29 Geriatric Emergency Medicine (GEM) Bootcamp and Bootcamp Bitesize Training

Introduction

In 2016 we ran a successful pilot of Geriatric Emergency Medicine (GEM) Bootcamp at Imperial College Healthcare Trust. This has developed into an annual regional conference which to date has been attended by over 440 delegates. This year we have been able to expand GEM Bootcamp to offer smaller ‘Bitesize Bootcamps’ with tailored learning for individual organisations, with more than 100 delegates already having accessed this resource.

Methods

In developing the curriculum for GEM Bootcamp and Bootcamp Bitesize we engaged a significant range of local healthcare providers. We undertook a learning needs analysis, which surveyed the target audience- specifically looking for self-reported gaps in knowledge- as well as analysing data from incidents, complaints and compliments. This allowed us to identify areas which there was opportunity for learning as well as ensuring a personalised curriculum

Results and conclusions

GEM Bootcamp feedback was overwhelmingly positive, with 100% of delegates stating they would recommend the day to colleagues. The relevance to practice was rated 4.4/5 with many positive comments about the opportunity to meet many interested people, generate conversations and raise awareness of frailty. The self-reported improvement of knowledge was from 2.95/5 pre-course to 3.89/5 post course.

To date we have delivered Bitesize Bootcamp to a local nursing care centre (which accounts for 50% of the admissions from care homes to the ICHT), London Ambulance Service (LAS), acute medicine and medicine for the elderly from a local trust, ICHT A&E nurses and Capital Nurse trainees. All bitesize training delegates self-reported an increase in their frailty knowledge. On average over the 5 bitesize sessions delegates reported an improvement from 3/5 pre-training to 4.1/5 post training. The development of links with local partners and the delivery of a consistent message about best practice in frailty have also been valuable outcomes

Optimising perioperative care for hip and knee arthroplasty in South Africa: a Delphi consensus study

Background

A structured approach to perioperative patient management based on an enhanced recovery pathway protocol facilitates early recovery and reduces morbidity in high income countries. However, in low- and middle-income countries (LMICs), the feasibility of implementing enhanced recovery pathways and its influence on patient outcomes is scarcely investigated. To inform similar practice in LMICs for total hip and knee arthroplasty, it is necessary to identify potential factors for inclusion in such a programme, appropriate for LMICs.

Methods

Applying a Delphi method, 33 stakeholders (13 arthroplasty surgeons, 12 anaesthetists and 8 physiotherapists) from 10 state hospitals representing 4 South African provinces identified and prioritised i) risk factors associated with poor outcomes, ii) perioperative interventions to improve outcomes and iii) patient and clinical outcomes necessary to benchmark practice for patients scheduled for primary elective unilateral total hip and knee arthroplasty.

Results

Thirty of the thirty-three stakeholders completed the 3 months Delphi study. The first round yielded i) 36 suggestions to preoperative risk factors, ii) 14 (preoperative), 18 (intraoperative) and 23 (postoperative) suggestions to best practices for perioperative interventions to improve outcomes and iii) 25 suggestions to important postsurgical outcomes. These items were prioritised by the group in the consecutive rounds and consensus was reached for the top ten priorities for each category.

Conclusion

The consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. It is anticipated that this study will provide the construct necessary for developing pragmatic enhanced care pathways aimed at improving patient outcomes after arthroplasty in LMICs.

Trauma-associated hyperfibrinolysis

Trauma-induced coagulopathy (TIC) has been considered for a long time as being due to depletion of coagulation factors secondary to blood loss, dilution and consumption. Dysfunction of the remaining coagulation factors due to hypothermia and acidosis is assumed to additionally contribute to TIC. Recent data suggest that hyperfibrinolysis (HF) represents an additional important confounder to the disturbed coagulation process. Severe shock and major tissue trauma are the main drivers of this HF. The incidence of HF is still speculative. According to visco-elastic testing of trauma patients upon emergency room admission, HF is present in approximately 2.5–7% of all trauma patients. However, visco-elastic tests provide information on severe forms of HF only. Occult HF seems to be much more common but diagnosis is still challenging. Results from a recent randomized, placebo-controlled trial suggest that the early treatment of trauma patients with tranexamic acid may result in a significant reduction of trauma-associated mortality.

Spatial and temporal analogies in microbial communities in natural drinking water biofilms

Biofilms are ubiquitous throughout drinking water distribution systems (DWDS), playing central roles in system performance and delivery of safe clean drinking water. However, little is known about how the interaction of abiotic and biotic factors influence the microbial communities of these biofilms in real systems. Results are presented here from a one-year study using in situ sampling devices installed in two operational systems supplied with different source waters. Independently of the characteristics of the incoming water and marked differences in hydraulic conditions between sites and over time, a core bacterial community was observed in all samples suggesting that internal factors (autogenic) are central in shaping biofilm formation and composition. From this it is apparent that future research and management strategies need to consider the specific microorganisms found to be able to colonise pipe surfaces and form biofilms, such that it might be possible to exclude these and hence protect the supply of safe clean drinking water.

A comparison of upper and lower body energetics during high-intensity exercise

AIM

The aim of the present study was to measure and compare the aerobic, anaerobic alactic and anaerobic lactic energy system contribution during the 30-sec Wingate anaerobic test (WAnT) for the upper and lower body within the same individuals.

