Outcomes of atherectomy in patients undergoing lower extremity revascularisation

BACKGROUND

There is a paucity of real-world data on the in-hospital (IH) and post-discharge outcomes in patients undergoing lower extremity peripheral vascular intervention (PVI) with adjunctive atherectomy.

AIMS

In this retrospective, registry-based study, we evaluated IH and post-discharge outcomes among patients undergoing PVI, treated with or without atherectomy, in the National Cardiovascular Data Registry PVI Registry.

METHODS

The IH composite endpoint included procedural complications, bleeding or thrombosis. The primary out-of-hospital endpoint was major amputation at 1 year. Secondary endpoints included repeat endovascular or surgical revascularisation and death. Multivariable regression was used to identify predictors of atherectomy use and its association with clinical endpoints.

RESULTS

A total of 30,847 patients underwent PVI from 2014 to 2019, including 10,971 (35.6%) treated with atherectomy. The unadjusted rate of the IH endpoint occurred in 524 (4.8%) of the procedures involving atherectomy and 1,041 (5.3%) of non-atherectomy procedures (p=0.07). After adjustment, the use of atherectomy was not associated with an increased risk of the combined IH endpoint (p=0.68). In the 6,889 (22.4%) patients with out-of-hospital data, atherectomy was associated with a reduced risk of amputation (adjusted hazard ratio [aHR] 0.67, 95% confidence interval [CI]: 0.51-0.85; p<0.01) and surgical revascularisation (aHR 0.63, 95% CI: 0.44-0.89; p=0.017), no difference in death rates (p=0.10), but an increased risk of endovascular revascularisation (aHR 1.21, 95% CI: 1.06-1.39; p<0.01) at 1 year.

CONCLUSIONS

The use of atherectomy during PVI is common and is not associated with an increase in IH adverse events. Longitudinally, patients treated with atherectomy undergo repeat endovascular reintervention more frequently but experience a reduced risk of amputation and surgical revascularisation.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Novel usage of everolimus-eluting coronary stent for intracranial atherosclerotic disease: a technical report and case series

Objectives

This report describes the use of an Everolimus-eluting stent (Xience Skypoint stent) for the treatment of medically-refractory ICAD.

Design

Retrospective, case-series.

Setting

In-hospital patients.

Participants

All patients in this report had a history of stroke secondary to ICAD. All patients failed aggressive medical treatments and had recurrence of symptoms despite anticoagulation or dual-antiplatelet therapy plus a statin. Diagnostic angiogram in each case showed severe vessel stenosis, therefore patients were recommended for intracranial artery stenting.

Main outcome measures

Technical feasibility of deploying Xience Skypoint stent for treatmet of ICAD.

Results

The Xience Skypoint stent was safely and effectively deployed in the vertebral artery (x1) and the internal carotid artery (x2) using trans-ulnar (x1), trans-radial (x1), and trans-femoral (x1) approaches without the use of an intermediate catheter.

Conclusion

Second-generation EES such as Xience Skypoint may be utilized for treatment of medically-refractory ICAD. This technical report serves as a proof of concept for further studies analysing long-term safety and efficacy of such stents for treatment of ICAD.

Agnogenic practices: an analysis of UK gambling industry-funded youth education programmes

Background

The corporate political activities of harmful industries, including the use of agnogenic (ignorance or doubt producing) practices and the construction of dystopian narratives, directed at influencing policymaking are well documented. However, the use of agnogenic practices by industry-funded organisations who deliver industry-favoured education-based measures remains unexplored. This study aims to build understanding of this by analysing three UK gambling industry-funded youth education programmes that represent key policy responses to gambling harms.

Methods

Using a published typology of corporate agnogenic practices the ways that evidence is used within the programmes’ resources to legitimise their content and implementation were analysed. Programme evaluations and claims about the programmes’ evidence base and effectiveness were also analysed.

Results

Agnogenic practices, including confounding referencing, misleading summaries and evidential landscaping, that resemble those adopted by harmful industries are used within gambling industry-funded youth education programmes and by the charities that oversee their delivery. These practices serve corporate interests, distort the limited evidence in support of youth gambling education measures, and legitimise industry favoured policies.

Conclusions

This novel study demonstrates that agnogenic practices are used to construct utopian narratives that claim that gambling industry-favoured youth education programmes are evidence-based and evaluation-led. These practices misrepresent the literature and evaluation findings and may undermine effective policymaking to protect children and young people from gambling harms.

