A single-site retrospective review of in-hospital stroke

BACKGROUND

In-hospital stroke refers to a stroke arising in a patient during hospital admission for another condition. Between 2 and 17% of all inpatient strokes are in-hospital strokes.

AIM

To compare the outcomes and performance on quality-of-care stroke measures of in-hospital stroke cases with community-onset strokes.

METHODS

Data collected for the Irish Annual Audit of Stroke from an Irish university teaching hospital was analysed for a 2-year period from 1st January 2020 to 31st December 2021. A retrospective cohort study was conducted to compare baseline characteristics, outcomes, and performance on standardised quality-of-care measures between the cohorts.

RESULTS

The rate of IHS was 15.6%. Median age was 73 years and 72 years for in-hospital and community-onset strokes respectively. Amongst in-hospital strokes, COVID-19 co-diagnosis (9.1% versus 1.3%; p = .0004), admission to intensive care (52.3% versus 5.3%; p < .0001), discharge to long term care (6.8% versus 2.3%; p = .04), mortality (12.5% versus 7.6%; p = .13), and modified Rankin score of two or more at discharge (58.0% versus 38.1%; p = .001), were more likely compared to community-onset strokes. Thrombolysis rates were lower (7.3% versus 12.0%; p = .22) and thrombectomy rates higher (9.8% versus 6.6;% p = .32), albeit non-significantly. Median time to thrombolysis was slower amongst in-hospital strokes (105 min versus 66 min; p = .03) and they were less likely to be admitted to the stroke unit (43.2% versus 78.5%; p < .0001).

CONCLUSIONS

When compared with community-onset stroke, in-hospital stroke represents a distinct stroke subgroup with poorer outcomes and delays to thrombolysis emphasising the need for standardised approaches to evaluation and management.

Clinical validation of in-hospital stroke diagnosis

OBJECTIVE

In-hospital stroke cases occur during hospitalization for another diagnosis and reflect a clinically distinct cohort from community-onset stroke. The objective was to validate the diagnostic accuracy of in-hospital stroke identification in stroke audit data at a large teaching hospital.

METHODS

A retrospective clinical validation of in-hospital stroke diagnoses from two linked data sources was completed for a 2-year period from January 1st 2020 to December 31st 2021. The linked data sources include the Hospital Inpatient Enquiry system which assigns coded stroke diagnoses at discharge and/or the local stroke audit coordinators who work clinically in stroke teams and input additional specific clinical data. Diagnostic sensitivity, specificity and the level of agreement using an unweighted Cohen's Kappa were calculated.

RESULTS

There were 597 strokes admitted during the 2-year period. The median age was 72 years and 55% occurred in males. In total, 88 cases of in-hospital stroke were clinically validated yielding an in-hospital stroke rate of 15%. The clinical audit coordinator identified in-hospital stroke with higher sensitivity (86%; 95% CI 77%-93%) whereas the coding process was more specific at 96% (95% CI 85% to 99%). Levels of agreement with the clinically validated gold standard sample were moderate for the audit coordinator and coding process with κ = 0.57 and K = 0.42 respectively. When both data sources were combined the level of agreement was substantial (κ = 0.65; p < .000).

CONCLUSIONS

Clinical validation studies are required to reinforce data quality within stroke registers. Combining clinical and administrative data sources improves diagnostic accuracy for in-hospital stroke identification.

An electronic medical record reminder is independently associated with improved opportunistic influenza vaccination rates for older inpatients

BACKGROUND

Influenza vaccination will have added importance this winter given the possibility of further waves of the COVID-19 pandemic. This study examines the impact of an electronic medical record (EMR) reminder on influenza vaccine uptake among eligible hospital inpatients.

METHODS

We included a convenience sample of 750 adults (median age 77 years) who are eligible for influenza vaccination (⩾65 years and/or length of stay >30 days). A live electronic dashboard identified patients eligible for vaccination, prompting reminders sent to the clinical teams via the EMR.

RESULTS

The EMR reminder was associated with almost a 50% higher likelihood of vaccination after adjusting for other covariates (odds ratio 1.48 (95% confidence interval 1.00-2.20); p = 0.048).

DISCUSSION

Reminders sent to the clinical team via the EMR appear to be an effective means of increasing vaccine uptake and should be considered as part of this year's drive to vaccinate eligible patients in hospital.

Inhibitory IL-10-producing CD4+ T cells are T-bet-dependent and facilitate cytomegalovirus persistence via coexpression of arginase-1

Inhibitory CD4+ T cells have been linked with suboptimal immune responses against cancer and pathogen chronicity. However, the mechanisms that underpin the development of these regulatory cells, especially in the context of ongoing antigen exposure, have remained obscure. To address this knowledge gap, we undertook a comprehensive functional, phenotypic, and transcriptomic analysis of interleukin (IL)-10-producing CD4+ T cells induced by chronic infection with murine cytomegalovirus (MCMV). We identified these cells as clonally expanded and highly differentiated TH1-like cells that developed in a T-bet-dependent manner and coexpressed arginase-1 (Arg1), which promotes the catalytic breakdown of L-arginine. Mice lacking Arg1-expressing CD4+ T cells exhibited more robust antiviral immunity and were better able to control MCMV. Conditional deletion of T-bet in the CD4+ lineage suppressed the development of these inhibitory cells and also enhanced immune control of MCMV. Collectively, these data elucidated the ontogeny of IL-10-producing CD4+ T cells and revealed a previously unappreciated mechanism of immune regulation, whereby viral persistence was facilitated by the site-specific delivery of Arg1.

