Deployment of whole genome next-generation sequencing of SARS-CoV-2 in a military maritime setting

BACKGROUND

SARS-CoV-2 can spread rapidly on maritime platforms. Several outbreaks of SARS-CoV-2 have been reported on warships at sea, where transmission is facilitated by living and working in close quarters. Core components of infection control measures such as social distancing, patient isolation and quarantine of exposed persons are extremely difficult to implement. Whole genome sequencing (WGS) of SARS-CoV-2 has facilitated epidemiological investigations of outbreaks, impacting on outbreak management in real time by identifying transmission patterns, clusters of infection and guiding control measures. We suggest such a capability could mitigate against the impact of SARS-CoV-2 in maritime settings.

METHODS

We set out to establish SARS-CoV-2 WGS using miniaturised nanopore sequencing technology aboard the Royal Fleet Auxiliary ARGUS while at sea. Objectives included designing a simplified protocol requiring minimal reagents and processing steps, the use of miniaturised equipment compatible for use in limited space, and a streamlined and standalone data analysis capability to allow rapid in situ data acquisition and interpretation.

RESULTS

Eleven clinical samples with blinded SARS-CoV-2 status were tested at sea. Following viral RNA extraction and ARTIC sequencing library preparation, reverse transcription and ARTIC PCR-tiling were performed. Samples were subsequently barcoded and sequenced using the Oxford Nanopore MinION Mk1B. An offline version of the MinKNOW software was used followed by CLC Genomics Workbench for downstream analysis for variant identification and phylogenetic tree construction. All samples were correctly classified, and relatedness identified.

CONCLUSIONS

It is feasible to establish a small footprint sequencing capability to conduct SARS-CoV-2 WGS in a military maritime environment at sea with limited access to reach-back support. This proof-of-concept study has highlighted the potential of deploying such technology in the future to military environments, both maritime and land-based, to provide meaningful clinical data to aid outbreak investigations.

Evaluation of the 30km/h speed limit trial in the City of Yarra, Melbourne, Australia

OBJECTIVE

Safe vehicle speeds were identified as a key element in a safe system approach to road safety. The City of Yarra in Melbourne, Australia has a 40 km/h default speed limit across their municipality, but wished to reduce the speed limit in local residential streets to 30 km/h. The Monash University Accident Research Center provided Council with a design for a demonstration trial and agreed to evaluate its safety benefits over 12 months. The trial was expected to show significant reductions in speed and increased community support.

METHOD

A before and after design was employed with a control (untreated) area to evaluate the safety outcomes of the trial. Speed limits were reduced to 30 km/h in the trial area for 12 months but kept at kept at the current 40 km/h (25 mph) limit in the control region. Vehicle speeds were measured at around 100 selected sites in the trial and control areas, and resident surveys were undertaken in both regions before and after the trial.

RESULTS

The findings showed a small but modest reduction of 1.1% in average speed in the trial region but a surprising 2.7% in the control region. On further examination, significant reductions were observed in the percent of vehicles exceeding 40 km/h (25 mph) and 50 km/h (31 mph) in both the treated and control regions, but not at 30 km/h (19 mph). A regression analysis further showed a significant treatment effect of 11% at 40 km/h and 25% at 50 km/h when adjusting for differences between treated and controls. Among other findings, the survey results found increased support for the lower speed limit of 17% with little adverse consequences.

CONCLUSION

The findings give support for the likely safety benefits of the 30 km/h trial with increased support from the residents. Speed reductions in the control region suggested a carry-over of the effects of the trial but also added support by local residents for reduced speed limits in the region. Potential injury savings were estimated at a 4% reduction in the risk of a pedestrian injury from the observed treatment effect in the trial region.

Circulating tumor DNA as a potential marker of adjuvant chemotherapy benefit following surgery for localized pancreatic cancer

BACKGROUND

In early-stage pancreatic cancer, there are currently no biomarkers to guide selection of therapeutic options. This prospective biomarker trial evaluated the feasibility and potential clinical utility of circulating tumor DNA (ctDNA) analysis to inform adjuvant therapy decision making.