METHODS

Physically active men (N.=14) completed two WAnTs on an electronic arm ergometer and a cycle ergometer separated by three days. A fly wheel braking force corresponding to 5% and 7.5% of the participants body weight was used for the upper and lower body WAnTs respectively. Oxygen uptake and blood lactate were measured before, during and after both WAnTs, and body composition was measured using dual-energy X-ray absorptiometry (DEXA).

RESULTS

The anaerobic lactic energy system contribution was significantly (P<0.01) higher during the upper body (60.3±5.6%) compared to the lower body (46.9±6.9%) WAnT. The contribution of the anaerobic alactic system was significantly higher (P<0.01) during the lower body (36.5±6.3%) compared to the upper body (28.3±4.9%) WAnT, with the aerobic system contribution significantly (P<0.05) higher for the lower body (16.8±2.5%) compared to the upper body (11.4±1.4%) WAnT.

CONCLUSION

The anaerobic lactic energy system provides over 60% of the energy requirements during an upper body WAnT but provides less the 50% during the lower body WAnT. In contrast, the aerobic and anaerobic alactic energy system contribution was significantly less for the upper body WAnT compared to the lower body WAnT.

Safety of fibrinogen concentrate: analysis of more than 27 years of pharmacovigilance data

Fibrinogen concentrate use as a haemostatic agent has been increasingly explored. This study evaluates spontaneous reports of potential adverse drug reactions (ADRs) that occurred during postmarketing pharmacovigilance of Haemocomplettan P/RiaSTAP, and reviews published safety data. This descriptive study analysed postmarketing safety reports recorded in the CSL Behring pharmacovigilance database from January 1986 to December 2013. A literature review of clinical studies published during the same period was performed. Commercial data indicated that 2,611,294 g of fibrinogen concentrate were distributed over the pharmacovigilance period, corresponding to 652,824 standard doses of 4 g each, across a range of clinical settings and indications. A total of 383 ADRs in 106 cases were reported (approximately 1 per 24,600 g or 6,200 standard doses). Events of special interest included possible hypersensitivity reactions in 20 cases (1 per 130,600 g or 32,600 doses), possible thromboembolic events in 28 cases (1 per 93,300 g or 23,300 doses), and suspected virus transmission in 21 cases (1 per 124,300 g or 31,000 doses). One virus transmission case could not be analysed due to insufficient data; for all other cases, a causal relationship was assessed as unlikely due to negative polymerase chain reaction tests and/or alternative explanations. The published literature revealed a similar safety profile. In conclusion, underreporting of ADRs is a known limitation of pharmacovigilance. However, the present assessment indicates that fibrinogen concentrate is administered across a range of indications, with few ADRs and a low thromboembolic event rate. Overall, fibrinogen concentrate showed a promising safety profile.

Theoretical modelling of fibrinogen supplementation with therapeutic plasma, cryoprecipitate, or fibrinogen concentrate

Background

We aimed to create a theoretical tool to model the effect of three haemostatic agents containing fibrinogen (therapeutic plasma, cryoprecipitate, and fibrinogen concentrate) on the patient's plasma fibrinogen level.

Methods

A mathematical model was developed step-wise. The relationship between the amount of haemostatic agent and plasma fibrinogen level was plotted for each agent. A fibrinogen concentration simulator (FCS_amount) was developed, where the amount of haemostatic agent was calculated from patient characteristics, agent characteristics, and target plasma fibrinogen level. Refinements were introduced so that (i) FCS_amount would account for in vivo fibrinogen recovery, (ii) circulatory volume would not increase ad infinitum with increasing amounts, and (iii) red blood cells would be included in the simulation if haematocrit decreased below a certain level. A second FCS (FCS_level) was created to calculate fibrinogen levels resulting from specified amounts of haemostatic agents.

Results

Fibrinogen concentration in haemostatic agents has a critical impact on their ability to increase patients' fibrinogen levels. If the target plasma fibrinogen level approaches the concentration of the fibrinogen source, the required amounts increase exponentially; it is impossible to achieve a target above the concentration of the fibrinogen source.

Conclusions

We successfully developed two theoretical tools answering the questions: ‘How much therapeutic plasma, cryoprecipitate, or fibrinogen concentrate would be needed to achieve a specified target fibrinogen level?’ and ‘What would be the resultant fibrinogen level for a specified amount of haemostatic agent?’ The current tools are not intended for clinical application, but they are potentially useful for educational purposes.

Time course of haemostatic effects of fibrinogen concentrate administration in aortic surgery

Background

There is currently a contrast between the demonstrated benefits of fibrinogen concentrate in correcting bleeding and reducing transfusion, and its perceived thrombogenic potential. This analysis evaluates the effects of fibrinogen concentrate on coagulation up to 12 days after administration during aortic surgery.

Methods

We performed a post hoc analysis of a prospective, randomized, double-blind, controlled trial of fibrinogen concentrate as first-line haemostatic therapy in aortic surgery. After cardiopulmonary bypass (CPB) and protamine administration, subjects with coagulopathic bleeding received fibrinogen concentrate or placebo. The placebo group received allogeneic blood products, including fresh-frozen plasma (FFP; n=32); the fibrinogen concentrate group received fibrinogen concentrate alone (FC; n=14), or fibrinogen concentrate followed by allogeneic blood products (FC+FFP; n=15). Plasma fibrinogen, fibrin-based clotting (ROTEM^®-based FIBTEM assay), and peri- and postoperative haematological and coagulation parameters were compared.

