies. The proportionate-mortality analysis was used to identify cancers that might be elevated in this occupational group compared with the U.S. white male population. All cancers with a significantly elevated proportionate-mortality ratio were more thoroughly evaluated in the case-control study, where there is presumably less of a selection bias in the comparison. In the case-control study, leukemia demonstrated a statistically significant linear trend with duration of employment as an extension agent. Smaller, but nonsignificant, trends were seen for non-Hodgkin's lymphoma, multiple myeloma, and brain cancer. The odds ratio for Hodgkin's disease and cancers of the colon, prostate, and kidney did not vary with the number of years on the job. These patterns resemble cancer risks seen among farmers, suggesting that agricultural factors may also play a role in the origin of these tumors among extension agents.

Biochemical characterization of fracture callus proteoglycans

The changes in proteoglycan molecules during the initial stages of fracture healing in rats were characterized. Following extraction of callus proteoglycan components with dissociative solvents, the components were purified in a cesium chloride density gradient. The recovered proteoglycans were characterized with respect to their molecular size distribution using gel filtration chromatography and a centrifugal transport methodology. During this early healing period, a decrease was observed in the relative proportion of the aggregate and in the hydrodynamic size and sedimentation coefficients of these molecules. While some molecular degradation could have occurred during the early stages of fracture healing, the dominant change of the proteoglycan molecules seemed to be disaggregation. No significant difference was observed in the proportion of aggregates reformed when exogenous hyaluronate and link glycoproteins were allowed to interact with the two corresponding monomer preparations. The molecular changes of the proteoglycan molecules seem to parallel those occurring during endochondral calcification of rat epiphyseal cartilage.

Canine pancreatic endocrine function after interruption of pancreatic exocrine drainage

Pancreatic endocrine function was studied in forty dogs after ligation or free i.p. drainage of the pancreatic duct, with or without simultaneous partial pancreatectomy. Shrinkage and fibrosis of the pancreas occurred in all dogs, with equal severity in the open duct and duct-tied groups. Fasting blood sugars remained within the normal range but fasting levels of plasma insulin and glucagon were reduced. Dynamic tests of endocrine function indicated that partial pancreatectomy reduced the insulin response to i.v. injection of dextrose or glucagon and delayed the reestablishment of glucose homeostasis. Glucose tolerance was normal in dogs with intact pancreases, but duct ligation was associated with deteriorating recovery after glucagon injection. The precise coordination of circulating glucose, insulin, and glucagon levels seen in normal dogs was lost in both partial and intact pancreas groups and these disturbances were attributed to the fibrotic changes arising from interference with the ductal drainage. Both ligation and free i.p. drainage of the pancreatic duct therefore resulted in abnormalities of islet function. When combined with partial pancreatectomy, both techniques were associated with significant pancreatic endocrine insufficiency.

Primary Pseudomonas pneumonia in a previously healthy man

A 29-year-old previously healthy man had a Pseudomonas aeruginosa pneumonia and bacteremia. Early recognition of the organism and institution of appropriate antibiotic therapy led to rapid clinical response and recovery. Although Pseudomonas is rarely the cause of pneumonia in a healthy host, it should be considered in the differential diagnosis.

Endocrine function of the heterotopic pancreatic allotransplant in dogs. I. Normal and rejection

After heterotopic pancreatic allotransplantation in dogs and in the absence of rejection there was a fasting normoglycemia with a marked hyperinsulinemia. On intravenous glucose tolerance testing and intravenous glucagon testing, the blood sugar response of dogs receiving no immunosuppression was normal but the response in dogs receiving immunosuppressive therapy was exaggerated. There was a marked increase in the insulin response compared with normal animals whether or not immunosuppressive therapy was administered. The first endocrine even during allograft rejection seemed to be a drop in the pancreatic insulin reserve as demonstrated by plasma insulin results during a glucagon test; occurring 2 to 3 days before clinically overt rejection. This was also found on glucose tolerance testing. A rise in the fasting plasma insulin occurred next, 1 to 2 days before a rise in the fasting blood sugar. As the rejection process progressed, the plasma insulin levels subsequently dropped until the death of the animal. If, during a rejection process, the blood sugar did not rise above 150 mg/100 ml and the plasma insulin level did not drop below the lower limit of normal the rejection was usually reversible with intravenous methylprednisolone.

Endocrine function of the heterotopic pancreatic allotransplant in dogs

After pancreatectomy and heterotopic pancreatic allotransplantation in dogs, there was a pattern of endocrine activity similar to that found following a combination of pancreatic denervation and total transposition of the pancreatic venous effluent from the portal of the systemic venous circulation. Denervation of the pancreas alone or total venous transposition alone did not mirror these results. The mechanism of the effect of these two factors is discussed.

Endocrine function of the heterotopic pancreatic allotransplant in dogs. II. Immediate post-transplant period

Pancreatic endocrine function was investigated in dogs after heterotopic pancreatic allotransplantation. A marked hyperinsulinemia was found in peripheral venous blood within the first 60 min postoperatively. This was associated with hypoglycemia and hypokalemia occurring within the next 2 to 3 hr resulting eventually in death. The hypoglycemia could be corrected by parenteral dextrose and potassium given during the first 2 hr postoperatively or prevented by parenteral hydrocortisone given at the time of transplantation.

Mammography: an aid in the treatment of carcinoma of the breast

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