Accelerated prostacyclin degradation in the thrombotic thrombocytopenic purpura

Plasma prostacyclin (PGI2) degradation rate was measured in a 39-year-old man with chronic thrombotic thrombocytopenic purpura (TTP). His disease responded to plasma exchange, or plasma infusion alone, given at 3-4 week intervals. Plasmapheresis with albumin replacement had an adverse effect. PGI2 degradation rate was measured by incubation of exogenous PGI2 with plasma at 37 degrees C and recording of PGI2 activity after one, five, and fifteen min incubation by measurement of inhibition of platelet aggregation. The PGI2 degradation rate of the patient was significantly higher than that of normal subjects. The degradation rate improved after each plasma treatment and correlated well with clinical improvement. Moreover, the degradation rate of PGI2 could be corrected in vitro by the addition of normal plasma. When the patients plasma was incubated with aortic rings, PGI2 activity was reduced but the level of its inactive end product, 6-keto-PGF1 alpha, was normal. These findings indicate that our patient had normal PGI2 stimulating activity but had an abnormal rate of PGI2 degradation. Accelerated PGI2 degradation which leads to PGI2 deficiency may be important in the pathogenesis of microvascular thrombosis.

Therapeutic plasmapheresis in systemic lupus erythematosus. Effect on immune complexes and antibodies to DNA

The effect of plasmapheresis in 8 patients with systemic lupus erythematosus (SLE) was investigated. Drug treatment was maintained at a constant level for at least 4 weeks before plasmapheresis. Levels of immune complexes were measured by a Raji cell radioimmunoassay, and by a solid-phase C1q-binding assay. Antibodies to ds-DNA and ss-DNA were measured by the Farr assay. In all cases, immune complexes and antibodies were lowered by plasmapheresis. In 5 patients, plasmapheresis was followed by a rapid rebound of complexes and antibody to pretreatment levels. In 3 in whom plasmapheresis was followed by treatment with cyclophosphamide for 1 month, a sustained immunochemical and clinical improvement followed, lasting in 2 cases for up to 3 years.

Audit of the frequency and clinical response to excessive oral anticoagulation in an out-patient population

A retrospective review of over-anticoagulated patients with critical international normalized ratios (INRs) was undertaken in a large outpatient laboratory. In the six-month study period, 85 prothrombin times (PTs) were identified with an INR of > or = 6.0, an overall incidence of elevated PTs of 0.2% or two per 1,000 INR tests. Complete follow-up data was available on 65 patients. When compared to an age- and gender-matched control group without INR > or = 6.0, high-INR patients were significantly more likely to manifest the presence of alcoholism or liver disease, to have been anticoagulated for less than six months, to have experienced more frequent warfarin dosage changes, and to have had the addition of a medication known to interact with warfarin. In the high-INR group, a likely cause for the specific critical INR was identified in 44 patients (68%). Drug interactions followed by compliance problems were the most common factors identified. The 13 patients (20%) who received vitamin K therapy experienced no difference in the clinical outcome compared with those managed conservatively. Conservative management of critically high INR values appeared to be as efficacious as intervention with vitamin K therapy.

Effectiveness of a community paramedic-led health assessment and education initiative in a seniors' residence building: the Community Health Assessment Program through Emergency Medical Services (CHAP-EMS)

Background

Seniors living in subsidized housing have lower income, poorer health, and increased risk for cardiometabolic diseases and falls. Seniors also account for more than one third of calls to Emergency Medical Services (EMS). This study examines the effectiveness of the Community Health Assessment Program through EMS (CHAP-EMS) in reducing blood pressure, diabetes risk, and EMS calls.

Methods

Paramedics on modified duty (e.g. injured) conducted weekly, one-on-one drop-in sessions in a common area of one subsidized senior’s apartment building in Hamilton, Ontario. Paramedics assessed cardiovascular, diabetes, and fall risk, provided health education, referred participants to local resources, and encouraged participants to return to CHAP-EMS for follow-up. Reports were faxed to the family physician regularly. Blood pressure was collected throughout the one year intervention, while diabetes risk was assessed at baseline and after 6–12 months. EMS call volumes were collected from the Hamilton Paramedic Service for two years pre-intervention and one year during the intervention.