Key messages

• Gambling industry-funded education programmes warrant greater scrutiny and conflicts of interest need to be addressed.

• The methods and findings of this study are of relevance to other contexts and areas in the field of the commercial determinants of health given other harmful industries adopt similar approaches.

Intravascular ultrasound guidance for lower extremity arterial and venous interventions

This review details the utility of intravascular ultrasound (IVUS) for the management of peripheral artery and venous disease. The purpose of this document is to provide an update in the use of IVUS in peripheral arterial and venous pathology and demonstrate the use of IVUS as a practical diagnostic imaging procedure to evaluate and treat peripheral vascular disorders. IVUS, a diagnostic tool that relies on sound waves to produce precise images of the vessel being evaluated, was originally introduced to the medical community for the purposes of peripheral artery imaging, though it was quickly adapted for coronary interventions with positive outcomes. The utility of IVUS includes vessel measurement, pre- and post-procedural planning, treatment optimisation, and detection of thrombus, dissection or calcium severity. While angiography remains the standard imaging approach during peripheral intervention, multiple observational studies and small prospective trials have shown that in comparison, IVUS provides more accurate imaging detail, which may improve procedural outcomes. IVUS can also address limitations of angiography, including the need to administer contrast medium and eliminate the ambiguity associated with other forms of imaging. This review provides contemporary examples of where IVUS is being used during peripheral intervention as well as representative imaging to serve as a resource for the practising clinician.

ACGME Interventional Cardiology Milestones 2.0-an overview: Endorsed by the Accreditation Council for Graduate Medical Education

This document provides an overview of the rationale, development, interpretation, and practical suggestions for implementation of the new Accreditation Council for Graduate Medical Education (ACGME) Interventional Cardiology (IC) Milestones 2.0. Previously, IC programs used the general ACGME Milestones for internal medicine. The IC Milestones version 2.0 updates the ACGME competencies to be specific to training in IC. In 2019 an ACGME working group consisting of IC program directors, a lay representative, and representatives from the American Board of Internal Medicine met to develop the IC Milestones version 2.0. The ACGME IC Milestones 2.0 establishes a framework for formative feedback for trainees within domains of patient care, medical knowledge, systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills. The 2021 IC Milestones 2.0 provides a framework for IC mentors and trainees to identify areas for improvement or commendation help stimulate meaningful educational discussions, and provide the basis for self-reflection and self-improvement.

Racial and ethnic disparities in coronary, vascular, structural, and congenital heart disease

Cardiovascular disease (CVD) remains the leading cause of death in the United States. However, percutaneous interventional cardiovascular therapies are often underutilized in Blacks, Hispanics, and women and may contribute to excess morbidity and mortality in these vulnerable populations. The Society for Cardiovascular Angiography and Interventions (SCAI) is committed to reducing racial, ethnic, and sex-based treatment disparities in interventional cardiology patients. Accordingly, each of the SCAI Clinical Interest Councils (coronary, peripheral, structural, and congenital heart disease [CHD]) participated in the development of this whitepaper addressing disparities in diagnosis, treatment, and outcomes in underserved populations. The councils were charged with summarizing the available data on prevalence, treatment, and outcomes and elucidating potential reasons for any disparities. Given the huge changes in racial and ethnic composition by age in the United States (Figure 1), it was difficult to determine disparities in rates of diagnosis and we expected to find some racial differences in prevalence of disease. For example, since the average age of patients undergoing transcatheter aortic valve replacement (TAVR) is 80 years, one may expect 80% of TAVR patients to be non-Hispanic White. Conversely, only 50% of congenital heart interventions would be expected to be performed in non-Hispanic Whites. Finally, we identified opportunities for SCAI to advance clinical care and equity for our patients, regardless of sex, ethnicity, or race.

Clinical Impact of Contralateral Carotid Occlusion in Patients Undergoing Carotid Artery Revascularization

BACKGROUND

The presence of a contralateral carotid occlusion (CCO) is an established high-risk feature for patients undergoing carotid endarterectomy (CEA) and is traditionally an indication for carotid artery stenting (CAS). Recent observational data have called into question whether CCO remains a high-risk feature for CEA.

OBJECTIVES

The purpose of this study was to determine the clinical impact of CCO among patients undergoing CEA and CAS in a contemporary nationwide registry.

