A Molecular Method to Detect Wound Cells in Bloodstains Resultant of Sharp Force Injuries for Crime Scene Reconstruction

Previous research by the authors on an animal model showed that bloodstains can contain additional information about their somatic origin in the form of wound cells. Bloodstains produced by a gunshot wound to the head were distinguished from bloodstains produced by a gunshot wound to the chest by testing the stains for a brain microRNA marker. In this study, the effectiveness of the technique was examined on blood drops shed externally from a stab wound to the liver of rat carcasses. Specifically, investigations were conducted on the liver microRNA marker, rno-mir-122-3p, with the QIAGEN miScript System, and PCR analysis. Between the two stabbing methods used, 67% of the scalpel blades and 57% of the blood drops tested positive for rno-mir-122-3p; however, other samples tested negative giving inconclusive results as to the wound-of-origin. The amount of the liver cells in the bloodstains appeared to be related to the extent of trauma.

Application of denaturing gradient gel electrophoresis (DGGE) for assessing fecal pollution sources at a recreational beach

We investigated the effectiveness of Escherichia coli community fingerprinting for identifying fecal pollution sources impacting a recreational beach. E. coli in water collected from the beach, nearby creek and storm sewer outfall were enumerated using membrane filtration, while E. coli communities were characterized following polymerase chain reaction analysis and denaturing gradient gel electrophoresis (DGGE) fingerprinting. Analysis of E. coli densities to determine the contributions of the creek and storm sewer during dry weather was inconclusive. However, DGGE fingerprinting indicated that the creek E. coli communities had a greater impact on the beach community composition (80-95% similarity), than on storm sewer communities (41-64%). Following rainfall events, E. coli communities in the creek were at least 93% similar to those at the beach, while the similarity of the outfall and beach communities varied from 72 to 96%. Furthermore, E. coli communities at the beach were more similar to creek communities than to storm sewer communities after the first 2 h and 48 h following the onset of rainfall, and of comparable similarity following 24 h of rainfall, suggesting transient contributions from the storm sewer. DGGE analysis of E. coli communities provided evidence that the creek was a consistent source of E. coli to the beach, while the storm sewer was a transient source.

Core curricular elements for fellowship training in international emergency medicine

OBJECTIVES

The objective was to describe the common educational goals, curricular elements, and methods of evaluation used in international emergency medicine (IEM) fellowship training programs currently. IEM fellowship programs have been developed to provide formal training for emergency physicians (EPs) interested in pursuing careers in IEM. Those fellowships are variable in scope, objectives, and duration. Previously published articles have suggested a general curriculum structure for IEM fellowships.

METHODS

A search of MEDLINE, EMBASE, and CINAHL databases from 1950 to June 2008 was performed, combining the terms international, emergency medicine, and fellowship. Online curricula and descriptive materials from IEM fellowships listed by the Society for Academic Emergency Medicine (SAEM) were reviewed. Knowledge and skill areas common to multiple programs were organized in discrete categories. IEM fellowship directors were contacted for input and feedback.

RESULTS

Eight articles on IEM fellowships were identified. Two articles described a general structure for fellowship curriculum. Sixteen of 20 IEM fellowship programs had descriptive materials posted online. These information sources, plus input from seven fellowship program directors, yielded the following seven discrete knowledge and skill areas: 1) emergency medicine systems development, 2) humanitarian relief, 3) disaster management, 4) public health, 5) travel and field medicine, 6) program administration, and 7) academic skills.

CONCLUSIONS

While IEM fellowships vary with regard to objectives and structure, this article presents an overview of the current focus of IEM fellowship training curricula that could serve as a resource for IEM curriculum development at individual institutions.

Incidence of thromboembolism in patients receiving vorinostat: Clinical trial and post-marketing data from more than 1,800 patients