Noise and transient ischaemic attacks - A challenge?

Consistency in medical decision-making is ideally expected. This includes consistency between different clinicians so that the same patient will receive the same diagnosis regardless of the assessing clinician. It also encompasses reliability as an individual clinician meaning at any given time or context, we apply the same process and principles to ensure the decisions we make do not deviate significantly from our peers or indeed our own past decisions. However, consistency in decision-making can be challenged when working within a busy healthcare system. We discuss the concept of 'noise' and explore how it affects decision-making in acute presentations of transient neurology where doctors can differ in terms of their diagnostic decisions.

The barriers and facilitators to the reporting and recording of self-harm in young people aged 18 and under: a systematic review

BACKGROUND AND AIMS

This systematic review sought to identify, explain and interpret the prominent or recurring themes relating to the barriers and facilitators of reporting and recording of self-harm in young people across different settings, such as the healthcare setting, schools and the criminal justice setting.

METHODS

A search strategy was developed to ensure all relevant literature around the reporting and recording of self-harm in young people was obtained. Literature searches were conducted in six databases and a grey literature search of policy documents and relevant material was also conducted. Due to the range of available literature, both quantitative and qualitative methodologies were considered for inclusion.

RESULTS

Following the completion of the literature searches and sifting, nineteen papers were eligible for inclusion. Facilitators to reporting self-harm across the different settings were found to be recognising self-harm behaviours, using passive screening, training and experience, positive communication, and safe, private information sharing. Barriers to reporting self-harm included confidentiality concerns, negative perceptions of young people, communication difficulties, stigma, staff lacking knowledge around self-harm, and a lack of time, money and resources. Facilitators to recording self-harm across the different settings included being open to discussing what is recorded, services working together and co-ordinated help. Barriers to recording self-harm were mainly around stigma, the information being recorded and the ability of staff being able to do so, and their length of professional experience.

CONCLUSION

Following the review of the current evidence, it was apparent that there was still progress to be made to improve the reporting and recording of self-harm in young people, across the different settings. Future work should concentrate on better understanding the facilitators, whilst aiming to ameliorate the barriers.

Amphetamine-induced cardiomyopathy complicated by embolic stroke: a case report

Background

Amphetamine use causes cardiomyopathy via catecholamine-mediated effects such as tachycardia, hypertension, vasoconstriction, and direct cardio-toxic effects. Traditionally, an increased risk of haemorrhagic stroke is associated with amphetamine use. However, up to one-third of stimulant-associated cardiomyopathy patients have left ventricular (LV) thrombus formation leading to an increased risk of systemic embolization. We report a case of amphetamine-induced cardiomyopathy complicated by embolic stroke secondary to LV thrombus.

Case summary

A 38-year-old man with 6-month history of sustained amphetamine use presented to the emergency department with left-sided weakness, facial droop, and dysarthria. Angiography confirmed right middle cerebral artery thrombus. Prompt mechanical thrombectomy yielded full neurological recovery. Dyspnoea prompted transthoracic echocardiography showing dilated cardiomyopathy with an ejection fraction of 5% and LV thrombus. Anticoagulation was initiated with warfarin as well as pharmacological therapy for heart failure with reduced ejection fraction including bisoprolol, spironolactone, loop diuretic, and sacubitril/valsartan. He was discharged successfully following resolution of ventricular thrombus and medical management of heart failure. Clinical recovery was hampered by psychosocial factors resulting in non-adherence to medical therapy and continued amphetamine use.

Conclusion

Sustained amphetamine use can result in severe dilated cardiomyopathy with LV thrombus formation and embolic complications such as ischaemic stroke. Avoidance of amphetamines in conjunction with guideline-directed pharmacological management are key components of therapy. However, psychosocial factors can exert significant influence on recovery.

Ultrasound-guided tenoscopic decompression of digital sheath synoviocoeles in 10 horses

OBJECTIVE

To report the diagnostic features and clinical outcome of horses with digital flexor tendon sheath (DFTS) synoviocoeles treated tenoscopically under ultrasonographic guidance.

STUDY DESIGN

Retrospective case series.

ANIMALS

Client-owned horses (n = 10).

METHODS

Medical records were searched for horses with lameness localized to the region of the DFTS and clinical evidence of a fluid-filled mass (synoviocoele) associated with the DFTS. Diagnostic imaging and surgical findings, together with long-term outcome, were reported.