Results

There were 79 participants (mean age = 72.2 years) and 1,365 participant visits to CHAP-EMS. The majority were female (68%), high school educated or less (53%), had a family doctor (90%), history of hypertension (58%), high waist circumference (64%), high body mass index (61%), and high stress (53%). Many had low physical activity (42%), high fat intake (33%), low fruit/vegetable intake (30%), and were current smokers (29%). At baseline, 42% of participants had elevated blood pressure. Systolic blood pressure decreased significantly by the participant’s 3^rd visit to CHAP-EMS and diastolic by the 5^th visit (p < .05). At baseline, 19% of participants had diabetes; 67% of those undiagnosed had a moderate or high risk based on the Canadian Diabetes Risk (CANRISK) assessment. 15% of participants dropped one CANRISK category (e.g. high to moderate) during the intervention. EMS call volume decreased 25% during the intervention compared to the previous two years.

Conclusions

CHAP-EMS was associated with a reduction in emergency calls and participant blood pressure and a tendency towards lowered diabetes risk after one year of implementation within a low income subsidized housing building with a history of high EMS calls.

Trial registration

Retrospectively registered on May 12^th 2016 with clinicaltrials.gov: NCT02772263

Evaluation of a diabetes specialty centre: structure, process and outcome

The purpose of this study was to evaluate the effectiveness of a diabetes specialty centre in assisting clients with noninsulin-dependent diabetes mellitus to improve their metabolic control and quality of life. A single-subject repeated measures design was used where data was collected on entry to the program, immediately following the 2-day education sessions, and at both 3- and 6-month follow-up visits. Structure and process were taken into consideration, and the main outcome variables measured were knowledge, attitudes, metabolic control (hemoglobin A1c) and perceived quality of life. These variables were chosen in the belief that many factors can influence behaviour and it is the combination of these factors which results in behavioural change and ultimately improvement in metabolic control and quality of life. The main findings were that the facilities and documentation records were adequate, the clients perceived that the primary function of the center was medical management rather than education, and knowledge, metabolic control and quality of life improved significantly after the program. For clients, perceived happiness and quality of life were primary issues. Therefore, improvement in quality of life should be one of the primary goals of diabetes education programs.

An investigation of the applicability of the inventory, satisfaction with amplification in daily life, at 2 weeks post hearing aid fitting

OBJECTIVE

To investigate the applicability of the self-report inventory, Satisfaction with Amplification in Daily Life (SADL), at 2 wk postfitting.

DESIGN

The SADL was completed by two groups of hearing aid users, one fitted 2 wk before completion, the other at least 1 yr before. All SADLs were completed as a paper and pencil exercise, without involvement of an audiologist or other clinic staff. All the aid users were Government funded, all were fitted with the same model hearing aid, all were over the age of 60 yr, and all were fitted and counselled by the same two audiologists. Comparisons were made of the two groups' scores on each subscale and Global score, as well as on scores for each individual question.

RESULTS

All scores for subscales, Global score, and individual questions were higher at 2 wk postfitting than at 1 yr. Significant differences were found for subscales Positive Effect (p < 0.05), Service and Cost (p < 0.025), Negative Features (p < 0.001), as well as for the Global score (p < 0.001). The only subscale not resulting in a significant difference was Personal Image (p > 0.10). It was noted that Negative Features, such as background interference, acoustic feedback, and problems with telephone use, apparently take longer to be observed than Positive Effects such as improved communication and good sound quality. By contrast with some other reported studies, these results all display a reduction in self-reported outcome, rather than stability, or even improvement, over time. Among other possibilities, this finding may suggest the SADL measures something different to that measured by other inventories.

CONCLUSIONS

The results of this investigation suggest that, if the aim is to predict long-term satisfaction with aid fitting, 2 wk postfitting is too early for meaningful application of the SADL as an outcome measure. It is possible that an earlier stability in SADL scores might be obtained by inclusion of additional questions aimed at earlier detection of negative features. Such inclusions may detract from one of the SADL's advantages, namely its brevity. It also is suggested that the long-term value of self-report methods will depend on development of rigorous and scientifically acceptable administration procedures, including appropriate times for application.