Results

Plasma fibrinogen and FIBTEM maximum clot firmness (MCF) decreased ∼50% during CPB but were corrected by FC or FC+FFP. At last suture, the highest values for plasma fibrinogen (360 mg dl⁻¹) and FIBTEM MCF (22 mm) were within normal ranges—below the acute phase increases observed after surgery. In patients receiving only FFP as a source of fibrinogen, these parameters recovered marginally by last suture (P<0.001 vs FC and FC+FFP). All groups displayed comparable haemostasis at 24 h post-surgery. Fibrinogen concentrate did not cause alterations of other haemostasis parameters.

Conclusions

Fibrinogen concentrate provided specific, significant, short-lived increases in plasma fibrinogen and fibrin-based clot firmness after aortic surgery.

Fast interpretation of thromboelastometry in non-cardiac surgery: reliability in patients with hypo-, normo-, and hypercoagulability

BACKGROUND

Conventional coagulation test are not useful to guide haemostatic therapy in severe bleeding due to their long turn-around time. In contrast, early variables assessed by point-of-care thromboelastometry (ROTEM(®)) are available within 10-20 min and increasingly used to guide haemostatic therapy in liver transplantation and severe trauma. However, the reliability of early ROTEM(®) variables to predict maximum clot firmness (MCF) in non-cardiac surgery patients with subnormal, normal, and supranormal MCF has not yet been evaluated.

METHODS

Retrospective data of 14,162 ROTEM(®) assays (3939 EXTEM(®), 3654 INTEM(®), 3287 FIBTEM(®), and 3282 APTEM(®) assays) of patients undergoing non-cardiac surgery were analysed. ROTEM(®) variables [clotting time (CT), clot formation time (CFT), α-angle, A5, A10, and A15] were related to MCF by linear or non-linear regression, as appropriate. The Bland-Altman analyses to assess the bias between early ROTEM(®) variables and MCF and receiver operating characteristics (ROC) were also performed.

RESULTS

Taking the best and worst correlation coefficients for each assay type, CT (r=0.18-0.49) showed the worst correlation to MCF. In contrast, α-angle (r=0.85-0.88) and CFT (r=0.89-0.92) demonstrated good but non-linear correlation with MCF. The best and linear correlations were found for A5 (r=0.93-0.95), A10 (r=0.96), and A15 (r=0.97-0.98). ROC analyses provided excellent area under the curve (AUC) values for A5, A10, and A15 (AUC=0.962-0.985).

CONCLUSIONS

Early values of clot firmness allow for fast and reliable prediction of ROTEM(®) MCF in non-cardiac patients with subnormal, normal, and supranormal MCF values and therefore can be used to guide haemostatic therapy in severe bleeding.

Haemostatic monitoring during postpartum haemorrhage and implications for management

Postpartum haemorrhage (PPH) is a major risk factor for maternal morbidity and mortality. PPH has numerous causative factors, which makes its occurrence and severity difficult to predict. Underlying haemostatic imbalances such as consumptive and dilutional coagulopathies may develop during PPH, and can exacerbate bleeding and lead to progression to severe PPH. Monitoring coagulation status in patients with PPH may be crucial for effective haemostatic management, goal-directed therapy, and improved outcomes. However, current PPH management guidelines do not account for the altered baseline coagulation status observed in pregnant patients, and the appropriate transfusion triggers to use in PPH are unknown, due to a lack of high-quality studies specific to this area. In this review, we consider the evidence for the use of standard laboratory-based coagulation tests and point-of-care viscoelastic coagulation monitoring in PPH. Many laboratory-based tests are unsuitable for emergency use due to their long turnaround times, so have limited value for the management of PPH. Emerging evidence suggests that viscoelastic monitoring, using thrombelastography- or thromboelastometry-based tests, may be useful for rapid assessment and for guiding haemostatic therapy during PPH. However, further studies are needed to define the ranges of reference values that should be considered ‘normal’ in this setting. Improving awareness of the correct application and interpretation of viscoelastic coagulation monitoring techniques may be critical in realizing their emergency diagnostic potential.

Hyperfibrinolysis is common in out-of-hospital cardiac arrest: results from a prospective observational thromboelastometry study

BACKGROUND

Cardiocirculatory arrest (CCA) activates procoagulant pathways. It has also been reported to inhibit fibrinolysis, resulting in fibrin deposition and further impairment of blood flow. Until now, no studies have used whole-blood viscoelastic tests to characterize coagulation and the impact of fibrinolysis in out-of-hospital cardiac arrest (OHCA).

METHODS

Patient with established OHCA who underwent cardiopulmonary resuscitation (CPR) were enrolled. Blood samples were obtained immediately after placement of an intravenous line at the scene, for full blood cell count, standard coagulation tests and rotational thromboelastometric (ROTEM(®)) analyses. Patients with return of spontaneous circulation (ROSC) were compared to non-ROSC patients.

RESULTS

Fifty-three patients (median age 67 years, interquartile range: 56-73 years) were included in the study. ROSC was established in 25 patients. Prothrombin time index (PTI) was significantly lower and activated partial thromboplastin time (aPTT) was significantly prolonged in non-ROSC patients compared to ROSC patients. Clotting time (CT) in the extrinsically activated ROTEM test (EXTEM) was significantly longer in non-ROSC versus ROSC patients. For the remaining EXTEM parameters, there were no significant differences between ROSC and non-ROSC patients. Hyperfibrinolysis (maximum lysis>15% according to ROTEM test results) was observed in 19 patients (35.8%). There was no difference between ROSC and non-ROSC patients in the incidence of hyperfibrinolysis.