RESULTS

Lameness and synoviocoeles were unilateral (5 forelimbs, 5 hindlimbs; 3 lateral and 2 medial in both) and located proximal to the palmar/plantar annular ligament. Synoviocoeles had a firm consistency and focal pain with inability to deflate on non-weight-bearing examination. Intrathecal DFTS anesthesia was positive in 7/8 horses in which it was performed, with the remainder localized to the region of the synoviocoele using perineural and/or intralesional anesthesia. Communication between the DFTS and synoviocoele was suspected ultrasonographically in all cases and confirmed on contrast tenography (6/6). Tenoscopic fenestration of the communication between the DFTS and synoviocoele under ultrasonographic guidance, with treatment of concurrent intrathecal injury (4/10), resolved the lameness in all horses re-evaluated by a veterinarian (9/9) and allowed return to full athletic function in all cases at long-term follow up (median 5 years; range 1.25-9 years).

CONCLUSION

Tenoscopic decompression was an effective treatment for DFTS synoviocoeles, which, along with treatment of concurrent intrathecal injury, carried an excellent prognosis and avoided the need for resection via an extrasynovial approach.

216 IMPROVING INPATIENT INFLUENZA VACCINATION RATES—THE VALUE OF AN ELECTRONIC PATIENT RECORD REMINDER SYSTEM

Background

Influenza vaccination, particularly for vulnerable, older adults, will have added importance this winter given the possibility of further waves of COVID-19 pandemic. Previous interventions at the study site noted poor awareness on the need for inpatient Influenza vaccination¹. This study examines a vaccination reminder process using an electronic patient record (EPR) to identify high-priority eligible inpatients.

Methods

The study site is a 900-bed university teaching hospital with all clinical notes accessed via an EPR.

We included a convenience sample of 750 adults aged≥50 years (mean age 75.9 +/− 0.4 years, 48% female) and high-priority for influenza vaccination (Age > 65 years and/or length of stay (LOS) >30 days) from October 1^st 2020 to January 12^th 2021.

A live electronic dashboard identified eligible inpatients for vaccination, prompting vaccination reminders to the clinical teams via the antimicrobial pharmacist.

Data was collected retrospectively. Logistic regression models reporting odds ratios were used to assess the association of these reminders with vaccine uptake.

Results

Over one third (35%, 264/750) of high-priority patients received the Influenza vaccine while inpatients, including 40% aged ≥80 years.

The reminder was sent on 41% (305/750) of patients and was associated with an almost 50% higher likelihood of vaccination after adjusting for other covariates (Odds Ratio 1.48 (95% CI 1.00–2.20); p = 0.048).

Other factors independently associated with vaccination were advancing age (Odds Ratio 2.69 (95% CI 1.12–6.47) for age ≥ 80 years); LOS (4% higher likelihood of vaccination for every additional day in hospital) and admission under geriatric medicine (Odds Ratio 3.71 (95% CI 2.45–5.62) when compared to other specialities).

Conclusion

Our study shows relatively low uptake of inpatient Influenza vaccination and strategies to improve uptake are required. Reminders sent to clinical teams using the EPR appear to be an effective means of increasing Influenza vaccination and should be considered as part of this year’s inpatient vaccination drive.

A Rare Presentation of Adrenocortical Carcinoma

An adrenal incidentaloma is a mass found incidentally on radiological imaging performed for other reasons. The prevalence of these incidentalomas increases with age, and they all must be evaluated to determine if they are benign or malignant and if they are functioning or non-functioning. A 71-year-old female presented with sub-acute bilateral lower limb pitting edema and dyspnoea. Imaging showed an 8 cm smoothly defined heterogeneous right adrenal mass and a number of low attenuation lesions throughout the liver. This case report describes a rare presentation of adrenocortical carcinoma due to an adrenal incidentaloma identified on imaging in a patient presenting with bilateral lower limb edema. The laboratory and imaging evaluation of these incidentalomas are also discussed.

Optimal CD8+ T-cell memory formation following subcutaneous cytomegalovirus infection requires virus replication but not early dendritic cell responses

Cytomegalovirus (CMV) induction of large frequencies of highly functional memory T cells has attracted much interest in the utility of CMV‐based vaccine vectors, with exciting preclinical data obtained in models of infectious diseases and cancer. However, pathogenesis of human CMV (HCMV) remains a concern. Attenuated CMV‐based vectors, such as replication‐ or spread‐deficient viruses, potentially offer an alternative to fully replicating vectors. However, it is not well understood how CMV attenuation impacts vector immunogenicity, particularly when administered via relevant routes of immunization such as the skin. Herein, we used the murine cytomegalovirus (MCMV) model to investigate the impact of vector attenuation on T‐cell memory formation following subcutaneous administration. We found that the spread‐deficient virus (ΔgL‐MCMV) was impaired in its ability to induce memory CD8⁺ T cells reactive to some (M38, IE1) but not all (IE3) viral antigens. Impaired‐memory T‐cell development was associated with a preferential and pronounced loss of polyfunctional (IFN‐γ⁺ TNF‐α⁺) T cells and also reduced accumulation of TCF1⁺ T cells, and was not rescued by increasing the dose of replication‐defective MCMV. Finally, whilst vector attenuation reduced dendritic cell (DC) recruitment to skin‐draining lymph nodes, systematic depletion of multiple DC subsets during acute subcutaneous MCMV infection had a negligible impact on T‐cell memory formation, implying that attenuated responses induced by replication‐deficient vectors were likely not a consequence of impaired initial DC activation. Thus, overall, these data imply that the choice of antigen and/or cloning strategy of exogenous antigen in combination with the route of immunization may influence the ability of attenuated CMV vectors to induce robust functional T‐cell memory.