Prothrombin time determination. The lack of need for a discard tube and 24-hour stability

The National Committee for Clinical Laboratory Standards (NCCLS) recommends that all coagulation studies be done on a specimen from the tube drawn second or later. For patients receiving long-term anticoagulant therapy, this may require that the first tube of blood drawn be discarded for each prothrombin evaluation. In a prospective study we compared the prothrombin times (PTs) as international normalized ratios (INRs) from a series of three tubes obtained from 241 patients receiving consistent dosages of oral anticoagulant therapy to determine the need for discarding the first tube drawn, as well as the stability of PT determinations over a 24-hour period. Tube one was treated as the discard tube. Tubes one and two were analyzed within the laboratory's standard 4-hour time frame, while tube three was kept stoppered at room temperature, centrifuged a half hour before PT determination, and analyzed after a 24-hour delay. Comparisons of the INRs were made in four ranges comprising 1.2 to 2.0, 2.1 to 3.5, 3.6 to 5.9, and 6.0 or more. Most INR comparisons were less than the 10% maximum variance listed as acceptable by the NCCLS. A comparison of INR results between tube two and tube one showed a statistically significant difference only for the INR range of 6.0 or more. The comparison of the 24-hour specimen with tube one showed statistically significant differences in paired t testing for the first three INR cohorts. However, the 95% confidence intervals demonstrated that these mean differences were probably too small to be clinically significant. For the fourth cohort (INR > or = 6.0) the mean difference was not significantly different on paired t testing, but the 95% confidence interval was larger at -0.07 to 0.839. In this sample of outpatients receiving consistent dosages of oral anticoagulant therapy the use of a discard tube seemed unnecessary, and the 24-hour stability of PT determinations was documented.

Field dependence as a factor in sports with preponderance of open or closed skills

Three groups of 120 male and female athletes, who were aged 13 to 22 yr. from Junior and Senior High School and College varsity sports having a preponderance of open skills or of closed skills or who were nonathletes of like age, were tested on Oltman's portable rod-and-frame apparatus to assess field dependence. Analysis indicated that individuals playing in sports with a preponderance of open skills were more field-dependent than those playing in sports with a preponderance of closed skills. Varsity participants were more field-independent than nonparticipants.

Analgesic and respiratory effect of nalbuphine and pethidine for adenotonsillectomy in children with obstructive sleep disorder

Opioids may depress respiration and contribute to airway obstruction after adenotonsillectomy for obstructive sleep disorder. We compared the respiratory and analgesic effects of nalbuphine, which has a ceiling effect for respiratory depression, and pethidine in 90 children (aged 2-12 years) with a history of obstructive sleep disorder undergoing adenotonsillectomy. Children were scored for their obstructive sleep disorder history and were randomly allocated to receive intravenously at induction of anaesthesia either nalbuphine 0.1 mg.kg-1 (group N) or pethidine 1 mg.kg-1 (group P). End-tidal carbon dioxide was measured in the recovery period using a nasopharyngeal catheter and oxygen saturation whilst breathing air; pain and sedation scores were recorded for 6 h postoperatively. Both groups were similar with respect to the demographic data and respiratory measurements: mean (SD) oxygen saturation on air in the recovery area (96.2% (1.2) vs. 96.5% (1.1) in group N and P, respectively) and mean (SD) end-tidal carbon dioxide (46.4 (5.5) mmHg vs. 47.7 (4) mmHg in group N and P, respectively). High obstructive sleep disorder score, history of apnoea, hyperactivity and loud snoring were found to be the best predictors of early postoperative oxygen desaturation in both groups.

Therapeutic trial of cryofiltration in patients with rheumatoid arthritis

Cryofiltration, a new technique for on-line plasma separation and its treatment by cold filtration, enables the selective removal of immune complexes and eliminates the need for replacement proteins. Fifteen patients with rheumatoid arthritis were treated for nine to 10 consecutive sessions over a three- to five-week period. Circulating immune complexes decreased by an average of 78 percent and rheumatoid factor by 32 percent. This was accompanied by significant clinical improvement in morning stiffness, articular index, 50-foot walking time, grip strength, and target joint circumference. Cryofiltration might thus be beneficial for a subgroup of rheumatoid arthritis patients in whom conventional therapy has failed.