CONCLUSIONS

PTI, aPTT and EXTEM CT revealed significant differences between ROSC and non-ROSC patients. Hyperfibrinolysis according to ROTEM test results was much more common than previously assumed. Routine use of fibrinolytic therapy in all patients with prolonged CPR cannot therefore be recommended.

Recovery of fibrinogen after administration of fibrinogen concentrate to patients with severe bleeding after cardiopulmonary bypass surgery

BACKGROUND

Normalization of plasma fibrinogen levels may be associated with satisfactory haemostasis and reduced bleeding. The aim of this retrospective study was to assess fibrinogen recovery parameters after administration of fibrinogen concentrate (Haemocomplettan P) to patients with diffuse bleeding in cardiovascular surgery. Data on transfusion and patient outcomes were also collected.

METHODS

Patient characteristic and clinical data were obtained from patient records.

RESULTS

of the thromboelastometry (FIBTEM)and of the standard coagulation tests, including plasma fibrinogen level, measured before surgery, before and after haemostatic therapy, and on the following day, were retrieved from laboratory records. Results Thirty-nine patients receiving fibrinogen concentrate for diffuse bleeding requiring haemostatic therapy after cardiopulmonary bypass were identified. The mean fibrinogen concentrate dose administered was 6.5 g. The mean fibrinogen level increased from 1.9 to 3.6 g litre(-1) (mean increment of 0.28 g litre(-1) per gram of concentrate administered); maximum clot firmness increased from 10 to 21 mm. The mean fibrinogen increase was 2.29 (sd 0.7) mg dl(-1) per mg kg(-1) bodyweight of concentrate administered. Thirty-five patients received no transfusion of fresh-frozen plasma (FFP) or platelet concentrate after receiving fibrinogen concentrate; the remaining four patients received platelet concentrate intraoperatively. Eleven patients received platelets, FFP, or both during the first postoperative day. No venous thromboses, arterial ischaemic events, or deaths were registered during hospitalization.

CONCLUSIONS

In this retrospective study, fibrinogen concentrate was effective in increasing plasma fibrinogen level, and contributed to the correction of bleeding after cardiovascular surgery.

Bleeding management with fibrinogen concentrate targeting a high-normal plasma fibrinogen level: a pilot study

BACKGROUND

Bleeding diathesis after aortic valve operation and ascending aorta replacement (AV-AA) is managed with fresh-frozen plasma (FFP) and platelet concentrates. The aim was to compare haemostatic effects of conventional transfusion management and FIBTEM (thromboelastometry test)-guided fibrinogen concentrate administration.

METHODS

A blood products transfusion algorithm was developed using retrospective data from 42 elective patients (Group A). Two units of platelet concentrate were transfused after cardiopulmonary bypass, followed by 4 u of FFP if bleeding persisted, if platelet count was < or =100 x 10(3) microl(-1) when removing the aortic clamp, and vice versa if platelet count was >100 x 10(3) microl(-1). The trigger for each therapy step was > or =60 g blood absorbed from the mediastinal wound area by dry swabs in 5 min. Assignment to two prospective groups was neither randomized nor blinded; Group B (n=5) was treated according to the algorithm, Group C (n=10) received fibrinogen concentrate (Haemocomplettan P/Riastap, CSL Behring, Marburg, Germany) before the algorithm-based therapy.

RESULTS

A mean of 5.7 (0.7) g fibrinogen concentrate decreased blood loss to below the transfusion trigger level in all Group C patients. Group C had reduced transfusion [mean 0.7 (range 0-4) u vs 8.5 (5.3) in Group A and 8.2 (2.3) in Group B] and reduced postoperative bleeding [366 (199) ml vs 793 (560) in Group A and 716 (219) in Group B].

CONCLUSIONS

In this pilot study, FIBTEM-guided fibrinogen concentrate administration was associated with reduced transfusion requirements and 24 h postoperative bleeding in patients undergoing AV-AA.

Platelet concentrates transfusion in cardiac surgery and platelet function assessment by multiple electrode aggregometry

BACKGROUND

Platelet dysfunction contributes to the pathophysiology of bleeding complications during and after cardiac surgery. In most surgical institutions, no peri-operative point-of-care monitoring of platelet function is used. We evaluated the usefulness of the Multiplate platelet function analyser based on impedance aggregometry for identifying groups of patients at a high risk of transfusion of platelet concentrates (PC).

METHODS

Platelet function parameters were determined in 60 patients before and after routine cardiac surgery. Impedance aggregometry measurements were performed on Multiplate using ADP (ADPtest), collagen (COLtest) and thrombin receptor activating peptide (TRAPtest) as platelet activators. The correlations between the aggregometry results and the transfusion of PC were calculated. The results of the aggregation tests were also divided into tertiles and the differences in PC transfusion between the low and the high tertile were assessed.

RESULTS

Low aggregometry delimited groups of patients with significantly higher PC transfusion. In the receiver operating characteristic curve, low pre-operative aggregation in the ADPtest identified patients with high total transfusion of PC (area under the curve 0.74, P=0.001), while the ADPtest performed at the end of the operation identified patients with high PC transfusion on the intensive care unit (ICU) (area under the curve 0.76, P=0.002).

CONCLUSIONS

Near-patient platelet aggregation may allow the identification of patients with enhanced risk of PC transfusion, both pre-operatively and upon arrival on the ICU.