METHODS

All patients undergoing CEA or CAS from 2007 to 2019 in the NCDR CARE (National Cardiovascular Data Registry Carotid Artery Revascularization and Endarterectomy) and PVI (Peripheral Vascular Intervention) registries were included. The primary exposure was the presence of CCO. The outcome was a composite of in-hospital death, stroke, and myocardial infarction. Multivariable logistic regression and inverse-probability of treatment weighting were used to compare outcomes.

RESULTS

Among 58,423 patients who underwent carotid revascularization, 4,624 (7.9%) had a CCO. Of those, 68.9% (n = 3,185) underwent CAS and 31.1% (n = 1,439) underwent CEA. The average age of patients with CCO was 69.5 ± 9.7 years, 32.6% were women, 92.8% were Caucasian, 51.7% had a prior transient ischemic attack or stroke, and 45.4% presented with symptomatic disease. Over the study period, there was a 41.7% decrease in the prevalence of CCO among patients who underwent carotid revascularization (p < 0.001), but CAS remained the primary revascularization strategy. Unadjusted composite outcome rates were lower in patients with CCO after CAS (2.1%) than CEA (3.6%). Following adjustment, CCO was associated with a 71% increase in the odds of an adverse outcome after CEA (95% confidence interval: 1.27 to 2.30; p < 0.001) compared with no increase after CAS (adjusted odds ratio: 0.94; 95% confidence interval: 0.72 to 1.22; p = 0.64).

CONCLUSIONS

CCO remains an important predictor of increased risk among patients undergoing CEA, but not CAS.

Impact of tornadoes on hospital admissions for acute cardiovascular events

BACKGROUND

There is a paucity of data describing cardiovascular events after tornado outbreaks. We proposed to study the effects of tornadoes on the incidence of cardiovascular events at a tertiary care institution.

POPULATION AND METHODS

Hospital admission records from a single center situated in a tornado-prone area three months before and after a 2013 tornado outbreak were abstracted. To control for seasonal variation, we also abstracted data from the same period of the prior year (control). Hospital admissions for cardiovascular events (CVEs) including acute myocardial infarction, stroke and venous thromboembolism (VTE) were summated by zip codes, and compared by time period.

RESULTS

There were 22,607 admissions analyzed, of which 6,705 (30%), 7,980 (35%), and 7,922 (35%) were during the pre-tornado, post-tornado, and control time frames, respectively. There were 344 CVE in the controls, 317 CVE in pre-tornado and 364 CVEs in post tornado periods. There was no difference in the prevalence of CVE during the post-tornado season compared with the control (PPR=1.05 95% CI: 0.91 to 1.21, p=0.50) or the pre-tornado season (PPR=0.96, 95% CI: 0.83 to 1.21, p=0.63).

CONCLUSION

In conclusion, tornado outbreaks did not increase the prevalence of cardiovascular events. In contrast to the effect of hurricanes, implementation of a healthcare policy change directed toward the early treatment and prevention of cardiovascular events after tornadoes does not seem warranted.

Antirecipient helper and cytotoxic T-cell frequencies in bone marrow transplantation

We assayed helper T-lymphocyte precursor frequencies (HTLPf), interferon (IFN)-gamma-producing cell frequencies (IFN-gammaPf) and CTL precursor frequencies (CTLPf) to see if they could predict the severity of acute graft-versus-host disease (aGVHD) and disease relapse after transplantation. In all, 48 bone marrow transplantation (BMT) patients and their HLA-identical sibling (n=29) or matched unrelated donors (MUD) (n=19) were recruited. HTLPf, IFN-gammaPf and CTLPf were measured using a limiting dilution assay (LDA). Patients were followed prospectively to assess the severity of aGVHD and the status of the primary disease after BMT. High (>5 x 10(-6)) HTLPf, CTLPf and IFN-gammaPf were significantly associated with the occurrence and severity of aGVHD in patients who received transplants from HLA-identical sibling. Among patients receiving BMT from MUD, HTLPf and CTLPf, but not IFN-gammaPf, were associated with aGVHD. Five patients had disease relapse post-BMT and the risk was not significantly associated with HTLPf, CTLPf or IFN-gammaPf. Patients with high (>5 x 10(-6)) HTLPf, IFN-gammaPf or CTLPf before BMT are at higher risk of developing aGVHD after transplantation from both matched sibling donors and MUD. Whether these parameters can predict disease relapse would have to be investigated with a larger cohort of patients.