Effects of the eyerobics visual skills training program on static balance performance of male and female subjects

10 male and 10 female students in physical education aged 19 to 23 yr. were each randomly assigned to both the experimental and control groups. Experimental subjects were given the 4-wk. Eyerobics visual skills training to assess its effects on static balance performance as measured on a balance stabilometer. Analysis indicated that the women performed significantly better than the men over-all. Balance performance by the trained group improved significantly.

Effects of the Eyerobics Visual Skills Training Program on Static Balance Performance of Male and Female Subjects

10 male and 10 female students in physical education aged 19 to 23 yr. were each randomly assigned to both the experimental and control groups. Experimental subjects were given the 4-wk. Eyerobics visual skills training to assess its effects on static balance performance as measured on a balance stabilometer. Analysis indicated that the women performed significantly better than the men over-all. Balance performance by the trained group improved significantly.

Production of Adeno-Associated Virus Vectors in Cell Stacks for Preclinical Studies in Large Animal Models

Adeno-associated virus (AAV) vectors are among the most clinically advanced gene therapy vectors, with three AAV gene therapies approved for humans. Clinical advancement of novel applications for AAV involves transitioning from small animal models, such as mice, to larger animal models, including dogs, sheep, and nonhuman primates. One of the limitations of administering AAV to larger animals is the requirement for large quantities of high-titer virus. While suspension cell culture is a scalable method for AAV vector production, few research labs have the equipment (e.g., bioreactors) or know how to produce AAV in this manner. Moreover, AAV titers are often significantly lower when produced in suspension HEK 293 cells as compared to adherent HEK293 cells. Described here is a method for producing large quantities of high-titer AAV using cell stacks. A detailed protocol for titering AAV as well as methods for validating vector purity are also described. Finally, representative results of AAV-mediated transgene expression in a sheep model are presented. This optimized protocol for large-scale production of AAV vectors in adherent cells will enable molecular biology laboratories to advance the testing of their novel AAV therapies in larger animal models.

Activation of complement by blood transfusion filters

Fresh blood, stored blood and granulocyte concentrates were passed through 170-micron and microaggregate blood filters to determine the degree of complement activation that occurs during transfusion of citrated blood products. Complement activation was assessed by measurement of C3 conversion using crossed immunoelectrophoresis and by assessment of C5a using a leukocyte aggregation functional assay. Prefiltration, fresh or stored blood products showed 0-1% C3 activation. Postfiltration, the degree of C3 conversion did not change for fresh blood or granulocyte concentrates. For stored whole blood, the degree of C3 conversion increased slightly to 2-3%. Prefiltration results for all samples showed a low level of C5a which did not change after passage through any filter. Serum incubated with filter material at 37 degrees C showed 2-10% C3 conversion. In contrast, results with citrated plasma showed less than 3% conversion of C3. We conclude that although some filter materials may activate complement in serum, filtration of citrated blood products through microaggregate blood filters induces little complement activation.

Safety and Tolerability of the Adeno-Associated Virus Vector, AAV6.2FF, Expressing a Monoclonal Antibody in Murine and Ovine Animal Models

Adeno-associated virus (AAV) vector mediated expression of therapeutic monoclonal antibodies is an alternative strategy to traditional vaccination to generate immunity in immunosuppressed or immunosenescent individuals. In this study, we vectorized a human monoclonal antibody (31C2) directed against the spike protein of SARS-CoV-2 and determined the safety profile of this AAV vector in mice and sheep as a large animal model. In both studies, plasma biochemical parameters and hematology were comparable to untreated controls. Except for mild myositis at the site of injection, none of the major organs revealed any signs of toxicity. AAV-mediated human IgG expression increased steadily throughout the 28-day study in sheep, resulting in peak concentrations of 21.4–46.7 µg/ mL, demonstrating practical scale up from rodent to large animal models. This alternative approach to immunity is worth further exploration after this demonstration of safety, tolerability, and scalability in a large animal model.

