Heterotopia in Individuals with 22q11.2 Deletion Syndrome

BACKGROUND AND PURPOSE

MR imaging studies and neuropathologic findings in individuals with 22q11.2 deletion syndrome show anomalous early brain development. We aimed to retrospectively evaluate cerebral abnormalities, focusing on gray matter heterotopia, and to correlate these with subjects' neuropsychiatric impairments.

MATERIALS AND METHODS

Three raters assessed gray matter heterotopia and other morphologic brain abnormalities on 3D T1WI and T2*WI in 75 individuals with 22q11.2 deletion syndrome (27 females, 15.5 [SD, 7.4] years of age) and 53 controls (24 females, 12.6 [SD, 4.7] years of age). We examined the association among the groups' most frequent morphologic findings, general cognitive performance, and comorbid neuropsychiatric conditions.

RESULTS

Heterotopia in the white matter were the most frequent finding in individuals with 22q11.2 deletion syndrome (n = 29; controls, n = 0; between-group difference, P < .001), followed by cavum septi pellucidi and/or vergae (n = 20; controls, n = 0; P < .001), periventricular cysts (n = 10; controls, n = 0; P = .007), periventricular nodular heterotopia (n = 10; controls, n = 0; P = .007), and polymicrogyria (n = 3; controls, n = 0; P = .3). However, individuals with these morphologic brain abnormalities did not differ significantly from those without them in terms of general cognitive functioning and psychiatric comorbidities.

CONCLUSIONS

Taken together, our findings, periventricular nodular heterotopia or heterotopia in the white matter (possibly related to interrupted Arc cells migration), persistent cavum septi pellucidi and/or vergae, and formation of periventricular cysts, give clues to the brain development disorder induced by the 22q11.2 deletion syndrome. There was no evidence that these morphologic findings were associated with differences in psychiatric or cognitive presentation of the 22q11.2 deletion syndrome.

Health care utilization and excess costs after pelvic fractures among older people in Germany

Our study demonstrates a strong increase in utilization of inpatient health care and clear excess costs in older people in the first year after pelvic fracture, the latter even after adjustment for several confounders. Excess costs were particularly high in the first few months and mainly attributable to inpatient treatment.

INTRODUCTION

We aimed to estimate health care utilization and excess costs in patients aged minimum 60 years up to 1 year after pelvic fracture compared to a population without pelvic fracture.

METHODS

In this retrospective population-based observational study, we used routine data from a large statutory health insurance (SHI) in Germany. Patients with a first pelvic fracture between 2008 and 2010 (n=5685, 82% female, mean age 80±9 years) were frequency matched with controls (n=193,159) by sex, age at index date, and index month. We estimated health care utilization and mean total direct costs (SHI perspective) with 95% confidence intervals (CIs) using BCA bootstrap procedures for 52 weeks before and after the index date. We calculated cost ratios (CRs) in 4-week intervals after the index date by fitting mixed two-part models including adjustment for possible confounders and repeated measurement. All analyses were further stratified for men/women, in-/outpatient-treated, and major/minor pelvic fractures.

RESULTS

Health care utilization and mean costs in the year after the index date were higher for cases than for controls, with inpatient treatment being particularly pronounced. CRs (95% CIs) decreased from 10.7 (10.2-11.1) within the first 4 weeks to 1.3 (1.2-1.4) within week 49-52. Excess costs were higher for inpatient than for outpatient-treated persons (CRs of 13.4 (12.9-13.9) and 2.3 (2.0-2.6) in week 1-4). In the first few months, high excess costs were detected for both persons with major and minor pelvic fracture.

CONCLUSION

Pelvic fractures come along with high excess costs and should be considered when planning and allocating health care resources.