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Background: Thromboembolic events (TEEs) occur in approximately 10–15% of advanced cancer patients. Risk factors include cancer therapy and extent and type of malignancy. Vorinostat, a histone deacetylase inhibitor, has been licensed in the USA for the treatment of cutaneous manifestations in patients with cutaneous T-cell lymphoma (CTCL) who have progressive, persistent, or recurrent disease on or following two systemic therapies. TEEs were observed in 6/86 patients (7.0%) enrolled in vorinostat CTCL clinical trials at licensure. To gain further insight into the association between TEEs and vorinostat treatment, we analyzed data from vorinostat clinical trials and post-marketing surveillance (PMS) reports. Methods: Serious adverse events (SAEs) reported through November 3, 2008, among patients receiving vorinostat in completed and ongoing clinical trials, PMS reports, and published literature were reviewed for terms consistent with TEEs. A committee of independent (non-Merck employees) academic experts evaluated these reports. Although no safety signals were observed, the committee recommended that d-dimer and/or plasmin-antiplasmin assays should be conducted. This recommendation has been implemented in three ongoing studies ( NCT00486720 , NCT00632931 , NCT006429542) and will provide further information on clotting parameters among patients being treated with vorinostat. Results: During the reporting period, data from >1,845 cancer patients who received vorinostat were reviewed. Irrespective of causality, 107 patients (<5.8%) reported TEE SAEs (Table). Of these, 47 (<2.6%) had TEE SAEs that were rated as related to vorinostat, four of which were fatal. As of the data cut off, review of the special assays in the three studies did not result in any conclusive correlation. Conclusions: The incidence rate of TEEs observed in vorinostat studies is similar to reported rates of TEEs for advanced cancer patients.

[Table: see text]

[Table: see text]

Vorinostat (suberoylanilide hydroxamic acid, SAHA) is clinically active in advanced cutaneous T-cell lymphoma (CTCL): Results of a phase IIb trial

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Background: Vorinostat is a histone deacetylase inhibitor that has demonstrated clinical activity at tolerable dose levels in patients (pts) with advanced CTCL in phase I and IIa trials. Methods: Open-label, single-arm, nonrandomized phase IIb trial of oral vorinostat 400 mg daily until disease progression or intolerable toxicity. Eligibility: advanced CTCL; ≥ 2 prior systemic therapies which must have included bexarotene unless unable to tolerate; adequate hematologic, hepatic and renal function. Planned sample size: ≥ 50 evaluable pts with clinical stage ≥ IIB. Primary endpoint: objective response rate (OR = CR + PR) as measured by a modified skin severity weighted assessment tool. The study would be positive if OR in ≥ stage IIB pts was ≥ 20%. Secondary endpoints: assessment of response duration (DOR), time to progression (TTP), time to response (TTR), pruritus relief and safety. Results: Seventy-four pts (median age, 60 y [range, 39–83]; median 3 prior systemic therapies) were enrolled (61 pts ≥ stage IIB) from 9/04 to 5/05 at 18 centers. Data cut-off was 11/05 with a median follow-up of 4 months. Efficacy data are shown in Table 1 . The OR was 29.5% (18 PR including 1 with later CR) in ≥ stage IIB pts. Median TTP was 148 d for all pts and 203.5+ d for responders. The most common drug-related adverse experiences (AE) were diarrhea (49%), fatigue (46%), nausea (43%) and anorexia (26%), and were mostly ≤ Grade 2. Drug-related ECG changes were Grade 1 in 5 pts (7%) and Grade 2 in 1 pt (1%), but not associated with cardiac symptoms. Seven pts discontinued and 10 had dose modification due to drug-related AE. Drug-related AE ≥ Grade 3 included fatigue (5%), pulmonary embolism (5%), nausea (4%) and thrombocytopenia (4%). Twenty-five pts discontinued due to progressive disease. Causes of the 3 deaths on study were: unknown (d 2), ischemic stroke (d 227) and disease progression (d 52). Conclusion: Oral vorinostat is effective in the treatment of advanced CTCL with an acceptable safety profile.

[Table: see text]

[Table: see text]

International emergency medicine fellowships

The active interchange of intellectual ideas in the quest to improve healthcare globally will likely be best served by active interchange among physicians around the world. Subspecialty fellowship training programs for United States and foreign graduates will provide a focused path to development of a global network of physicians dedicated to the delivery of high-quality emergency health services.

Intravenous epinephrine in life-threatening asthma

STUDY OBJECTIVE

Intravenous epinephrine is a potentially vital therapy for patients with life-threatening asthma but is often avoided because of concerns about its safety. We evaluated the safety of intravenous epinephrine in a series of adults with life-threatening asthma.

METHODS

We performed an explicit retrospective chart review on a case series of 27 emergency department patients aged 19 to 58 years (mean 25 years) who were treated with intravenous epinephrine for a life-threatening exacerbation of asthma between 1989 and 1997. Explicit criteria for adverse effects, including cardiac arrhythmia or ischemia, hypotension or hypertension, neurologic injury, and death, were defined before chart review.

RESULTS

No patient had an arrhythmia other than sinus tachycardia, and there were no cases of cardiac ischemia, hypotension, neurologic deficit, or death.