Metabolomics and a breath sensor identify acetone as a biomarker for heart failure

Introduction

Metabolomics delivers more biological and clinical insight than targeted investigations. We applied metabolomics to patients with heart failure (HF) with reduced ejection fraction (HFrEF).

Methods

46 patients with HFrEF and 20 controls underwent metabolomic profiling, including liquid/gas chromatography mass spectrometry (LC-MS/GC-MS), nuclear magnetic resonance (NMR) metabolomics and solid-phase microextraction (SPME) volatilomics in plasma and urine. HFrEF was defined using left ventricular global longitudal strain (GLS) &lt;18%, ejection fraction &lt;50% and NTproBNP ≥35 pmol/L. A low cost consumer breath acetone (BrACE) sensor validated SPME results in 69 patients.

Results

34 metabolites were identified by GCMS, 33 by LCMS and 2 volatiles by SPME (acetone, 2-pentanone in plasma and urine). Alanine, aspartate and glutamate, citric acid cycle, arginine biosynthesis, glyoxylate and dicarboxylate metabolism were altered in HFrEF. Plasma acetone correlated with NT-proBNP (r=0.59, 95% CI 0.4 to 0.7), triacylglycerol (55:9), 2-oxovaleric and cis-aconitic acid, involved with ketone metabolism and mitochondrial energetics. BrACE &gt;1.5 ppm discriminated HF from other cardiac pathology (AUC 0.88, 95% CI 0.77 to 0.99, P&lt;0.0001).

Conclusion

Breath acetone was detectable in HFrEF patients using a consumer sensor ($1/test) and although not cardiac specific, discriminated HF from other cardiac pathology.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Health Research Council of New Zealand

Peroxynitrite is essential for the initiation of cytomegalovirus replication in vitro and in vivo

Human cytomegalovirus (HCMV) is a pathogenic beta-herpesvirus that establishes a lifelong infection in hosts. It causes significant morbidity and mortality in the immunocompromised and is associated with a range of birth defects following congenital infection. Current therapeutic approaches that target key viral proteins are toxic and antiviral drug resistance is common. Thus, targeting host genes and cellular pathways essential for HCMV infection offers an alternative strategy for the development of antivirals. Here we show that host oxidative/nitrosative stress responses to CMV are critical for virus replication. Oxidative/nitrosative stress occurs due to accumulation of reactive oxygen/nitrogen species (ROS/RNS). Using a range of ROS/RNS scavengers, we identified that peroxynitrite, a powerful oxidant and nitrating agent, dramatically promoted virus replication in both in vitro and in vivo models of CMV infection. HCMV rapidly induced production of intracellular peroxynitrite upon infection. Inhibition of peroxynitrite within the first 24 hours alleviates efficient HCMV infection in both cell-free and cell-associated infection systems, indicating that peroxynitrite may influence pathways necessary for HCMV entry and/or replication. Furthermore, peroxynitrite inhibition also inhibited HCMV reactivation from latency. Interestingly, the neurotransmitter and naturally-occurring peroxynitrite antagonist 5-hydroxytryptamine, commonly known as serotonin, also impinged on HCMV-induced peroxynitrite production and exhibited anti-HCMV activity. Thus, overall, our study demonstrates a novel role for intracellular peroxynitrite in CMV pathogenesis and implies that peroxynitrite could be targeted as a novel approach to inhibiting CMV infection.

252 Physicians’ Perceptions to Electronic Alerts for Delirium and Dementia Screening - Qualitative Analysis of Bypass Reasons in an Electronic Patient Record

Background

Delirium and dementia are common cognitive disorders within an inpatient hospital population (Mukadam & Sampson 2010) Efforts were made to improve detection by embedding the 4As Test (4AT) cognitive screening tool within the hospital electronic patient record (EPR). Non consultant hospital doctors (NCHDs) and consultants were prompted to complete the electronic 4AT on all inpatients aged 65 years and over at 24 hours into admission. Doctors could opt to bypass completion of the screening assessment but a reason for bypassing was required.

Methods

Reasons for bypassing the 4AT electronic alert were analysed using mixed methods during a seven week time period between June 28th and August 16th 2018. Free text entries were grouped into 15 qualitative categories. Quantitative methods using descriptive statistics were subsequently applied to qualitative categorisation.

Results

During seven weeks of analysis, hospital doctors bypassed electronic 4AT screening on 2473 occasions equating to a mean of 50.5 bypasses per day. Overall 40% of free text reasons documented were unintelligible. Examples of unintelligible bypass reasons documented in the EPR included “2321” and “dghj”. Amongst the qualitative categories analysed, the most common reasons for bypass observed were “Accessing EPR Remotely from Patient” (33%), “Specific Clinical Reason for Override” (12%) and “Not Patient’s Primary Team” (11%). Twenty-five entries (2%) were deemed to be angry or inappropriate. Examples included “Stop sending me delirium assessment”, “this is irrelevant, restrict this message to intern log-ins” and “I am consultant and I have to prioritise”.