Successful mismatched sibling cord blood transplant in Hb Bart's disease

A 20-month-old girl with Hb Bart's disease, who had survived neonatal complications, underwent HLA-DR antigen mismatched sibling cord blood transplantation successfully. Immune thrombocytopenia, which occurred around 2.5 months after transplant, responded to intravenous gamma-globulin. The fetal hemoglobin level rose to a peak of 52.3% on day +69 post transplant and declined gradually during the following year. Ten percent of hemoglobin Bart's was detected 2 months after transplant and this reflects the alpha-thalassemia trait of the donor.

Benign paroxysmal positional vertigo: diagnosis and treatment in the emergency department--a review of the literature and discussion of canalith-repositioning maneuvers

Dizziness is a frequent presenting complaint in emergency department patients. Although seen in patients of all ages, it is more prevalent in patients older than 50 years of age. Vertigo represents a subset of dizziness and is defined as an illusion of movement, usually rotational, of the patient or the patient's surroundings. The illusion of motion may be of oneself (subjective vertigo) or of external objects (objective vertigo). The emergency physician should consider a large differential in the evaluation of vertigo with special attention to whether the vertigo is central or peripheral in origin.

Continuing Education in Nursing: A 10-Year Retrospective Study of CE Offerings Presented by the Kentucky Nurses Association

BACKGROUND

The purpose of this retrospective study was to evaluate continuing education (CE) offerings presented by the Kentucky Nurses Association during a 10-year period.

METHOD

Data were collected and analyzed from 37 CE offerings (N = 474 respondents).

RESULTS

Findings revealed that the majority of the respondents reported that the CE offerings were useful, stimulated them to seek further information, and resulted in acquisition of significant knowledge or skills for nursing education or practice. However, fewer than half of the respondents reported they were able to implement changes in nursing education or practice as a result of the CE offerings.

CONCLUSION

Findings supported the usefulness of CE in nursing education and practice and the need for further research evaluating CE and the correlation between CE and nursing education and practice.

Enlargement of atrophy and visual acuity loss in the geographic atrophy form of age-related macular degeneration

OBJECTIVE

To describe the progression of geographic atrophy (GA) from age-related macular degeneration (AMD) with respect to visual acuity (VA) loss and enlargement of atrophy.

DESIGN

A prospectively observed case series.

SETTING

Tertiary retinal referral center.

PARTICIPANTS

One hundred twenty-three patients with GA due to AMD who completed at least 1 year of follow-up (median follow-up, 3 years) were examined annually.

METHODS

At each examination, a protocol best-corrected VA of each eye was measured, a clinical examination was performed, and color fundus photographs were taken. The areas of atrophy were drawn and measured.

MAIN OUTCOME MEASURES

Visual acuity loss and enlargement of total and central atrophy.

RESULTS

At baseline, median VA was poorer with larger areas of atrophy, but there was wide variation related to sparing of the fovea. Thirty-one percent of all study eyes suffered a three-line VA loss from baseline by 2 years, and 53% had a three-line loss by 4 years. Those eyes with VA better than 20/50 had the highest rate of acuity loss; 27% of these eyes had acuities of 20/200 or worse at 4 years. Visual acuity loss in the GA study eye was similar in patients with bilateral GA and in those with choroidal neovascularization in the fellow eye. Total atrophy enlarged a median of 1.8 Macular Photocoagulation Study disc areas (DA) at 2 years; atrophy within a 4-DA circle centered on the fovea enlarged a median of 0.9 DA. Two (22%) of nine patients with GA in one eye and only drusen without advanced AMD in the fellow eye developed GA in the fellow eye at 2 years.

CONCLUSIONS

Geographic atrophy is associated with a significant decline in VA over time in many eyes. Areas of atrophy continue to enlarge over time, even when already large at baseline. The combination of reduced VA with enlargement of atrophy, occurring bilaterally in most patients, can lead to significant impairment of visual function.

The development of choroidal neovascularization in eyes with the geographic atrophy form of age-related macular degeneration

OBJECTIVE

To determine the rate of developing choroidal neovascularization (CNV) in eyes with geographic atrophy (GA) from age-related macular degeneration (AMD) and the characteristics of the CNV in these eyes.

DESIGN

Prospective natural history study with cohort analysis.

PARTICIPANTS

One hundred fifty-two patients with GA and no CNV by fluorescein angiography in at least 1 eye, with annual follow-up.