MATERIALS AND METHODS

Patients considered by the multidisciplinary team to have resectable pancreatic adenocarcinoma were enrolled. Pre- and post-operative samples for ctDNA analysis were collected. PCR-based-SafeSeqS assays were used to identify mutations at codon 12, 13 and 61 of KRAS in the primary pancreatic tumor and to detect ctDNA. Results of ctDNA analysis were correlated with CA19-9, recurrence-free and overall survival (OS). Patient management was per standard of care, blinded to ctDNA data.

RESULTS

Of 112 patients consented pre-operatively, 81 (72%) underwent resection. KRAS mutations were identified in 91% (38/42) of available tumor samples. Of available plasma samples (N = 42), KRAS mutated ctDNA was detected in 62% (23/37) pre-operative and 37% (13/35) post-operative cases. At a median follow-up of 38.4 months, ctDNA detection in the pre-operative setting was associated with inferior recurrence-free survival (RFS) [hazard ratio (HR) 4.1; P = 0.002)] and OS (HR 4.1; P = 0.015). Detectable ctDNA following curative intent resection was associated with inferior RFS (HR 5.4; P < 0.0001) and OS (HR 4.0; P = 0.003). Recurrence occurred in 13/13 (100%) patients with detectable ctDNA post-operatively, including in seven that received gemcitabine-based adjuvant chemotherapy.

CONCLUSION

ctDNA studies in localized pancreatic cancer are challenging, with a substantial number of patients not able to undergo resection, not having sufficient tumor tissue for analysis or not completing per protocol sample collection. ctDNA analysis, pre- and/or post-surgery, is a promising prognostic marker. Studies of ctDNA guided therapy are justified, including of treatment intensification strategies for patients with detectable ctDNA post-operatively who appear at very high risk of recurrence despite gemcitabine-based adjuvant therapy.

Consumer Products Contributing to Fall Injuries in Children Aged <1 to 19 Years Treated in US Emergency Departments, 2010 to 2013: An Observational Study

Consumer products are often associated with fall injuries, but there is limited research on nonfatal unintentional falls in children that examines both the child’s age group and the involvement of consumer products and activities. We combined 2 data sources to investigate products and activities that contribute to fall injuries in children at different developmental ages (ie, <1, 1-2, 3-4, 5-9, 10-14, and 15-19 years). We analyzed data from the National Electronic Injury Surveillance System–All Injury Program for the years 2010 through 2013 and augmented it with product information from the National Electronic Injury Surveillance System. Between 2010 and 2013, children aged <1 to 19 years accounted for 11.1 million nonfatal unintentional fall-related emergency department visits. Fall injuries associated with home furnishings/fixtures were highest among children in age groups <1 year, 1 to 2 years, and 3 to 4 years. In the home furnishings/fixtures product group, beds were the leading contributor to falls. Fall injuries associated with sports/recreation were highest among children in age groups 5 to 9 years, 10 to 14 years, and 15 to 19 years. In this product group, monkey bars and basketball were the leading contributors to falls. Our findings indicate priority areas for falls injury prevention and intervention.

Towards valid 'serious non-fatal injury' indicators for international comparisons based on probability of admission estimates

BACKGROUND

Governments wish to compare their performance in preventing serious injury. International comparisons based on hospital inpatient records are typically contaminated by variations in health services utilisation. To reduce these effects, a serious injury case definition has been proposed based on diagnoses with a high probability of inpatient admission (PrA). The aim of this paper was to identify diagnoses with estimated high PrA for selected developed countries.

METHODS

The study population was injured persons of all ages who attended emergency department (ED) for their injury in regions of Canada, Denmark, Greece, Spain and the USA. International Classification of Diseases (ICD)-9 or ICD-10 4-digit/character injury diagnosis-specific ED attendance and inpatient admission counts were provided, based on a common protocol. Diagnosis-specific and region-specific PrAs with 95% CIs were calculated.