Accidental injuries in agriculture in the UK

The rate of occupational accidents in British agriculture is higher than in most other industries. The most common fatal accidents are those involving vehicles and machinery, falls from a height and electrocution. A substantial proportion of reported non-fatal injuries in agricultural employees is attributable to manual handling, but among self-employed farmers the contribution is much smaller. Few data are available on longer-term determinants of risk, but accidental deaths are most frequent in July, August and September. The main approaches to preventing agricultural accidents are through engineering improvements, and education and training of the workforce. The introduction of roll-over protection structures for tractors has been an important development in recent decades. Other engineering controls include guards for power take off shafts, guard rails to prevent falls, better handling facilities for animals and closed transfer systems for pesticides. Training on safety is available from several sources, but its effectiveness in reducing accidents is uncertain.

Interleukin-13 induces dramatically different transcriptional programs in three human airway cell types

Interleukin (IL)-13, a cytokine released by T lymphocytes during immediate hypersensitivity responses, is a central mediator of asthma. Because IL-13 induces phenotypic features of asthma in mice deficient in T and B lymphocytes, it is likely that this cytokine contributes to the development of asthma by acting directly on resident airway cells. To analyze the global effects of IL-13 on gene expression in airway cells that could contribute to the phenotypic features of asthma, we used Genechip HuGene FL arrays (Affymetrix, Santa Clara, CA) that contain probes for approximately 6,500 human genes. Despite activating a common signaling pathway, IL-13 induced dramatically different patterns of gene expression in primary cultures of airway epithelial cells, airway smooth muscle cells, and lung fibroblasts, with little overlap among cell types. The most prominent effects of IL-13 were on airway smooth muscle, but several genes induced in airway epithelial cells and fibroblasts are also candidates that may contribute to phenotypic features of asthma. These results suggest that the in vivo response to IL-13 in the airways likely results from a combination of distinct effects on each of several resident airway cell types.

Melanoma risk in relation to height, weight, and exercise (United States)

Height and weight and derivations thereof are positively associated with a number of cancers. While several authors have reported an increased risk of melanoma among people at the higher extremes of these measures, the association has not been fully explored. New cases of primary cutaneous melanoma in 1997 in western Washington State (n = 386) were compared to controls selected by random-digit dialing (n = 727). Each study participant completed a telephone survey, and data were collected on height, weight, sun-related melanoma risk factors, demographic characteristics, as well as habits such as diet and exercise. Risk of melanoma was analyzed by logistic regression with adjustment for age, hair color, lifetime sun exposure, and fruit and vegetable intake. An excess risk of melanoma was identified in men in the upper quartiles of height (OR = 2.4, 95% confidence interval (CI) = 1.3-4.5), weight (OR = 2.8, CI = 1.5-5.2), and body surface area (OR = 2.8, CI = 1.5-5.1) vs. the lowest quartiles. In women, no association was present for any anthropometric measure. In addition, we found that men and women exercising five to seven days per week were at a decreased risk of melanoma (OR = 0.7, CI = 0.5-1.0). The anthropometric findings are largely consistent with previous studies, while this is the first report of an association of exercise with melanoma risk. The mechanisms for the effect of exercise and for the difference between men and women in the effect of anthropometric factors are unknown. Future research in basic and epidemiologic science should focus on biochemical or behavioral explanations for these observations.

Physical activity and risk for cardiovascular events in diabetic women

BACKGROUND

Increased physical activity has been associated with reduced risk for cardiovascular disease in the general population, but data are limited on its role among persons with type 2 diabetes mellitus.

OBJECTIVE

To determine whether physical activity decreases risk for cardiovascular disease among diabetic women.

DESIGN

Prospective cohort study.

SETTING

The Nurses' Health Study.

PATIENTS

5125 female nurses with diabetes.

MEASUREMENTS

Physical activity was first assessed in 1980 and was updated in 1982, 1986, 1988, and 1992 through validated questionnaires. Average hours of moderate or vigorous exercise and a metabolic equivalent of task (MET) score were computed.

RESULTS

During 14 years of follow-up (31 432 person-years), 323 new cases of cardiovascular disease were documented (225 cases of coronary heart disease and 98 cases of stroke). The age-adjusted relative risks according to average hours of moderate or vigorous activity per week (<1, 1 to 1.9, 2 to 3.9, 4 to 6.9, >/=7) were 1.0, 0.93 (95% CI, 0.69 to 1.26), 0.82 (CI, 0.61 to 1.10), 0.54 (CI, 0.39 to 0.76), and 0.52 (CI, 0.25 to 1.09) (P < 0.001 for trend). These figures did not change materially after adjustment for smoking, body mass index, and other cardiovascular risk factors (1.0, 1.02, 0.87, 0.61, and 0.55, respectively; P = 0.001 for trend). In separate analyses, levels of physical activity were inversely associated with coronary heart disease and ischemic stroke. Among women who did not exercise vigorously, the multivariate relative risks for cardiovascular disease across quartiles of MET score for walking were 1.0, 0.85, 0.63, and 0.56 (P = 0.03 for trend). Faster usual walking pace was independently associated with lower risk.

CONCLUSION

Among diabetic women, increased physical activity, including regular walking, is associated with substantially reduced risk for cardiovascular events.