Conclusion

Bypass of cognitive screening alerts within the EPR by doctors is common. Qualitative analysis of reasons for bypassing electronic alerts may provide insights on physicians’ perceptions to computer-generated prompts as well as informing future customisation and optimisation of alerts. Education and awareness amongst physicians regarding the nature and quality of documentation within electronic records is required.

259 The Electronic Patient Record as an Enabler for Hospital Wide Delirium and Dementia Screening -Lessons Learned from a Clinical Implementation

Background

The validated 4 As Test (4AT) cognitive screening tool was incorporated into the electronic patient record (EPR) to facilitate hospital wide delirium and dementia screening. Completion of the 4AT was mandated by its incorporation into a computer alert targeted at doctors. This alert was generated on all hospital inpatients aged 65 years and over at 24 hours into admission in keeping with the National Institute for Health and Care Excellence guidelines. An option to bypass the 4AT alert was available.

Methods

Multidisciplinary clinical stakeholder workshops informed the design of the electronic cognitive screening alert. An implementation strategy was undertaken using intensive clinical engagement. On June 27th 2018, the 4AT electronic alert was deployed. Data entries from the completed electronic 4AT assessments were extracted from the EPR facilitating descriptive statistical analysis and point prevalence analysis for delirium and dementia. Specialty-based comparisons were also made.

Results

During the first 24 hours post-implementation, 4AT screening assessments were completed in 61% of instances equating to 324 completed assessments. Forty eight percent (n=155) had a score of zero suggestive of normal cognitive status. Notably, 20% assessments yielded a score reflective of possible delirium (four or more). Dementia was a recognised clinical diagnosis in 23% (n=76) of patients. One in two of these dementia patients scored four or more indicative of coexistent delirium.

Conclusion

Electronic patient records can be harnessed to facilitate hospital-wide delirium and dementia screening and improve detection. This also represents a novel method to capture data for the purposes of audit and research as well as to inform and improve future directions in clinical care and resource allocation. Innovative computer-based strategies may offer future directions to augment detection of cognitive disorders in hospitalised populations.

312 Implementation of a Formalised Weekend Hospital Handover Process

Background

Patient handover has been described as “one of the most perilous procedures in medicine” (British Medical Association, 2004). The Irish Medical Council underlines the importance of high-quality, relevant clinical information communication at shift changes.

Methods

On Friday January 26th 2018, the weekend handover practice for medical inpatients requiring medical registrar review was formalised in a large Dublin teaching hospital. Firstly, pertinent clinical information and the purpose of review were captured in an electronic order placed on the electronic patient record (EPR). A verbal handover meeting each Friday supported further discussion and patient handover. Data from the 26th of January to the 7th of July 2018 was analysed from the EPR. The purpose of weekend review was grouped under four categories - full clinical review, laboratory results review, review to facilitate discharge and patients who did not demand formal review but were handed over for information only.

Results

Over the 23 week period, 652 electronic orders for weekend review were placed on medical inpatients. This equated to an average of 27 reviews per weekend. The average age of patients reviewed was 63 years (SD 18.8 years). Median length of stay (LOS) was 4 days with a higher median LOS (6.7 days) observed for those aged 65 years and over. Over half (54%) of all weekend reviews required full clinical review whilst 27% of reviews were for laboratory results follow up only. Comparison between medical inpatients aged less than 65 and greater than 65 years noted little differences between the two cohorts in terms of the purpose of weekend review. Daily review was required for 73% of patents handed over to the medical registrar.

Conclusion

Weekend review of medical inpatients by medical registrars constitutes a significant workload. A formalised weekend handover practice complimented by an electronic process facilitates safer patient handover by improving the quality, transparency and accessibility of clinical information.

Effects of Introducing a Secure Web-based Messenger Application for Communication Among Non-consultant Hospital Doctors (NCHDs)

Introduction: Use of web-based messaging applications to communicate clinical information is common between non-consultant hospital doctors (NCHDs). This study sought to assess web-based messenger use in NCHDs following the introduction of a more secure alternative to WhatsApp (WhatsApp, Inc., Menlo Park, CA, USA).

Methods: A 10-item survey was undertaken on two NCHD cohorts. The second cohort received training on data protection and an alternative application to WhatsApp. Quantitative data analysis was conducted using the IBM Statistical Package for Social Sciences (SPSS) (IBM SPSS Statistics, Armonk, NY).

Results: The total response rate across both groups was 63% (N = 68). The majority of respondents used WhatsApp to communicate clinical information. In the second cohort, fewer NCHDs shared identifiable sensitive patient information 97% (n = 29/30) vs 81% (n = 25/31) and fewer NCHDs shared/stored clinical images.

Discussion: WhatsApp use is common among NCHDs. An alternative means of communication can improve the safety of patient data. NCHDs require more training on data protection laws and their own responsibilities.