RESULTS

The results confirmed that femoral fractures have high PrA across all countries studied. Strong evidence for high PrA also exists for fracture of base of skull with cerebral laceration and contusion; intracranial haemorrhage; open fracture of radius, ulna, tibia and fibula; pneumohaemothorax and injury to the liver and spleen. Slightly weaker evidence exists for cerebellar or brain stem laceration; closed fracture of the tibia and fibula; open and closed fracture of the ankle; haemothorax and injury to the heart and lung.

CONCLUSIONS

Using a large study size, we identified injury diagnoses with high estimated PrAs. These diagnoses can be used as the basis for more valid international comparisons of life-threatening injury, based on hospital discharge data, for countries with well-developed healthcare and data collection systems.

In vivo activation of the aryl hydrocarbon receptor during viral infection up-regulates immunoregulatory factors in dendritic cells (IRC10P.411)

Activation of the aryl hydrocarbon receptor (AHR) substantially dampens host resistance to infection with influenza A viruses. We previously reported that AHR activation negatively regulates the expansion and differentiation of CD8+ cytotoxic T lymphocytes (CTL), and reduces the ability of dendritic cells (DC) to prime naïve CD8 T cells. However, the mechanism by which AHR activation dampens DC function in vivo is unknown. Given that AHR is a ligand inducible transcription factor, we used unbiased gene expression profiling to identify DC specific pathways modulated by in vivo AHR activation. Lung DCs from mice that were exposed to the prototype AHR ligand 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) or control were sorted and used for unbias transcriptome analysis with RNA-seq. This approach revealed multiple gene targets of AHR in DCs, which may play a role in modulating DC function. For example, indoleamine-2,3-dioxygenase (Ido1) was highly induced. Accompanying increased Ido1 expression were significant increases in the proportion of plasmacytoid DCs (pDCs) and regulatory T cells. Expanding our findings into an in vitro human system, monocyte-derived DCs from healthy human donors exposed to TCDD and influenza A virus presented a similar suite of altered genes, including elevated Ido1. This is further evidence that AHR activation in DCs intrinsically changes gene expression, inducing an immunoregulatory phenotype that exerts strong influence on the antiviral immune response.

EGFR/TGFα and TGFβ/CTGF Signaling in Neuroendocrine Neoplasia: Theoretical Therapeutic Targets

Neuroendocrine neoplasms (NENs) are a heterogeneous family of malignancies whose proliferation is partially dependent on growth factors secreted by the microenvironment and the tumor itself. Growth factors which were demonstrated to be important in experimental models of NENs include EGF (epidermal growth factor), TGF (transforming growth factor) α, TGFβ and CTGF (connective tissue growth factor). EGF and TGFα bind to the EGF receptor to stimulate an intact RAS/RAF/MAPK pathway, leading to the transcription of genes associated with cell proliferation, invasion and metastasis. Theoretically, TGFα stimulation can be inhibited at several points of the MAPK pathway, but success is limited to NEN models and is not evident in the clinical setting. TGFβ1 stimulates TGFβ receptors (TGFβRI and TGFβRII) resulting in inhibition of neuroendocrine cell growth through SMAD-mediated activation of the growth inhibitor P21(WAF1/CIP1). Although some NENs are inhibited by TGFβ1, paradoxical growth is seen in experimental models of gastric and small intestinal (SI) NENs. Therapeutic targeting of TGFβ1 in NENs is therefore complicated by uncertainty of the effect of TGFβ1 secretion on the direction of proliferative regulation. CTGF expression is associated with more malignant clinical phenotypes in a variety of cancers, including NENs. CTGF promotes growth in gastric and SI-NEN models, and is implicated as a mediator of local and distant fibrosis caused by NENs of enterochromaffin cell origin. CTGF inhibitors are available, but their anti-proliferative effect has not been tested in NENs. In summary, growth factors are essential for NEN proliferation, and although interventions targeting these proteins are effective in experimental models, only limited clinical efficacy has been identified.

Evaluation of the subaxial injury classification system

Study design:

Retrospective clinical study of patients treated for subaxial cervical spine trauma (SCST) at a tertiary medical center.

Purpose:

Evaluate the validity of the Subaxial Injury Classification (SLIC) system in surgical versus non-surgical decision making for SCST.