CONCLUSION

Intravenous epinephrine was safe in this small series of younger adults with acute life-threatening asthma. A prospective trial of its use to better define an efficacy and risk-benefit relationship is justified.

Post-war Kosovo: Part 3. Development and rehabilitation of emergency services

The recent crisis in Kosovo led to nearly complete destruction of a healthcare system serving the needs of approximately 2 million people. Even prior to the crisis, the pre-existing healthcare system had inadequate provisions for the delivery of Emergency Medical Services. More than 440 diverse governmental and non-governmental organizations (NGOs) arrived to assist (and often compete) in the rehabilitation of Kosovo's healthcare needs. Each brought with them individual biases and strategies for how this rehabilitation should occur, and each faced numerous unforeseen barriers to the implementation of its programs. The authors used a four-step, multi-modal, needs assessment to gather information on the needs and potential barriers to the implementation of a program to rehabilitate emergency services as discussed in Part II. This paper chronicles the phases of the Emergency Medicine program development and the process of responding to barriers and changing needs. The program's successes and failures are noted, and the actual barriers encountered are reviewed. Overall, the needs assessment tool employed in this program was useful in the implementation of a program to restore and rehabilitate Emergency Services in Kosovo. The authors recommend the use of combined quantitative and qualitative methods for developing priorities for interventions in post-conflict settings following complex emergencies.

Post-war Kosovo: Part 1. Assessment of prehospital emergency services

The United Nations Mission in Kosovo (UNMIK) designated that the World Health Organization (WHO) develop health policy to assist in the recovery and rehabilitation of the post-war health system of Kosovo. As a critical part of the pre-policy evaluation, an assessment of current prehospital medical services was performed. This assessment identified a basic healthcare infrastructure upon which additional prehospital capabilities can be built, especially in communications, staffing, equipment, and transport services. To serve Kosovo properly in the future, it is recommended that capacity building must include the parallel development of emergency departments and specialty-trained physicians.

Post-war Kosovo: Part 2. Assessment of emergency medicine leadership development strategy

Since the return of the refugee population to Kosovo, attempts at development of an emergency medical system in Kosovo have met with varied success, and have been hampered by unforeseen barriers. These barriers have been exacerbated by the lack of detailed health system assessments. A multimodal approach of data collection and analysis was used to identify potential barriers, and determine the appropriate level of intervention for emergency medicine (EM) development in Kosovo. The four step, multi-modal, data collection tool utilized: 1) demographic and health systems data; 2) focus group discussions with health-care workers; 3) individual interviews with key individuals in EM development; and 4) Q-Analysis of the attitudes and opinions of EM leaders. Results indicated that Emergency Medicine in Kosovo is under-developed. This method of combined quantitative and qualitative analysis identified a number of developmental needs in the Kosovar health system. There has been little formal training, the EMS system lacks organization, equipment, and a reliable communication system, and centralized emergency centers, other than the center at Prishtina Hospital, are inadequate. Group discussions and interviews support the desire by Kosovar health-care workers to establish EM, and highlight a number of concerns. A Q-methodology analysis of the attitudes of potential leaders in the field, supported these concerns and identified two attitudinal groups with deeper insights into their opinions on the development of such a system. This study suggests that a multi-modal assessment of health systems can provide important information about the need for emergency health system improvements in Kosovo. This methodology may serve as a model for future, system-wide assessments in post-conflict health system reconstruction.

[Levels of soluble intracellular adhesion molecules 1 (sICAM-1) , soluble receptors for interleukin 2 (sIL-2R) and anti-Epstein-Barr viral capsid antigen (anti-VCA IgM) in blood serum during the course of infectious mononucleosis]

The clinical picture of infectious mononucleosis and the consequences of EBV infection are due to immune response mechanisms. The level of soluble form of IL-2 receptor (sIL-2R) is thought to be a marker of T-cell activity, especially CD8+. Intercellular adhesion molecule (ICAM-1, CD 54) plays an important role in the process of antigen presentation. The aim of this study was to assess the serum concentration of sIL-2R, ICAM-1 and anti-VCA IgM in patients with infectious mononucleosis. The study group comprised 42 persons: 20 healthy subjects as a control group and 22 individuals with infectious mononucleosis. The highest anti-VCA IgM serum level in all patients was during the 1st day of hospitalization, and decreased in the 8th day of hospitalization. The lowest antibody concentration was observed when the symptoms and sings ceased. The level of sIL-2R was significantly increased and during farther hospitalization we observed lower, but still elevated concentrations. Our study has demonstrated statistically significant elevation of sICAM-1 level during the entire period of hospitalization. This data indicates the importance of antigen presentation process. Although the serum concentration of immune response mediators does not reflect their contents in organism, but is a useful method for in vivo examination.