Two redundant octanoyltransferases and one obligatory lipoyl synthase provide protein-lipoylation autonomy to plastids of Arabidopsis

Octanoyltransferases (LIP2) are important for the lipoylation of several α-ketoacid decarboxylases and glycine decarboxylase, all of which are essential multienzyme complexes of central metabolism, by attaching de novo-synthesised octanoyl moieties to the respective target subunits. Lipoyl synthase (LIP1) then inserts two sulphur atoms each into the protein-bound octanoyl chains to generate the functional lipoamide arms. In plants, most of the above multienzyme complexes occur only in mitochondria. Pyruvate dehydrogenase is an exception, since it also occurs in plastids. Plastidial LIP1 and LIP2 are known, but it is not clear how essential these enzymes are. Here, we report that not just one but two redundant LIP2 isoforms, LIP2p and LIP2p2, operate in plastids of Arabidopsis. The combined deletion of the two isoenzymes is embryo-lethal. Deletion of the plastidial lipoyl synthase LIP1p is also embryo-lethal, indicating that all plastidial LIP1 activity is due to LIP1p. These features suggest that protein lipoylation is based on an autonomous and partially redundant de novo lipoylation pathway in plastids.

[On the prognosis of hip fractures. Assessment of mortality after hip fractures by analyzing overlapping segments of longitudinal data]

BACKGROUND

Data on the treatment of hip fractures in acute care settings have been collected in a report card system for quality assurance in Germany since the beginning of the 1990s. However, there are no data on the long-term outcome and long-term quality of care.

MATERIAL AND METHOD

In a retrospective study, data on 1393 patients from 1999 were collected from different sources: from the department of quality assurance at the medical association of Westfalia-Lippe, the Statutory Health Insurance Funds (AOK), and the Medical Review Board of the Statutory Health Insurance Funds (Medizinischer Dienst der Krankenkasse, MDK). Statistical analyses were performed by the Center for Clinical Studies of the University of Düsseldorf.

RESULTS

Uni- and multivariate analyses reveal the following prognostic parameters for survival after hip fracture: sex, age, nursing care dependency, living in a nursing home, risk stratification according to ASA, and postoperative complications. Timing of the operation had no affect on survival.

CONCLUSIONS

Prognostic factors for the outcome after hip fracture can only be obtained by analyzing data from the hospital stay and the post-hospital setting as well. Chances of survival can be significantly improved by rehabilitative care.

Antimicrobial use in long-term-care facilities

There is intense antimicrobial use in long-term-care facilities (LTCF), and studies repeatedly document that much of this use is inappropriate. The current crisis in antimicrobial resistance, which encompasses the LTCF, heightens concerns of antimicrobial use. Attempts to improve antimicrobial use in the LTCF are complicated by characteristics of the patient population, limited availability of diagnostic tests, and virtual absence of relevant clinical trials. This article recommends approaches to management of common LTCF infections and proposes minimal standards for an antimicrobial review program. In developing these recommendations, the article acknowledges the unique aspects of provision of care in the LTCF.

Short-term water stress leads to a stimulation of sucrose synthesis by activating sucrose-phosphate synthase

The aim of this work was to identify which aspects of photosynthetic metabolism respond most sensitively to leaf water deficit. Spinach (Spinacia oleracea L.) leaf discs were floated on sorbitol concentrations of increasing molarity and changes of the protoplast volume were estimated using [(14)C]sorbitol and (3)H2O penetration. Detached leaves were also wilted until 10% of their fresh weight was lost. Photosynthesis was studied at very high external CO2 concentrations, to eliminate the effect of closing stomata. There was no large inhibition of CO2 fixation after wilting leaves, or until the external water deficit was greater than-1.2 MPa. However, partitioning changed markedly at these moderate water deficits: more sucrose and less starch was made. When an inhibition of CO2-saturated photosynthesis did appear at a water deficit of-2.0 MPa and above, measurements of chlorophyll-fluorescence quenching and metabolite levels showed the thylakoid reactions were not especially susceptible to short-term water stress. The inhibition was accompanied by a small increase of the triose phosphate: ribulose-1,5-bisphosphate ratio, showing regeneration of ribulose-1,5-bisphosphate was affected. However, there was also a general increase of the estimated concentrations of most metabolites, indicating that there is no specific site for the inhibition of photosynthesis. Increasing water deficit led to a large increase of fructose-2,6-bisphosphate. This is explained in terms of a simultaneous increase of fructose-6-phosphate and inorganic phosphate as the cell shrinks. The high fructose-2,6-bisphosphate led to the accumulation of triose phosphates, and the potential significance of this for protection against photoinhibition is discussed. There was an increase in the extractable activity of sucrose-phosphate synthase. This was only detected when the enzyme was assayed in conditions which distinguish between different kinetic forms which have previously been identified in spinach leaves. It is proposed that activation of sucrose-phosphate synthase is one of the first sites at which spinach leaves respond to a rising water deficit. This could be of importance for osmoregulation.