Inclusion criteria:

Age >12 years, presence of SCST with complete clinical and radiological (CT and MRI) data.

Exclusion criteria:

Patients with incomplete radiographic or clinical data, pathological fractures, isolated upper cervical trauma (occiput to C2), isolated transverse process or spinous process fractures, chronic or age indeterminate fractures, isolate MRI findings, and severe systemic trauma with death prior to either surgical or non-surgical treatment.

Results:

Fourteen patients were treated non-surgically (C), whereas 24 were treated surgically (S). In the C group, the SLIC score ranged from 0 to 5 points (standard deviation [SD] = 1.20 points; mean 1.07; median 1). Just 1 patient had an SLIC score greater than 2 (7.1% of the patients). In the S group, the SLIC score ranged from 1 to 10 points (standard deviation [SD] = 2.03 points; mean 5.6; median 6). Just 2 patients had an SLIC score smaller than 4 (both with 1 point each, 8.3% of the total group). All the other 22 (accounting for 91.6%) patients had an SLIC of 4 or more points.

Conclusions:

Our study suggests that the SLIC classification looks to be a promising system to aid spinal surgeons in the decision-making process of subaxial cervical trauma, but a large prospective cohort study is required.

Incidence and cost of injury among youth in agricultural settings, United States, 2001-2006

OBJECTIVE

Estimate the annual US incidence and cost of fatal and nonfatal youth injury in agricultural settings.

METHODS

We used 2001-2006 Childhood Agricultural Injury Survey data to estimate the incidence of nonfatal injury and 2001-2006 Multiple Cause of Death data to estimate the incidence of fatal injury. To estimate the costs for injuries suffered by youth working/living in agricultural settings, we multiplied the number of injuries times published unit costs by body part, nature of injury, and age group.

RESULTS

An average of 26 655 agricultural injury incidents occurred annually to youth (ages 0-19) in the United States during the period 2001-2006 (95% confidence interval [CI]: 24 263-29 046). These injuries cost society an estimated $1.423 billion per year in 2005 dollars (95% CI: $1.333 billion-$1.513 billion). Fatalities alone cost an estimated $420 million per year. Work related injuries annually cost $347 million or 24.4% of the total cost (95% CI: 20.3%-28.5%). Most agricultural youth injuries were not work related.

CONCLUSIONS

We found that, similarly to adult agricultural injuries, youth agricultural injuries tend to be more severe and more costly than nonagricultural injuries. Only 1.4% of injured youth in the United States were hospitalized in 2000, but 14% of youth injured in agriculture were hospitalized in 2001-2006. To address this serious problem, prevention should focus on better controlling both child access to agricultural recreational activities and child assignment to agricultural work tasks that exceed developmental norms.

Creating a learning culture for quality and leadership. Panel discussion

Today's fast-changing health care environment requires adept and knowledgeable leadership. Leaders must develop consistent standards across the organization to ensure quality and operational excellence. This will require the adoption of new skill sets and behaviors by clinicians and other employees. Leaders, too, will need to develop new skills and behaviors to effectively implement positive change. Health Forum convened a group of health care executives and industry experts July 13 in San Francisco to examine how hospital leaders can build and disseminate a consistent quality culture throughout the organization. Health Forum would like to thank all of the participants for their open and candid discussion, as well as GE Healthcare for sponsoring this event.

Prevalence and risk of hospitalized pregnant occupants in car crashes

Hospitalized maternal injuries pose a serious threat to the fetus, therefore understanding their burden is important. In addition, this study examined whether the risk of serious injury from crashes changes during pregnancy. Using 1997 hospital discharge data from 19 states, injuries to younger women were classified as motor-vehicle related with and without pregnancy-associated diagnoses. The pregnancy screen identified 1488 motor-vehicle occupant injury discharges (rate=129/100000 person-years, rate-ratio=1.88, 95% CI=1.49, 1.98). Pregnancy-associated cases were younger, their median charge-per-visit and mean ISS were lower and their average length-of-stay was shorter. Once adjusted for severity, the age-specific rate-ratios were not significantly different than one.