MAIN OUTCOME MEASURES

The development of CNV.

RESULTS

Thirteen eyes with GA developed CNV. For patients with bilateral GA and no CNV at baseline, 2% developed CNV by 2 years and 11% by 4 years. For patients with CNV in the fellow eye, 18% developed CNV in the study eye with GA by 2 years and 34% by 4 years. The eyes that developed CNV experienced more acuity loss than did the eyes with only GA. Within the fellow eye CNV group, those study eyes with GA that had less central atrophy (and better acuity) at baseline were more likely to develop CNV. The CNV developed at a peripheral border of GA in nine eyes, in the spared foveal region in two eyes, and in both center and border in one eye. No eye developed CNV in the area of atrophy itself. The appearance of CNV was evanescent in some cases and had a final appearance of an enlarged area of GA. Twelve other eyes had hemorrhages without definite evidence of CNV; three were thought to be suspicious for CNV and the remainder were thought to be hemorrhages that may be seen in elderly patients.

CONCLUSION

An eye with GA whose fellow eye has CNV is at significant risk for the development of CNV in the GA eye. A patient with bilateral GA and no evidence of CNV is at relatively low risk for developing CNV. The CNV may be evanescent and may not be detected. Intraretinal hemorrhages unrelated to CNV are relatively common in this older population.

Clinical profiles of Chinese patients with diffuse panbronchiolitis

BACKGROUND

Diffuse panbronchiolitis (DPB), characterised by progressive sinobronchial sepsis, is well characterised in Japanese subjects but not in other ethnic groups. The experience with DPB in seven Chinese patients is described and the clinical profiles compared with those of Japanese subjects.

METHODS

Seven Chinese patients (three women; mean (SD) age 48(18.6) years, all never smokers) who attended a teaching hospital centre and fulfilled the diagnostic criteria for DPB were assessed prospectively for clinical, radiological, lung function, microbiological, and other "characteristic" laboratory parameters.

RESULTS

Lung function assessment showed a typical obstructive pattern (n = 5) and air trapping (n = 7). Typical bronchiolar infiltration by lymphocytes and plasma cells and accumulation of foamy macrophages in the intraluminal tissue were detected in open lung biopsy specimens (n = 2). Chest radiographs and high resolution computed tomographic scans revealed hyperinflation, diffuse nodules, bronchial thickening and dilatation, peripheral hypoattenuation, and bronchiolectasis. Radiological improvement, manifest as a reduction in nodular density and bronchial thickening, and persistence of other abnormalities such as air trapping were not accurately depicted by the classical Nakata or Akira classifications. The other "characteristic" features such as HLA-B54, IgG subclass deficiency, raised CD4/CD8 T lymphocyte ratio, cold haemagglutinaemia, raised IgA, IgG, and rheumatoid factor were not present. Treatment with erythromycin led to excellent responses in symptoms, lung function indices, and the radiological picture. A review of the non-Japanese cases in the literature reveals that this absence of typical "additional features" in DPB might also be applicable to non-Japanese patients.

CONCLUSIONS

We report the only series of non-Japanese Mongoloid patients with well characterised DPB who had uncharacteristic investigation profiles. This experience should help other clinicians in the investigation and management of DPB in non-Japanese patients.

Factors related to research utilization by registered nurses in Kentucky

The current health care environment mandates an outcomes-driven approach to care. Outcomes-based, and practice-driven, nursing research can be an essential organizational investment to maintain viability. Registered nurses in Kentucky appear motivated and ready to participate in and use relevant nursing research in their practice environment. Administrative support for those endeavors can be a key component in the successful conduct of clinical research and translation into clinical practice. Participation in research endeavors by both nursing staff and management can support the value of nursing in the current health care delivery system. This study adds to the literature in the area of research utilization in that random selection, a relatively large sample size, and all RNs in the state (not just members of the professional nursing organization) were used. Hopefully, the results of this study can be used to bring together all important parties in the research utilization process--experts, quality assurance nurses, managers in control of resources, risk managers, and those providing patient care.