Interferon lambda is required for interferon gamma-expressing NK cell responses but does not afford antiviral protection during acute and persistent murine cytomegalovirus infection

Interferon lambda (IFNλ) is a group of cytokines that belong to the IL-10 family. They exhibit antiviral activities against certain viruses during infection of the liver and mucosal tissues. Here we report that IFNλ restricts in vitro replication of the β-herpesvirus murine cytomegalovirus (mCMV). However, IFNλR1-deficient (Ifnλr1-/-) mice were not preferentially susceptible to mCMV infection in vivo during acute infection after systemic or mucosal challenge, or during virus persistence in the mucosa. Instead, our studies revealed that IFNλ influences NK cell responses during mCMV infection. Ifnλr1-/- mice exhibited defective development of conventional interferon-gamma (IFNγ)-expressing NK cells in the spleen during mCMV infection whereas accumulation of granzyme B-expressing NK cells was unaltered. In vitro, development of splenic IFNγ+ NK cells following stimulation with IL-12 or, to a lesser extent, IL-18 was abrogated by IFNλR1-deficiency. Thus, IFNλ regulates NK cell responses during mCMV infection and restricts virus replication in vitro but is redundant in the control of acute and persistent mCMV replication within mucosal and non-mucosal tissues.

Expression of BrpA in Streptococcus mutans is regulated by FNR-box mediated repression

Our previous studies showed that brpA in Streptococcus mutans, which encodes a member of the LytR-CpsA-Psr family of proteins, can be co-transcribed with brpB upstream as a bicistronic operon, and the intergenic region also has strong promoter activity. To elucidate how brpA expression is regulated, the promoter regions were analyzed using polymerase chain reaction-based deletions and site-directed mutagenesis and a promoterless luciferase gene as a reporter. Allelic exchange mutagenesis was also used to examine genes encoding putative trans-acting factors, and the impact of such mutations on brpA expression was analyzed by reporter assays. Multiple elements in the short brpA promoter (nucleotide -1 to -344 relative to start cordon ATG) were shown to have a major impact on brpA expression, including an FNR-box, for a putative binding site of an FNR-type of transcriptional regulator. When compared with the intact brpA promoter, mutations of the highly conserved nucleotides in FNR-box from TTGATgtttAcCtt to TTACAgaaaGtTac resulted in 1362-fold increases of luciferase activity (P < .001), indicative of the FNR-box-mediated repression as a major mechanism in regulation of brpA expression. When luciferase reporter was fused to the upstream brpBA promoter (nucleotides -784 to -1144), luciferase activity was decreased by 4.5-fold (P < .001) in the brpA mutant, TW14D, and by 67.7-fold (P < .001) in the brpB mutant, JB409, compared with the wild-type, UA159. However, no such effects were observed when the reporter gene was fused to the short brpA promoter and its derivatives. These results also suggest that brpA expression in S. mutans is auto-regulated through the upstream brpBA promoter.

A systematic quality assessment of Environmental Impact Statements in the oil and gas industry

The global economy relies heavily on oil and gas resources. However, hydrocarbon exploitation projects can cause significant impacts on the environment. But despite the production of numerous Environmental Impact Statements (EISs) to identify/mitigate such impacts, no study has specifically assessed the quality of EISs for both onshore and offshore oil and gas projects, with tested hypotheses. To address this research gap, our paper, for the first time, develops a modified Lee and Colley evaluation model to assess the quality of 19 sampled oil and gas project EISs produced from 1998 to 2008 in Nigeria. Our findings show that Project Description and Communication of Results are the main areas of strength. However, Environmental Impact Prediction, and Project Decommissioning, were among the key areas requiring attention. A key finding, though, is that Mann-Whitney tests suggest that there is no evidence that the quality of EISs for the latter period (2004-2008) is higher than that of the earlier period (1998-2004). We suggest that periodic systematic review of the quality of submitted/approved EISs (c. every 3-5years) should be established to monitor trends in EIS quality and identify strong and weak areas. This would help to drive continual improvement in both the EIA processes and the resultant EISs of technical engineering projects. Such reviews have the potential to illuminate some of the underlying problems of, and solutions to, oil and gas exploration, production and transportation, and their related environmental impacts. This suggested change would also be useful internationally, including for the burgeoning exploration and production of unconventional hydrocarbon resources.

Debunking health IT usability myths

Poor usability is a threat to patient safety and linked to productivity loss, workflow disruption, user frustration, sub-optimal product use and system de-installations. Although usability is receiving more attention nationally and internationally, myths about usability persist. This editorial debunks five common myths about usability (1) usability only concerns the look and feel of a product and is, therefore, only a minor concern, (2) usability is not measurable, (3) usability stifles innovation, (4) vendors are solely responsible for product usability, and (5) usability methods are not practical for use in healthcare.

Risk factors for self-harm in children and adolescents admitted to a mental health inpatient unit

OBJECTIVE

The aim of this study was to identify risk factors for self-harm for children and adolescents in a mental health inpatient unit.