[The case of mumps complicated by one-sided hearing loss]

We presented the case of mumps complicated by left ear's hearing loss in 32-year-old man. Audiological examinations performed after one, two and three months since the date of discharge from hospital showed the maintenance of hearing loss.

Concentration of volatile fatty acids in digesta samples obtained from healthy cows and cows with cecal dilatation or dislocation

OBJECTIVE

To compare concentrations of acetic, propionic, butyric, and i- and n-valerianic acids in digesta samples obtained from the rumen, cecum, proximal loop of the ascending colon (PLAC), and rectum of healthy cows and cows with cecal dilatation or dislocation (CDD).

ANIMALS

20 cows with CDD and 20 healthy cows.

PROCEDURE

Samples were collected from all sites during surgical correction of CDD and also from the rectum 1, 2, and 3 days after surgery (group CDD). Samples from healthy (control) cows, matched on the basis of diet and milk yield, were obtained at a slaughterhouse. Concentrations of volatile fatty acids (VFA) were analyzed by use of gas chromatography. Absolute concentration of each VFA was additionally corrected for pH to allow calculation of the concentration of undissociated VFA.

RESULTS

Absolute concentration and concentration of the undissociated form of all analyzed VFA were significantly increased in samples collected from the cecum and PLAC of cows in group CDD, compared with concentrations for control cows. Within 3 days after surgery, significant decreases of the absolute concentration of butyric, i- and n-valerianic acids, and undissociated i- and n-valerianic acids were evident in samples obtained from the rectum of group-CDD cows. Concentrations of VFA in samples obtained from the rectum during surgery correlated with corresponding VFA concentrations in samples obtained from the PLAC.

CONCLUSIONS

Concentrations of VFA are increased in the cecum and PLAC of cows with CDD. However, the role of increased concentrations of VFA in the etiopathogenesis of CDD is unknown.

Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study

BACKGROUND

This was a multicenter investigation examining the efficacy of 4 psychosocial treatments for cocaine-dependent patients.

METHODS

Four hundred eighty-seven patients were randomly assigned to 1 of 4 manual-guided treatments: individual drug counseling plus group drug counseling (GDC), cognitive therapy plus GDC, supportive-expressive therapy plus GDC, or GDC alone. Treatment was intensive, including 36 possible individual sessions and 24 group sessions for 6 months. Patients were assessed monthly during active treatment and at 9 and 12 months after baseline. Primary outcome measures were the Addiction Severity Index-Drug Use Composite score and the number of days of cocaine use in the past month.

RESULTS

Compared with the 2 psychotherapies and with GDC alone, individual drug counseling plus GDC showed the greatest improvement on the Addiction Severity Index-Drug Use Composite score. Individual group counseling plus GDC was also superior to the 2 psychotherapies on the number of days of cocaine use in the past month. Hypotheses regarding the superiority of psychotherapy to GDC for patients with greater psychiatric severity and the superiority of cognitive therapy plus GDC compared with supportive-expressive therapy plus GDC for patients with antisocial personality traits or external coping style were not confirmed.

CONCLUSION

Compared with professional psychotherapy, a manual-guided combination of intensive individual drug counseling and GDC has promise for the treatment of cocaine dependence.

Topical application of synthetic pyrethroids to cattle as a source of persistent environmental contamination

Following the application of permethrin or cyhalothrin to cattle for the control of ectoparasites, the occurrence and persistence of these chemicals was assessed on the animals and in their environment. The release of permethrin from ear tags containing 1 g of the drug on cattle was followed for 65 days and lead to concentrations of 5 to 35 micrograms of permethrin per gram of hair on the shoulders. On the flanks of the animals, the corresponding values were 10 times lower. Across the 1.5 acre pasture, high concentrations of permethrin were measured at various locations and long after treatment: 6 micrograms/g on bark of a birch after one week, 5 micrograms/g on a pole of the fence after two weeks, 1 microgram/g in grass from a resting site of the animal after six weeks, and 0.5 microgram/g in bark of a pine tree after three month and two weeks after the animals had left the pasture. In similar assays, cyhalothrin applied to milk cows as a pour-on preparation was monitored. One week following treatment with 0.2 g/animal, hair cut from the shoulders contained 5 micrograms/g of the insecticide, which disappeared with a half-life of 12 days. Dust collected two weeks after the pour-on treatment from the milk barn where the cows were milked twice daily contained 47 micrograms/g of cyhalothrin, which disappeared with a half-life of 44 days. These results show that synthetic pyrethroids used on farm animals can be the source of widespread and persistent contamination.