An investigation of the effects of touchpad location within a notebook computer

This study evaluated effects of the location of a notebook computer's integrated touchpad, complimenting previous work in the area of desktop mouse location effects. Most often integrated touchpads are located in the computer's wrist rest, and centered on the keyboard. This study characterized effects of this bottom center location and four alternatives (top center, top right, right side, and bottom right) upon upper extremity posture, discomfort, preference, and performance. Touchpad location was found to significantly impact each of those measures. The top center location was particularly poor, in that it elicited more ulnar deviation, more shoulder flexion, more discomfort, and perceptions of performance impedance. In general, the bottom center, bottom right, and right side locations fared better, though subjects' wrists were more extended in the bottom locations. Suggestions for notebook computer design are provided.

Intellectual, neuropsychological, and academic functioning in long-term survivors of leukemia

OBJECTIVE

To assess the effects of treatment for acute lymphoblastic leukemia (ALL) on children's cognitive functioning.

METHOD

Participants were long-term survivors of ALL treated with cranial irradiation and central nervous system (CNS) chemotherapy (n = 20), or CNS chemotherapy only (n = 21), healthy children (n = 21), and children with chronic asthma (n = 21). The groups were compared on measures of intellectual, neuropsychological, and academic functioning.

RESULTS

CNS chemotherapy, with and without cranial irradiation, was associated with significantly lower levels of intellectual and academic functioning. Children with chronic asthma obtained lower scores than healthy controls, but these differences were not significant. Tests of neuropsychological functioning did not consistently separate the groups.

CONCLUSIONS

CNS chemotherapy and, to a lesser extent, chronic illness both contribute to the poorer performance of long-term survivors of ALL on measures of intellectual and academic functioning.

Savings from four transport safety efforts in native America

This paper presents cost-outcome analyses of four transportation injury prevention efforts in Native American jurisdictions. Pre- and post-intervention data were analyzed to estimate projects' impact on injury reduction. Projects' costs were amortized over the time period covered by the evaluation or over the useful life of physical capital invested. Projects' savings were calculated based on estimated reduction in medical and public program expenses, on estimated decrease in lost productivity, and on estimated quality adjusted life years saved. All four projects yielded positive benefit-cost ratios. The net cost per quality adjusted life years was less than zero for all the projects.

Development, implementation, and evaluation of a multicenter pharmaceutical care outcomes study

OBJECTIVES

To: (1) develop a pharmaceutical care multicenter outcomes research project using clinical pharmacy residents and preceptors; (2) develop two research protocols to document pharmacists' impact on clinical, economic, and humanistic outcomes of therapy; (3) develop and implement a data collection process and methodology for outcomes research; (4) evaluate the effectiveness of the multicenter outcomes research process; and (5) prepare clinical pharmacy preceptors and residents to conduct outcomes research.

DESIGN AND SETTING

Two research protocols were developed, each a randomized, parallel, open-label evaluation of patients at 10 Department of Veterans Affairs and 1 university medical center. One protocol focused on patients with chronic obstructive pulmonary disease (COPD) and the other on patients with hypertension. The study evaluated pharmacists' management of these two patient groups.

PATIENTS AND OTHER PARTICIPANTS

133 patients with hypertension and 98 patients with COPD; 33 pharmacy directors and preceptors; 45 pharmacy residents.

MAIN OUTCOME MEASURES

Clinical, economic, and humanistic outcomes of pharmacists' interventions. The processes of developing a multicenter outcomes study were evaluated, including the data collection process.

RESULTS

The two study protocols and an educational program for study participants were developed. A data collection process was developed and implemented, with the paper process being successful and the computer data collection process not implemented due to time constraints. Overall, the multicenter outcomes research process was successful.

CONCLUSION

The study provides a framework of processes and sites for the future development of other outcomes research studies. Clinical, economic, and humanistic outcomes are reported in Parts 2 and 3.