The unique tryptophan residue of the vitamin D receptor is critical for ligand binding and transcriptional activation

The human vitamin D receptor (hVDR) is a member of the nuclear receptor superfamily of transcriptional regulators. Here we show that tryptophan 286 of the hVDR is critical for ligand binding and transactivation of 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] target genes. Two mutants of the hVDR were produced, W286A and W286F, in which the tryptophan was replaced with an alanine or a phenylalanine, respectively. The W286A mutant did not bind 1,25(OH)2D3, interact with steroid receptor coactivator 1 (SRC-1) in vitro, or activate transcription. Moreover, the W286A receptor did not heterodimerize in a ligand-dependent manner with the human retinoid X receptor alpha (hRXRalpha). Although the W286F receptor heterodimerized with hRXRalpha, interacted with SRC-1, and bound 1,25(OH)2D3, its capacity to transactivate was attenuated severely. Thus, tryptophan 286 of hVDR plays an important role in specific 1,25(OH)2D3 ligand interaction and subsequently in hVDR/RXR interaction, SRC-1 binding, and ligand-dependent transactivation of 1,25(OH)2D3 target genes. These results identify the first amino acid that is absolutely required for ligand binding in the VDR and further define the structure-function relationship of 1,25(OH)2D3 interaction with its receptor.

Vitamin D resistance in RAS-transformed keratinocytes: mechanism and reversal strategies

Human retinoid X receptor alpha (hRXRalpha) plays a critical role in DNA binding and transcriptional activity through its heterodimeric association with several members of the nuclear receptor superfamily, including the vitamin D receptor (VDR). Several cancer cell lines derived from different tissues have been shown to be resistant to the growth-inhibitory action of 1,25-dihydroxyvitamin D(3) [1,25(OH)(2)D(3)], the biologically active metabolite of vitamin D(3). Here we show that in RAS-transformed keratinocytes, Ser260 of hRXRalpha is phosphorylated through the RAS-RAF-MAP kinase cascade. This phosphorylation event results in the inhibition of vitamin D signaling via VDR/hRXRalpha heterodimers. Strategies to reverse this resistance include the use of the MAP kinase inhibitor, PD098059, and a non-phosphorylatable hRXRalpha mutant, Ala260, which completely abolishes RXR phosphorylation and restores the function of both 1,25(OH)(2)D(3) and a specific RXR ligand, LG1069 (4-[1-(5,6,7,8-tetrahydro-3,5,5,8,8-pentamethyl-2-naphtalenyl)ethenyl]-benzoic acid). In addition, we show that a vitamin D analog with low calcemic activity (EB1089) is more potent than 1,25(OH)(2)D(3) in inhibiting cancer cell growth in this system. Targeted therapy with selective analogs such as EB1089, in combination with the inhibition of phosphorylation of the RXR, could play a critical role in the development of strategies for cancer treatment.

Variation in the quality of lumbar spine MR images in Washington State

PURPOSE

To investigate the variation in quality of lumbar spine magnetic resonance (MR) images as a function of type of ownership of the imaging center, number of studies performed per month, specialty training of the image interpreter, and field strength of the MR unit.

MATERIALS AND METHODS

Data were collected from all imaging facilities in western Washington state that received reimbursement from the Washington State Health Care Authority. Three readers with expertise in spine imaging, who were blinded to center and patient identification information, rated the technical image quality of each study. All MR images of the lumbar spine (maximum of six) paid for by the health care authority were evaluated. If a center had performed more than six studies, then six were randomly selected for evaluation.

RESULTS

Variation in quality scores among sites was significant (P =.001). Field strength was the strongest predictor of better quality. Poorer quality was associated with for-profit ownership, a larger number of radiologists at the site reading MR images, and a larger percentage of studies checked by a radiologist prior to the end of the examination.

CONCLUSION

There was significant variation in the quality of MR images of the lumbar spine, and at least a portion of this variation was attributable to characteristics of the imaging center.

Effects of azithromycin on ozone-induced airway neutrophilia and cytokine release

Exposure of humans to ozone causes increased neutrophils and inflammatory cytokines in airway lining fluid. Recent research shows that macrolide antibiotics may reduce interleukin (IL)-8 production by bronchial epithelial cells and inhibit neutrophil chemotaxis. A double-blind, cross-over study was performed in which 12 healthy subjects underwent two separate 4-h exposures to 0.2 parts per million ozone while exercising intermittently. In the 73.5 h before exposure, subjects were pretreated with either 1,250 mg azithromycin or placebo. Sputum induction conducted 74 h pre- and 18 h post-exposure was used to measure total cells, per cent neutrophils, IL-6, and IL-8. There were significant (p<0.05) pre- to post-exposure increases in total cells, neutrophils, IL-6 and IL-8 in both the azithromycin and placebo arms. However, no significant differences were found between azithromycin and placebo conditions in the post- minus pre-exposure value for these variables. The results suggest that in healthy subjects, in the design used, azithromycin, in usual clinical doses, does not have anti-inflammatory effects on human airways as indicated in the measured variables.

Effect of serial-day exposure to nitrogen dioxide on airway and blood leukocytes and lymphocyte subsets

Nitrogen dioxide (NO2) is a free radical-producing oxidant gas. Inhalation of NO2 could cause airway inflammation, and decrease immune function. This experiment tested the hypothesis that exposure to NO2 would: 1) increase leukocytes in bronchoalveolar lavage (BAL); and 2) change the distribution of lymphocyte subsets and activation in BAL and peripheral blood (PB). Using a counter-balanced, repeated-measures design, 15 healthy volunteers were exposed to filtered air (FA) or 2.0 parts per million NO2 for 4 h x day(-1) (4 x 30 min of exercise), for three consecutive days. Bronchoscopy was performed 18 h following each exposure set, and PB was drawn pre-exposure and pre-bronchoscopy. Flow cytometry was used to enumerate lymphocyte subsets and activation makers in BAL and PB. In the bronchial fraction, there was an increase in the percentage of neutrophils following NO2 exposure compared to FA (median (interquartile range): 10.6 (4.8-17.2)% versus 5.3 (2.5-8.3)%; p=0.005). In the BAL, there was a decrease in the percentage of T-helper cells following NO2 exposure compared to FA (55.9 (40.8-62.7)% versus 61.6 (52.6-65.2)%; p=0.022). For PB, there were no between-condition differences in any leukocyte or lymphocyte subsets, or activation. In conclusion exposure to nitrogen dioxide results in bronchial inflammation and a minimal change in bronchoalveolar lavage T-helper cells, and no changes in peripheral blood cells.