METHODS

A retrospective file audit of patient files over three years (2006-2009) was conducted to determine risk factors associated with self-harm in children and adolescents admitted to a mental health unit. A checklist of potential factors was based on risk factors found in a review of the literature including demographic information, diagnosis, home situation, environmental stressors, childhood trauma and previous mental health care. The study compared those who self-harmed with a control group who did not self-harm.

RESULTS

There were 150 patients who self-harmed (mean age 14 years) and 56 patients who did not self-harm with a mean age of 13 years. Several factors were identified that increased the likelihood of self-harm, including a diagnosis of depression, female gender, increasing age, being Australian-born, living with a step parent, not having received previous mental health care, having a history of trauma, and having other stressors including problems within the family.

CONCLUSIONS

While increasing age, female gender, a history of trauma and a diagnosis of depression are well known as risk factors for self-harm, this study confirms that family factors, in particular living with a step parent, significantly add to the risk. Child and adolescent services should be aware of the increased risk of self-harm in young people with mental health problems who live in blended families. Treatment approaches need to involve parents as well as the child or young person.

Temporal trends in self harm and aggression on a paediatric mental health ward

OBJECTIVE

The aim of this paper is to describe trends in aggression and self harm on a mental health inpatient unit for children and adolescents between January 2006 and August 2009. Various ward interventions and the ward milieu were evaluated as possible explanatory factors for trends.

METHOD

This was a retrospective study whereby incidents of aggression, self harm and seclusion were obtained from a computerized Incident Information Management System (IIMS) database. Trends in incidents were analysed using linear regression analyses.

RESULTS

Over a 44-month period, 292 incidents of aggression and 139 incidents of self harm were reported. The use of seclusion and the number of aggressive incidents both significantly decreased over time. Trends suggested a positive relationship between the introduction of restraint training, changes in leadership and full staff complement, and a reduction in aggression and seclusion.

CONCLUSIONS

Although the findings are limited by their retrospective nature and reliance on formal records, this study suggests that different factors can contribute to decrease the incidence of adverse events on a psychiatric ward. Future prospective research is needed to assess the effectiveness of different interventions in both the prevention and management of self harm, aggression and seclusion in child and adolescent inpatient units.

Periodic paralysis: an unusual presentation of thyrotoxicosis

Thyrotoxic Periodic Paralysis (TPP) is a rare complication of thyrotoxicosis and is up to 20 times more common in males. Cases usually present with painless muscle weakness precipitated by heavy exercise, fasting, an alcohol binge or large carbohydrate meal. Serum potassium is low in the majority, but normokalaemic (or even hyperkalaemic) TPP is recognised. Acute treatment of any electrolyte disorder, administration of a beta-blocker and treatment of the thyrotoxicosis leads to complete resolution. This rare diagnosis should be considered by the Acute Physician when confronted with any case of muscle weakness.

One stop fertility clinic

The objective of this study was to determine the feasibility and acceptability of out-patient based investigation of infertile couples using a prospective observational study based in a large undergraduate teaching hospital. We studied couples referred to secondary care for investigation of their infertility. Investigations involved pelvic ultrasound, diagnostic hysteroscopy and culdoscopy. The main outcome measures were feasibility of investigations, findings, patient views, and a management plan.

RESULTS

199 of 347 (57.3%) couples referred met our selection criteria, and 162 of this group have attended. Thirty-one (19.1%) were judged to be unsuitable for culdoscopy, and culdoscopy failed in a further 29 (17.9%). The average time for the three procedures was 41.2 (SD 17.2) minutes, and over 1/3 of patients were found to have pelvic pathology. The investigations were well tolerated and there was only one complication necessitating admission to hospital. Most patients appreciated the need for a single hospital visit and the availability of immediate results.

CONCLUSIONS

A One Stop approach to the investigation of infertility is attractive but not suitable for or desired by all infertile couples. Organisational issues were also identified.

Synergistic neurotoxicity of carbon tetrachloride/carbon disulfide (80/20 fumigants) and other pesticides in grain storage workers

Neurophysiologic, neurobehavioral, and neuropsychologic profiles in 17 grain storage workers, 1 grain inspector, and 4 malting laboratory workers are described. The effects of CS2 toxicity as seen in viscose rayon workers as well as in experimental animals is remarkably similar to the clinical profile of our grain storage workers. CS2 use explains the dysfunction of peripheral axons, auditory nerve, the optic nerve, and the extrapyramidal system, as well as altered behavior and cognition changes. The signs and symptoms in these workers seem to be dose-related and we note that workers separated out from the areas where fumigation took place reported improvement not seen by fellow workers who continued the fumigant treatment routine. Likewise, malting laboratory workers exposed only to the grain dust from 3 to 7 years showed only minimal symptoms. Though a number of mechanism have been suggested for the alteration of neuropsychological function, the chelating ability of DDC derived from CS2 and its ability to markedly increase copper and zinc within the central nervous system suggests a mechanism of toxicity analogous to copper intoxication as in Wilson's Disease and may explain the production of extrapyramidal symptoms in these patients. Chelation of copper might prove therapeutic in CS2 poisoning. It is obvious that both basic and clinical research will be necessary to sort out the questions raised. We applaud the EPA's decision to ban the use of 80/20 fumigants and also methyl bromide, and trust that similar toxic substances be carefully studied before their selection for replacing these previous toxic agents. We further decry the technique of re-introducing grain dust into the food chain rather than destroying it, since the dust contains very high residues of fumigant material. We speculate on the possible role of CS2 and other pesticides in the food chain and the incidence of Parkinsonian symptoms in these patients and the general public.