Nutritional supplementation of nucleotides restores opioid CNS-mediated phenomena in mice

Previous experiments have demonstrated that suppression of immune function by either cyclosporin A or by a nucleotide free (NF) diet results in attenuation of morphine withdrawal symptoms in mice suggesting that immune status impacts CNS opioid-related phenomena. The present study elaborates on these initial findings by examining the effects of repletion of the NF diet with nucleotides or their precursors on opiate withdrawal. Female Balb/c mice were divided into six groups: a control group (C) given a standard lab chow diet and five experimental groups each given one of the following diets: a nucleotide free diet (NF); the NF supplemented with 0.25% RNA (NFR 0.25); the NF supplemented with 2.5% RNA (NFR 2.5) the NF supplemented with 0.06% uracil (NFU 0.06); the NF supplemented with 0.6% uracil (NFU 0.6). The mice were made morphine dependent by subcutaneous implantation of morphine pellets. Seventy-two hours after morphine pellet implantation, withdrawal was precipitated with naloxone (2 mg/kg). The mice were then observed and two indicators of withdrawal scored: jumping and diarrhea. The NF, NFR 0.25, NFR 2.5 and NFU 0.06 groups demonstrated significantly attenuation of the withdrawal signs relative to control animals. The NFU 0.6 group, however, had withdrawal scores restored to near control levels for both jumping and diarrhea. This suggests that nucleotides, particularly uracil, may play an important role in the immune-to-brain signaling pathway.

Performance of selected lightweight wheelchairs on ANSI/RESNA tests. American National Standards Institute-Rehabilitation Engineering and Assistive Technology Society of North America

OBJECTIVE

This study provides data for clinicians and wheelchair users to compare the durability, stability, and cost effectiveness of three different lightweight wheelchair models: the Everest & Jennings EZ Lite, the Invacare Rolls 2000, and the Quickie Designs Breezy. A second objective was to compare the results from this study to those published for ultralight and institutional depot wheelchairs.

DESIGN

Randomized standards testing of three wheelchair models from each manufacturer (nine wheelchairs total).

RESULTS

There were no significant differences (p > .05) in fatigue life, life-cycle cost, or static stability between the three models of lightweight wheelchairs (ie, EZ Lite, Rolls 2000, or Breezy). There were, however, significant differences (p < .05) in fatigue life among the lightweight wheelchairs of this study and the published results for ultralight rehabilitation wheelchairs and for depot wheelchairs. The lightweight wheelchairs had an average fatigue life greater than the depot wheelchairs but less than the rehabilitation wheelchairs. A depot-type wheelchair was defined as a manual wheelchair designed for hospital or institutional use. At lightweight wheelchair was defined as a manual wheelchair with minimal adjustments designed for individual or institutional use. An ultralight rehabilitation wheelchair was defined as a manual wheelchair designed for an individual's use as a long-term mobility aid.

CONCLUSION

The three models of lightweight wheelchairs tested are substantially similar and their fatigue lives are significantly (p < .05) lower than rehabilitation wheelchairs. Ultralight rehabilitation wheelchairs are the most cost effective over the life of the wheelchair, costing 3.4 times less (dollars per life cycle) than depot wheelchairs, and 2.3 times less (dollars per life cycle) than the lightweight wheelchairs tested in this study.

General lexical slowing and the semantic priming effect: the roles of age and ability

Older adults performed three lexical information-processing tasks approximately 1.3 times slower than young adults. Consistent with general lexical slowing, slopes of regressions based on individual subjects' RTs on two of the tasks (single lexical decision and category judgment) did not differ from slopes based on the third (double lexical decision) task. Moreover, slopes based on the single lexical decision and category judgment tasks accurately predicted the size of semantic priming effects on the third (double lexical decision) task. This was true for the older group as a whole, and also for subgroups of fast, medium and slow older adults, as well as for young adult subgroups. The size of the semantic priming effects for the fast old and slow young subgroups (who differed in age but not in processing speed) were approximately equal, consistent with the idea that the effect of age on priming is entirely attributable to slowing. Across all tasks, each old subgroup (fast, medium, or slow) showed the same degree of slowing relative to the corresponding young subgroup, so that the differences in RTs observed between subgroups in the young sample were magnified in the old sample. Taken together, the present findings suggest that ability-related differences in lexical processing speed may be functionally equivalent to age-related differences and that both factors interact to determine performance on speeded lexical tasks.