Daughters and caregiving: taking care of our own

The purpose of this study is to identify the stressors experienced by caregiving daughters of frail, elderly parents and the coping skills used to manage those stressors. The differential effects of paid employment on caregiving daughters are also examined to explore the relationship between work force participation and caregiving stress. Data were collected from a non-random sample of 21 caregivers selected from the caseloads of a home health agency and a state continuity of care association. Two instruments were administered to caregiving daughters: the Caregiver Stress and Coping Instrument, and Lawton and Brody combined ADL and IADL instruments to assess functional level of parents. Finding included: 1) employed caregiving daughters had significantly higher stress scores (M = 52.9) than unemployed caregiving daughters (M = 46.8, p < .05); and 2) there was no significant relationship between stress scores and combined ADL and IADL scores. The stressors most often identified were needing help with recreational activities for the care recipient, and worrying about the future. The findings from the study can be used to plan nursing interventions specific to caregiving daughters, develop employee assistance programs promoting family health care or on site adult day care, and reduce costs by increasing employee productivity and retention.

Solution structure of the B-chain of insulin as determined by 1H NMR spectroscopy. Comparison with the crystal structure of the insulin hexamer and with the solution structure of the insulin monomer

The solution structure of the isolated B-chain of bovine insulin has been determined by 1H NMR spectroscopy combined with simulated annealing calculations. Complete sequence-specific assignments for the proton resonances are reported together with a set of 309 NOEs used in the structure calculations. Chemical-shift variations from random coil values provide support for the existence of helical regions in the polypeptide chain, as do a characteristic series of d alpha beta(i, i + 3) NOEs from residues B8 to B17. While there is some evidence for a limited degree of conformational averaging over the helical region, in general the helix is relatively well defined and corresponds closely to the helical region seen in the X-ray crystal structure of the insulin hexamer. Other similarities with the crystal structure include turn-like conformations at the carboxy terminal end of the helix and extended strands at both the amino and carboxy termini of the peptide. These similarities between the crystal structure and the isolated B-chain suggest that this peptide has intrinsic folding properties, which allow it to adopt its characteristic structure in intact insulin without the need for extensive cooperative interactions with the A-chain. Despite these general similarities, an important difference between the isolated B-chain and the intact protein occurs in the carboxy terminal region. This region appears significantly more mobile in the isolated B-chain. As a conformational change involving the carboxy terminus has been implicated in receptor binding, the current study of the isolated B-chain provides valuable information on the extent of this region's intrinsic mobility.

An unrelated marrow donor registry in Hong Kong

One of the limitations of allogeneic bone marrow transplant is the availability of HLA-compatible donors. HLA-identical or one antigen mismatched related donors can only be found for up to 40% of adult and 25% of paediatric patients in Hong Kong requiring a marrow transplant. The rest must rely on donors identified from volunteer unrelated marrow donor panels. Almost all our patients are Chinese but most volunteers in the worldwide marrow donor registries are Caucasians whose HLA profiles are different. Thus an unrelated marrow donor registry for Chinese was established in Hong Kong in 1991 and > 17,000 volunteers have participated. More than 300 local and overseas Chinese patients have so far been referred to our Registry for donor search. Suitable donors have been found ultimately for 40% of them. So far, 26 marrow transplants have been performed using unrelated donors from this registry. They include six overseas Chinese patients.

A randomized evaluation of smoking cessation interventions for pregnant women at a WIC clinic

Pregnant smokers attending a local health department WIC clinic were randomly assigned to one of two self-help smoking cessation programs or usual care. The multiple component program resulted in larger quit rates than usual care during the last month of pregnancy (11 percent vs 3 percent) and postpartum (7 percent vs 0 percent). Achieving quit rates in WIC similar to those in studies conducted at prenatal care settings, suggests that smoking cessation programs for low-income pregnant WIC clients are feasible.

IgA nephropathy associated with ankylosing spondylitis: occurrence in women as well as in men

Two patients (one male, one female) with ankylosing spondylitis (AS) and IgA nephropathy are described. The female patient is the first reported case to have AS and IgA nephropathy concurrently. Contrary to previously reported cases, her renal manifestation preceded her rheumatic symptoms. It is suggested that women with IgA nephropathy and AS may be overlooked as the severity of spondylitis and joint involvement is less than in men.

Deficiency of C4A is a genetic determinant of systemic lupus erythematosus in three ethnic groups

Systemic lupus erythematosus (SLE) has shown associations with the major histocompatibility complex (MHC) class II DR antigens and class III complement components C2 and C4 in previous studies. The primary susceptibility locus has been difficult to identify, however, on account of linkage disequilibrium within the MHC. We have studied C4A and C4B distributions in 63 Caucasoid, 75 Chinese and 51 Japanese SLE patients. All three populations showed a statistically significant increase in C4A*Q0 (null) alleles when compared with 323 ethnically matched controls. We conclude that complete or partial deficiency of C4A is a genetic determinant of SLE common to these three ethnically distinct populations.