A multi-hospital hepatitis B vaccine program: prevalence of antibody and acceptance of vaccination among high-risk hospital employees

In July 1982, five Hartford hospitals embarked on a joint hospital-sponsored program to immunize high-risk employees against hepatitis B virus (HBV). The program included a questionnaire to characterize relative risk, serology for anti-HBs, vaccination and a follow-up survey of vaccine non-recipients. Of 2,065 employees who were considered to be at high-risk for infection with HBV, 1,894 (91.7%) responded to the screening questionnaire and 1,279 (67.5%) were tested for anti-HBs serology. The prevalence of antibody varied from hospital to hospital; the highest prevalence (10.9%) was observed at one of the urban university-affiliated community hospitals and the lowest prevalence (4.1%) was reported from the smaller, rural hospital. The prevalence of antibody also varied greatly within the high-risk groups; the highest prevalence of antibody was seen among surgical house officers (15%). The rate of acceptance of vaccine among hospitals ranged from 57.5% to 23.7%. Reasons for vaccine non-acceptance included fear of as yet unknown side effects, perceived low risk of hepatitis acquisition and possible effects on present or future pregnancies. Our experience illustrates some of the epidemiologic and practical aspects that must be addressed in administering a hospital-based HBV vaccine program. Among the five hospitals, we saw marked inter- and intra-hospital variations in the prevalence of anti-HBs among high-risk employees. More significantly, we observed unexpectedly low rates of vaccine acceptance among high-risk personnel.

Relationships of physician characteristics to performance quality and improvement

The quality of ambulatory medical care provided by 1,135 physicians in five separate practice settings in the Midwest was measured using predetermined process criteria. Specialists performed better in their own areas of specialized training than did family/general practitioners or specialists performing outside their specialty areas. Physicians with fewer years of practice performed somewhat better than physicians with more years since medical school graduation. Board certification was not consistently related to performance. Performances of the physicians improved following quality assurance interventions in these sites. Differences in the rates of change in performance quality were not consistently related to any of the physician characteristics studied.

Method of evaluating and improving ambulatory medical care

The usefulness of an action-research model is demonstrated in the evaluation and improvement of ambulatory medical care in a variety of settings: solo office practice, prepaid capitation multiple-specialty group practice, and medical school hospital-based outpatient clinic practice. Improvements in the process of medical care are found to relate directly to the intensity and duration of planned interventions by the study group and are demonstrated to follow organizational changes in the participating sites--primarily managerial and support services initiated by policy decisions in each study site. Improvement in performance approaching one standard deviation results from the most intense intervention, about one-half standard deviation at the next level of intervention, and virtually no change from a simple feedback of performance measures. On the basis of these findings and other operational and research efforts to improve physician performance, it is unlikely that simple feedback of performance measures will elicit a change in behavior. However, noncoercive methods involving health care providers in problem identification, problem solving, and solution implementation are demonstrated to be effective.

Problems of case finding and data collection in ambulatory care settings

The experience gained in a four-year ambulatory care study suggests that major problems of patient care data collection include: 1) Difficulties in obtaining listings of patients by diagnosis/condition that accurately reflect the actual practice experience; 2) Inaccurate coding or identification of the reason for patient visits; and 3) Inability to find the medical record within the system. Data presented here suggest there are certain regularities in completion rates characteristic of research sites and of diagnostic categories.

Patient responses to request for written permission to review medical records

2,163 patients of 55 physicians in one county, were sent letters asking for their written permission to have their medical records audited by the University of Michigan research team. The overall positive response rate was 64.1% for one county. Differences in response rates were statistically significant among specialties, among diagnoses, and among individual physicians.