Life-cycle analysis of depot versus rehabilitation manual wheelchairs

The proper selection of a wheelchair requires making several critical decisions, not the least of which is what type of wheelchair is appropriate. The International Organization for Standards (ISO) continues to develop and refine wheelchair standards. Standards allow the objective comparison of products from various sources, permitting consumers or clinicians to assess wheelchairs with which they are not familiar by comparing test results. This study consisted of three components: 1) the comparison of fatigue test results with a planar ANSI/RESNA test dummy to a HERL contoured test dummy; 2) the comparison of fatigue test results for common depot versus common rehabilitation manual wheelchairs; and 3) the comparison of fatigue test results for manual rehabilitation wheelchairs with solid 8-inch casters versus those with pneumatic 8-inch casters. Rehabilitation wheelchairs lasted on average 13.2 times longer than the depot wheelchairs. Both types, tested with the standard ISO-ANSI/RESNA dummy, lasted on average 2.1 times longer than those wheelchairs tested using the contoured dummy. The three rehabilitation wheelchairs equipped with 8-inch pneumatic casters lasted on average 3.2 times longer than the 6 rehabilitation wheelchairs equipped with solid 8-inch casters. The depot wheelchairs cost about 3.4 times as much to operate per cycle or per meter than the rehabilitation wheelchairs. The rehabilitation wheelchairs tended to experience component failures, while the depot wheelchairs tended to experience frame failures. Our testing indicates that the tests in the ISO-ANSI/RESNA standards can relate design features to fatigue test results and durability. Rehabilitation wheelchairs tend to use higher quality materials and better manufacturing practices, and they provide greater mobility for wheelchair users. Purchasers and prescribers of wheelchairs should consider the life-cycle cost and not just the purchase price for wheelchairs.

Prevention of intraoperative contamination from large ulcerative cutaneous lesions

A method for managing head and neck malignancies with cutaneous ulceration prior to excision is described. At our institution all lesions with cutaneous extension and erosion have been treated in this manner prior to excision. The exact number of treated cases, however, is unknown, since this number is not placed in the medical record. Although the risk of tumor "take" resulting from the spillage or implantation of tumor cells from an ulcerated lesion is probably small, the previously described technique is simple and inexpensive and should be employed as a precautionary measure to further minimize this risk.

Concomitant ipsilateral intertrochanteric and subcapital fracture of the hip

A unique case of coexistent intertrochanteric and subcapital fractures of the hip is presented. A review of the literature found only one previous report of the simultaneous occurrence of these fractures. Closed reduction with in situ pinning was performed. Other treatment alternatives are reviewed and discussed.

Shyness and education: the relationship between shyness, social class and personality variables in adolescents

The study considers the relationship between shyness, some related personality variables and socio-economic status. Adolescent shyness levels are examined using two self-report questionnaires which cover the spectrum of inherent, emotional and situational shyness. These findings were correlated with individual levels of anxiety, neuroticism and also with socio-economic status. The educational implications of these results are discussed and the problem of the definition of shyness is addressed. The sample comprised 650 adolescents in the age range 11-18 years, drawn at random from two secondary schools, the number of boys being 300 and the number of girls 350. The results indicate that high levels of both situational and inherent shyness are related significantly to high levels of anxiety and neuroticism. Inherent shyness and situational shyness correlate only moderately with one another. Low levels of situational and inherent shyness are related positively and significantly to high levels of self-esteem and extraversion. Similar patterns of relationships occur for the other variables considered. The stability coefficients of correlations for each type of shyness were high after an interval of six months. Furthermore, shyness is related significantly to the socio-economic class of adolescents: a relatively higher percentage of shyness occurs among adolescents of lower socio-economic class.