Opportunities for pregnant and parenting teenagers: a school-based and school-linked intervention program

Three hundred and ninety (390) pregnant and parenting teens participated in a school-based and school-linked federally funded program at 10 high-risk schools. The program was designed to (1) increase the use of referred services and attendance at these services without students' missing school, (2) increase academic skills, and (3) increase health and well-being of the students and their infants. The program provided 18 services coordinated at the school or provided on site. The end-of-year evaluations indicated 88% to 95% of teens attended services that were recommended, and 69% did not miss school to receive these services. The teens' rate of passing their grade level increased at the end of the program year. Additionally, 78% used birth control, and over 90% of the infants received timely health care. The qualitative data provided by students indicated pregnant and parenting teens wanted to remain in school despite the struggles they encountered. The process evaluation provided by the coordinators at each school indicated that communication and cooperation between program staff and school nurses were the key elements in enabling teens to receive the targeted services.

Venous morphology predicts class of chronic venous insufficiency

OBJECTIVES

this study aimed to determine specific morphological differences in long saphenous veins from patients with various grades of chronic venous insufficiency.

DESIGN

comparable veins from a control group were compared with patients with either primary varicose veins or those with associated skin changes including venous ulcers.

MATERIALS

below-knee segments of saphenous vein were examined from a total of 64 patients.

METHODS

veins were examined for elastic-tissue disruption and endothelial-cell changes and comparisons made between clinical groups.

RESULTS

elastic-tissue disruption, as measured by fragmentation of the elastic lamina and the percentage of the intimal-medial boundary containing elastin, increased with increasing severity of venous disease. Moreover, endothelial cells became more densely packed, as measured by endothelial cell and endothelial-cell nuclei density, with increasing severity of disease. Other measures such as the density of multinucleated "giant" endothelial cells and the number of nuclei per "giant" cell did not correlate with venous disease, however.

CONCLUSIONS

this study demonstrates that several morphological characteristics of superficial saphenous veins correlate with severity of venous disease. In particular, the alterations to the structure of elastic tissue within these veins appears indicative of the progressive nature of chronic venous insufficiency.

Mitogen-activated protein kinase inhibits 1,25-dihydroxyvitamin D3-dependent signal transduction by phosphorylating human retinoid X receptor alpha

Human retinoid X receptor alpha (hRXR alpha) is a member of the nuclear receptor family of transcriptional regulators. It regulates transcription through its association with several heterodimeric partners, including the vitamin D3 receptor (VDR). Signaling through the VDR is essential for normal calcium homeostasis and has been shown to inhibit the proliferation of cancer cells derived from a number of tissues. Here we show that phosphorylation of hRXR alpha in ras-transformed human keratinocytes through the activated Ras-Raf-mitogen-activated protein kinase (Ras-Raf-MAP kinase) pathway results in attenuated transactivation by the VDR and resistance to the growth inhibitory action of 1,25 dihydroxyvitamin D3 [1,25(OH)2D3] and RXR-specific agonist LG1069 (4-[1-(5,6,7, 8-tetrahydro-3,5,5,8,8-pentamethyl-2-naphthalenyl) ethenyl]-benzoic acid). Phosphorylation of hRXR alpha occurs at serine 260, a consensus MAP kinase site. Inhibition of MAP kinase activity or point mutagenesis of serine 260 of hRXR alpha reverses the observed resistance to 1,25(OH)2D3 and LG1069. Thus, hRXR alpha is a downstream target of MAP kinase, and its phosphorylation may play an important role in malignant transformation.

Recurrent varicose veins: patterns of reflux and clinical severity

Duplex scanning was used to determine patterns of recurrent varicose veins in 264 limbs and to relate these to clinical factors. All limbs had previously undergone sapheno-femoral ligation in the groin. A recurrent sapheno-femoral junction was present in 172 (65.2%). Incompetence was found in long or short saphenous veins in 232 limbs (87.9%), perforators in 176 (66.7%), and deep veins in 156 (59.1%). Residual long saphenous veins were present in 43.4% and 73.6% of limbs that were with and without stripped long saphenous veins, respectively. An incompetent thigh perforator was present in 14.0% and 15.3% of these two groups, respectively. Multiple sites of incompetence were observed in the majority (75.4%). In general, no particular reflux pattern in the groin was related to an increased incidence of ulceration. However, ulceration was more frequent in limbs with deep reflux to knee or below-knee levels. None of those with isolated reflux in the groin that was unrelated to the common femoral vein had ulceration. The pattern of reflux was unrelated to striping or non-striping of the long saphenous veins and the time since initial surgery. A history of deep vein thrombosis was invariably associated with some degree of deep reflux. A system of recurrent patterns in the groin is described for the purpose of surgical audit. In 15.1%, recurrence was attributed with some confidence to inadequate surgery. These results indicate that the pattern of recurrence is highly variable and often with multiple sites of incompetence. In a few instances, the pattern of recurrence was associated with specific clinical factors. A full work-up including duplex scanning is recommended.