Influence of participation on mortality in a randomized trial of vitamin A prophylaxis

Mortality of Sumatran children living in villages randomized to participate in a vitamin A capsule (200,000 IU) distribution program who received the capsule (n = 9776) was compared with those who did not (n = 2447) and with children living in villages randomized to serve as control subjects (n = 12,173). During the 4 mo after completion of the first distribution, mortality among preschool capsule recipients was less than 4% that of nonrecipients (p less than 0.001). Mortality among preschool nonrecipients was three times that of controls (p less than 0.05), suggesting strong selection bias. The potential biologic impact on childhood mortality attributable to vitamin A supplementation is estimated to exceed the 34% previously derived from the more conservative intent-to-treat analysis. One capsule every 6 mo may provide adequate protection for the vast majority of children. The single major limitation to maximum impact appears to be inadequate program coverage.

Measurement of adenosine triphosphate and 2,3-diphosphoglycerate in stored blood with 31P nuclear magnetic resonance spectroscopy

Conditions for blood storage are chosen to assure adequate levels of adenosine triphosphate (ATP) and 2,3-diphosphoglycerate (2,3-DPG). Because of the invasive nature of the techniques, biochemical assays are not routinely used to measure levels of these compounds in stored blood. However, 31P NMR spectroscopy measures phosphorylated intermediates in intact cells and could be used without disruption of the storage pack. We compared levels of ATP and 2,3-DPG measured by 31P spectroscopy and standard enzyme-linked biochemical assays in whole blood (WB) and packed red blood cells (PRBCs) at weekly intervals during a 35-day storage period. NMR demonstrated a marked decrease in 2,3-DPG and an increase in inorganic phosphate after the first week of storage. No significant differences in ATP concentrations were seen in WB during the storage period, but a significant decrease in ATP in PRBCs was documented. There was good agreement in levels of ATP and 2,3-DPG measured by NMR and biochemical techniques. 31P NMR spectroscopy is a noninvasive technique for measuring ATP and 2,3-DPG which has a potential use in quality assurance of stored blood.

15N-labeled Escherichia coli tRNAfMet, tRNAGlu, tRNATyr, and tRNAPhe. Double resonance and two-dimensional NMR of N1-labeled pseudouridine

The N1 imino units in Escherichia coli tRNAfMet, tRNAGlu, tRNAPhe, and tRNATyr were studied by 1H-15N NMR using three different techniques to suppress signals of protons not attached to 15N. Two of the procedures, Fourier internuclear difference spectroscopy and two-dimensional forbidden echo spectroscopy permitted 1H and 15N chemical shifts to be measured simultaneously at 1H sensitivity. The tRNAs were labeled by fermentation of the uracil auxotroph S phi 187 on a minimal medium containing [1-15N]uracil. 1H and 15N resonances were detected for all of the N1 psi imino units except psi 13 at the end of the dihydrouridine stem in tRNAGlu. Chemical shifts for imino units in the tRNAs were compared with "intrinsic" values in model systems. The comparisons show that the A X psi pairs at the base of the anticodon stem in E. coli tRNAPhe and tRNATyr have psi in an anti conformation. The N1 protons of psi in other locations, including psi 32 in the anticodon loop of tRNAPhe, form internal hydrogen bonds to bridging water molecules or 2'-hydroxyl groups in nearby ribose units. These interactions permit psi to stabilize the tertiary structure of a tRNA beyond what is provided by the U it replaces.

Bacterial meningitis in the elderly

To assess the implications of meningitis in a more mature population, we reviewed the records of patients with meningitis: 71 aged 50 years and older and 138 patients aged 15 to 49 years. Among the older population, 54 (76%) had bacterial, nine (13%) had granulomatous, and eight (11%) had aseptic meningitis. Among the cases of bacterial meningitis in the older age group, Streptococcus pneumoniae accounted for 24% (13/54) and enteric bacilli accounted for 17% (9/54). Serious complications occurred in 38 elderly patients (70%) with bacterial meningitis, and mortality occurred in 24 (44%). In the younger age group with bacterial meningitis, the complication rate and mortality were 41% (13/32) and 13% (4/32), respectively. Meningitis in the elderly is likely to be bacterial and to cause greater morbidity and mortality.