Suppression of opiate withdrawal by cyclosporin A and dietary modification

It has been demonstrated in a murine model that a defined diet (Purina Basal Diet 5755) has immunosuppressive effects similar to cyclosporin A (CsA). It was also shown that CsA treatment in opiate dependent rats can attenuate the severity of opiate withdrawal. In this study, an opiate dependence model was established in Balb/c mice to assess the effects of the 5755 diet and CsA on morphine withdrawal - a CNS mediated phenomenon. Three groups of mice were used; a chow-fed control group (Purina 5008), a chow fed CsA treated group, and a group maintained on the 5755 diet. Morphine dependence was established by subcutaneous implantation of a 100 mg morphine base pellet under ether anesthesia. Seventy-two hours after pellet implantation, withdrawal was precipitated by a single injection of the opiate antagonist naloxone (2 mg/kg ip). Two indicators of withdrawal were assessed; jumping and diarrhea. The data demonstrated that both CsA and the 5755 diet resulted in significant attenuation of withdrawal symptoms with the 5755 diet being the most effective of the two. These findings suggest that immune modulation elicited by the 5755 diet and CsA treatment has a direct impact on the CNS opioid function.

Aldosterone and dexamethasone binding in human arterial smooth muscle cells

Regulation of blood pressure by direct action of corticosteroids on blood vessel walls was first hypothesized in 1952 [1]. The presence of receptors specific for these hormones within the peripheral vessel walls is a pre-requisite of this hypothesis. This report documents specific binding of both aldosterone (AL) and dexamethasone (DM) in cultured human arterial smooth muscle cells. After the arterial smooth muscle cultures were incubated with tritiated AL or DM at 37 degrees C for 30-60 min, the cells were sonicated and the protein bound steroid fraction isolated on a Sephadex G25 column. Using ion exchange chromatography of this fraction, each corticosteroid receptor complex displayed a distinct, reproducible elution pattern. Aldosterone showed a single peak at 0.096 +/- 0.005 mol/l sodium phosphate and DM had two peaks at 0.029 +/- 0.003 and 0.050 +/- 0.004 mol/l sodium phosphate. The Scatchard plots of specific binding from AL saturation curves are linear and revealed mean +/- s.d. steady state binding parameters of dissociation constant (Kd) = 0.35 +/- 0.15 nmol/l and maximum binding capacity (Bmax) = 98 +/- 53 X 10(-18) mol/micrograms DNA. Similarly, the mean +/- s.d. steady state binding parameters for DM are Kd = 4.4 +/- 2.0 nmol and Bmax = 3031 +/- 1385 X 10(-18) mol/micrograms DNA. Therefore, there are approximately 1150 AL binding sites and 30000 DM binding sites per cell. The Kd and Bmax values are similar to those previously described for corticoid receptors in rat aortic smooth muscle cells and are consistent with physiological steroid concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)

In vivo sensitivity test in otitis media: efficacy of antibiotics

During a 10-year period, antibiotics were assigned in random, double-blind fashion in six combinations to treat 948 episodes of otitis media in children. Exudate from the middle ear of all patients was cultured before treatment. Three follow-up visits were conducted; the first follow-up visit was three to five days after the start of therapy, and the second and third visits were 14 and 31 days after onset of treatment. Exudates were recultured for 75% of the patients on the first follow-up visit. Comparison of treatment results showed that triple sulfonamide combined with either phenoxymethyl penicillin, or benzathine and procaine penicillin G given intramuscularly (IM) was as effective as was ampicillin or amoxicillin. Phenoxymethyl penicillin and cyclacillin alone were usually effective against pneumococci but relatively ineffective against Haemophilus influenzae. Cefaclor and trimethoprim-sulfamethoxazole produced unsatisfactory results in about half the cases caused by pneumococci or H influenzae. Although production of beta-lactamase by some otitis-causing Haemophilus and Staphylococcus species may explain the ineffectiveness of some treatments, the percentage of organisms positive for beta-lactamase was too small to be responsible for the poor results with certain drugs.

Corynebacterium parvum versus BCG adjuvant immunotherapy in human malignant melanoma

One-hundred and sixteen patients with Stage I and Stage II malignant melanoma were randomized to treatment with either Bacillus Calmette-Guerin (BCG) (Tice) or subcutaneous Corynebacterium parvum (Burroughs-Wellcome). Life table analysis failed to reveal a difference between these two forms of treatment in 68 Stage I patients. The relapse rate was significantly reduced in Stage II patients treated with C. parvum.