Tamoxifen and risk of large bowel cancer in women with breast cancer

BACKGROUND

The increasingly consistent association between estrogen replacement therapy and colorectal cancer suggests that the anti-estrogen tamoxifen may also be associated with large bowel cancer incidence.

METHODS

Women with new diagnoses of breast cancer were identified from the Surveillance Epidemiology and End Results (SEER) Program, a set of geographically defined, population based cancer registries representing approximately ten percent of the U.S. population. Of 85,411 women with local or regional breast cancer diagnosed from 1983-90, 14,984 women were reported to have received hormonal therapy and 70,427 were not known to have received hormonal therapy. Subsequent cancer diagnoses were identified in this cohort beginning 6 months after initial breast cancer diagnosis until death, or December 31, 1994. Multivariate Cox proportional hazards models were used to estimate the risk of developing colorectal cancer and other second cancers according to hormonal therapy use.

RESULTS

Over the follow-up period 793 colorectal, 2,648 contralateral breast, 506 endometrial, 250 ovarian, 98 gastric, and 1,765 other cancers were identified in the study cohort. While overall there was no association between hormonal therapy use and colorectal cancer (relative risk (RR) 1.09, 95% confidence interval (CI) 0.88-1.35), in the period five or more years after diagnosis, risk was increased significantly by about 50% (95% CI 1.00-2.15). As expected, based upon clinical trials data, cancers of the contralateral breast were significantly decreased, and cancers of the uterine endometrium were significantly increased. No other meaningful associations were observed. When women were excluded for whom hormonal therapy might represent therapy other than tamoxifen (premenopausal women and those who received chemotherapy), this did not meaningfully alter these estimates.

CONCLUSIONS

The results of this large population based cohort study suggest that tamoxifen therapy may modestly increase risk of large bowel cancer in women, but only after 5 years following initiation of breast cancer therapy.

Disruption of vitamin D receptor-retinoid X receptor heterodimer formation following ras transformation of human keratinocytes

A partial resistance to the growth inhibitory influence of 1, 25-dihydroxyvitamin D3 is apparent when immortalized keratinocytes are transformed by the ras oncogene. The vitamin D receptor (VDR) was isolated, analyzed, and found to be identical in normal, immortalized, and ras-transformed keratinocytes. Subsequently, nuclear extracts from immortalized and ras-transformed keratinocytes were analyzed in gel mobility shift assays utilizing labeled vitamin D response elements or thyroid hormone response elements. A specific protein.DNA complex that was shown to contain VDR using an anti-VDR antibody was identified in both types of extracts; however, the addition of an anti-retinoid X receptor (RXR) antibody identified RXR in the complex of both normal and immortalized keratinocyte cell extracts, but not in ras-transformed keratinocytes. Furthermore, transfection of ras-transformed keratinocytes with wild-type human RXRalpha rescued VDR.RXR and thyroid hormone receptor.RXR complexes as demonstrated by a supershift in the presence of the anti-RXR antibody. Both cell lines were found to express RXRalpha message in equal amounts. Western blot analysis revealed that RXRalpha protein from ras-transformed keratinocytes was indistinguishable from that from immortalized keratinocytes and from control cells. These results suggest a causal relationship between resistance to the growth inhibitory influences of 1,25-dihydroxyvitamin D3 and disruption of the VDR.RXR complex in malignant keratinocytes.

Video image analysis of hands: development of an 'anatomic index' as a potential outcome measure in rheumatoid arthritis

In this study, we used video image analysis for the measurement of hand dimensions to reflect destructive changes in rheumatoid arthritis. Thirteen dimensions were measured from anteroposterior and lateral views of the hands, open and closed. Comparison of measurements in 19 patients and 19 control subjects showed significant differences for nine of the 13 measurements. Five were reproducible on retesting in a subset of patients and normals. Two were eliminated because they were similar to other measurements. The three remaining measurements selected for differentiation of patients and normals, and reproducibility, were combined in an arbitrary 'anatomic index'. This enhanced separation of normals and patients with rheumatoid arthritis. The results demonstrate that measurement of certain hand dimensions and their combination in an 'anatomic index' could provide a measure reflecting the progressive anatomical abnormality caused by rheumatoid arthritis. Validation of this concept could provide a further outcome measure in patients with rheumatoid arthritis.

Endothelin-1 is increased overlying atherosclerotic plaques in human arteries

The distribution of Endothelin-1 (ET-1), a potent vasoactive peptide, within endothelium of human atherosclerotic arteries was examined using a novel en face immunohistochemical technique. The vast majority of endothelial cells were immunoreactive for ET-1. Staining intensity was increased in areas overlying atherosclerotic plaques, calcified media, fatty streaks and about flow dividers, compared with adjacent regions. Multinucleated 'giant' endothelial cells were more common in regions containing strong ET-1 staining than elsewhere. Clusters of leucocytes (probably monocytes) were frequently observed adhering to the endothelial monolayer but not neighbouring regions of denudation. Occasionally underlying macrophage/foam cells and smooth muscle cells were exposed to the surface and included in the en face (Häutchen) preparation. Smooth muscle cells did not stain for ET-1 while macrophages and the larger foam cells were positive for ET-1. These results support the hypothesis that expression of ET-1, at sites containing atheromatous disease, may be involved in the development of atherosclerosis.