Investigation of retroviral involvement in chronic fatigue syndrome

Within the last few years significant efforts have been made to identify objective reliable diagnostic markers from individuals with chronic fatigue syndrome (CFS). We report the absence of a previously described retroviral marker (HTLV-II gag) in a blinded study of CFS cases. Even with excellent reproducible sensitivities, this marker failed in repeated attempts to distinguish cases from controls. In addition, four other retroviruses (simian T cell leukaemia virus, human spumavirus, bovine leukaemia virus and simian retrovirus) were examined for their presence in these CFS cases and found to be absent. Our findings suggest that these agents, at least as markers, are non-distinguishing for CFS and that other factors may be confounding the resolution of an aetiology to this syndrome.

Inter-Rater Reliability of the Diagnoses of Psychosis and Depression in Individuals with Intellectual Disabilities

BACKGROUND: There is a history of over-prescription of antipsychotics to individuals with intellectual disability (ID), while antidepressants may be under-prescribed. However, appropriate treatment is best supported when the diagnosis of psychosis or depression is valid and carries good predictive validity. The present authors report a study examining one aspect of validity, namely whether skilled clinicians can agree on whether an individual with an ID is psychotic or depressed. MATERIALS AND METHODS: Pairs of clinicians assessed 52 individuals. Agreement was assessed using Cohen's kappa statistic and agreement proportion. RESULTS: Overall agreement was high for both psychosis and depression. Whether the individual had mild ID or moderate/severe ID did not have a significant impact on agreement. CONCLUSIONS: Experienced clinicians achieved a high level of agreement as to whether a person with ID was psychotic or depressed similar to that found for those without ID. The findings provide some support for treatment interventions based on diagnosis.

DNA recognition by the oestrogen receptor: from solution to the crystal

BACKGROUND

The steroid/nuclear hormone receptors are a large family of conserved ligand-activated transcription factors that regulate gene expression through binding to response elements upstream of their target genes. Most members of this family bind to DNA as homodimers or heterodimers and recognize the sequence, spacing and orientation of the two half-sites of their response elements. The recognition and discrimination of the sequence and arrangements of these half-sites are mediated primarily by a highly conserved DNA-binding domain.

RESULTS

Here we describe the DNA-binding properties of the isolated DNA-binding domain of the oestrogen receptor, the ERDBD, and its refined NMR structure. This domain is monomeric in solution, but two molecules bind cooperatively to specific DNA sequences; this cooperativity determines the arrangement of half-sites that is recognized by the ERDBD. The 10 carboxy-terminal residues and a region of 15 residues within the domain are disordered in the solution structure, yet are important for DNA binding.

CONCLUSION

The cooperative nature of ERDBD binding to DNA is important. The previously-determined X-ray structure of the ERDBD dimer bound to DNA shows that the 15 internal residues disordered in solution make contact both with DNA and with the corresponding region of the other monomer. These results suggest that these residues become ordered during the process of binding to DNA, forming the dimer interface and thus contributing to the cooperative interaction between monomers.

Randomized controlled trial of olanzapine in the treatment of cognitions in anorexia nervosa

OBJECTIVE

Recovery from anorexia nervosa is confounded by intrusive anorectic cognitions and rituals. It has been observed that olanzapine, an atypical antipsychotic, can reduce this anorexic rumination. A pilot study was designed to test the effectiveness of olanzapine in this role.

METHODS

A randomized trial of olanzapine versus chlorpromazine, with anorexic rumination as the primary outcome, was conducted. Of the 26 patients who presented, 15 were randomized in a balanced block design, eight to olanzapine and seven to chlorpromazine.

RESULTS

Only the olanzapine group had a significant reduction in the degree of rumination.

CONCLUSION

Olanzapine may be of benefit in anorexia nervosa by causing a reduction in anorexic rumination.

Structure of the TRFH dimerization domain of the human telomeric proteins TRF1 and TRF2

TRF1 and TRF2 are key components of vertebrate telomeres. They bind to double-stranded telomeric DNA as homodimers. Dimerization involves the TRF homology (TRFH) domain, which also mediates interactions with other telomeric proteins. The crystal structures of the dimerization domains from human TRF1 and TRF2 were determined at 2.9 and 2.2 A resolution, respectively. Despite a modest sequence identity, the two TRFH domains have the same entirely alpha-helical architecture, resembling a twisted horseshoe. The dimerization interfaces feature unique interactions that prevent heterodimerization. Mutational analysis of TRF1 corroborates the structural data and underscores the importance of the TRFH domain in dimerization, DNA binding, and telomere localization. A possible structural homology between the TRFH domain of fission yeast telomeric protein Taz1 with those of the vertebrate TRFs is suggested.