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Rationale and methods

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study is a large, multisite psychotherapy clinical trial for outpatients who meet the DSM-IV criteria for cocaine dependence. For 480 randomized patients, the outcomes of 4 treatments are compared for an 18-month period. All treatments include group drug counseling. One treatment also adds cognitive therapy, one adds supportive-expressive psychodynamic therapy, and one adds individual drug counseling; one consists of group drug counseling alone. In addition, 2 specific interaction hypotheses, one involving psychiatric severity and the other involving degree of antisocial personality characteristics, are being tested. This article describes the main aims of the project, the background and rationale for the study design, the rationale for the choice of treatments and patient population, and a brief description of the research plan.

Differential regulation of the two glyceraldehyde-3-phosphate dehydrogenase genes during Drosophila development

Drosophila melanogaster contains two genes encoding glyceraldehyde-3-phosphate dehydrogenase, Gapdh-1 and Gapdh-2. The two genes are highly conserved in their coding sequences but not in their noncoding and flanking sequences. We report that both genes are expressed at higher levels in larval, late pupal, and adult stages than in embryonic, early, and midpupal stages. However, a major difference in the expression of the two genes is observed in the adult stage, during which the level of the Gapdh-1 transcript decreases over fourfold, while that of the Gapdh-2 transcript remains at a constant high level. In addition, the Gapdh-1 transcript appears highly enriched in the thorax section compared with the head and abdomen sections, while the Gapdh-2 transcript is evenly distributed. Analyses of the expression patterns of the two Gapdh hybrid genes, GAP1/2 and GAP2/1, revealed that the two genes have a distinct organization of their regulatory sequences. The principle regulatory sequences of Gapdh-2 reside upstream of the translation start, while the principle sequences specifying the level and developmental pattern of Gapdh-1 expression reside downstream of the translation start.

Portable microcomputer software for nucleotide sequence analysis

The most common types of nucleotide sequence data analyses and handling can be done more conveniently and inexpensively on microcomputers than on large time-sharing systems. We present a package of computer programs for the analysis of DNA and RNA sequence data which overcomes many of the limitations imposed by microcomputers, while offering most of the features of programs commonly available on large computers, including sequence numbering and translation, restriction site and homology searches with dot-matrix plots, nucleotide distribution analysis, and graphic display of data. Most of the programs were written in Standard Pascal (on an Apple II computer) to facilitate portability to other micro-, mini-, and and mainframe computers.

Physical map of two D. melanogaster DNA segments containing sequences coding for the 70,000 dalton heat shock protein

The isolation of the two hybrid plasmids 56H8 and 132E3, which contain D. melanogaster (Dm) DNA sequences complementary to the mRNA coding for the 70,000 dalton heat shock protein, has been reported (Schedl et al., 1978). Here we compare the sequence arrangement in the two cloned Dm DNA segments by restriction, cross-hybridization and heteroduplex analysis. The results show that the two cloned DNA segments derive from nonoverlapping regions of the Dm genome; that they contain homologous regions present once in 56H8 and twice in 132E3; and that each homologous region is composed of three distinct contiguous sequence elements, x, y and z, which together define a 3 kb common unit. While the 2.5 kb z elements show a high degree of sequence homology in all three common units, the three x and y elements display an intriguing relationship. The localization of the mRNA coding sequences within each of these common units is presented in the accompanying paper (Artavanis-Tsakonas et al., 1979).

Genes for the 70,000 dalton heat shock protein in two cloned D. melanogaster DNA segments

Two hybrid plasmids, 56H8 and 132E3, which contain D. melanogaster (Dm) DNA segments coding for the 70,000 dalton heat shock protein, have been isolated (Schedl et al., 1978). The analysis of the sequence arrangement presented in the accompanying paper (Moran et al., 1979) shows that both Dm segments contain homologous regions composed of three distinct sequence elements which together define a common unit. We report here that the sequences complementary to the 70,000 dalton protein mRNA appear to be confined to a major portion of the largest element of the common unit and that the other sequence elements are located at the 5' end of the gene. We have also determined the cytogenetic location of the 70,000 dalton protein genes and have investigated whether these sites are transcriptionally active in salivary gland chromosomes.