Guidelines for the use of imaging techniques for the investigation of venous thromboembolic disease

The diagnosis of venous thromboembolic disease remains a difficult challenge. Chest radiography, ventilation/perfusion lung scanning, noninvasive leg testing, and pulmonary angiography were evaluated with regard to sensitivity, specificity, positive and negative predictive values. The need for treatment, observation, or serial testing with respect to risks and benefits of treatment and likelihood of serious outcomes was evaluated. The evidence for conclusions was based on the methodology and values of the Canadian Task Force on the Periodic Health Examination. The Diagnostic Imaging Advisory Group of the Canadian Association of Emergency Physicians developed eight recommendations.

Peripheral blood stem cell transplantation: Impact on procedure load and workload in an apheresis unit

Peripheral blood stem cells (PBSC) reinfusion appears to hasten hematologic reconstitution following myeloablative therapy. While procurement of PBSC adds apheresis procedures, rapid engraftment could decrease the demand for platelet transfusions. To determine the impact of PBSC collection on workload in our apheresis unit, we studied 3 consecutive groups of patients with metastatic breast cancer given comparable high-dose chemotherapy and autologous bone marrow transplant, with or without PBSC or granulocyte-colony stimulating factor (G-CSF). Forty-one transplants were performed with bone marrow cells only: 31 patients (Group A) did not receive G-CSF, while the following 10 patients (group B) received daily G-CSF until neutrophil engraftment. Bone marrow cells and PBSC were used for the most recent 11 transplants (group C), followed by daily G-CSF until engraftment. PBSC were mobilized with cyclophosphamide (4 g/m2) and etoposide (1 g/m2), followed by G-CSF, 8 micrograms/kg/day. PBSC collection was carried out on a Fenwal CS3000+ cell collector, using modified procedure 1, to obtain a minimum of 5 x 10(8) mononuclear cells/kg. The times to neutrophil count over 500/microL, platelet count over 20,000/microL, and discharge from the hospital after transplant were significantly shorter for patients in group C (medians of 8, 8, and 21 days, respectively) compared to group A (medians of 14, 14, and 29 days; P = 0.001) or group B (medians of 11, 24, and 32 days; P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Adaptive optics for array telescopes using piston-and-tilt wave-front sensing

A near-infrared adaptive optics system operating at approximately 50 Hz has been used to control phase errors adaptively between two mirrors of the Multiple Mirror Telescope by stabilizing the position of the interference fringe in the combined unresolved far-field image. The resultant integrated images have angular resolutions of better than 0.1 arcsec and fringe contrasts of >0.6. Measurements of wave-front tilt have confirmed the wavelength independence of image motion. These results show that interferometric sensing of phase errors, when combined with a system for sensing the wave-front tilt of the individual telescopes, will provide a means of achieving a stable diffraction-limited focus with segmented telescopes or arrays of telescopes.

Patient health management: a promising paradigm in Canadian healthcare

Disease management, or the focused application of resources to achieve desired health outcomes, began in Canada in 1971 with the introduction of a universal healthcare program and a single government payor. Although relatively unfocused and nonrestrictive by contemporary standards, this program was successful in terms of outcomes. However, it is expensive, and Canada's rapidly aging population is fueling a growing demand for more efficacious medical therapies. As a result, isolated services are being restricted in an effort to reduce costs. As a result of these changes and low prescription and patient compliance rates for efficacious therapies, total system costs have risen, there is a growing concern about deterioration of health outcomes, and stakeholders are dissatisfied. To optimize healthcare outcomes and reduce costs, a new paradigm--patient health management (PHM)--has emerged. With PHM, clinical and cost outcomes are continually measured and communicated to providers in an attempt to promote more efficacious care. PHM also seeks to avoid restrictive practices that are now associated with detrimental health outcomes and increased costs. PHM has proved successful when applied to acute and chronic cardiac disease treatment. It remains untested for most other diseases, but available data suggest that the comprehensive, evidence-based disease and systems management that characterizes PHM is likely to achieve the best health outcomes for the most people at the lowest possible costs.