P6155Early computed tomographic evaluation for out-of-hospital cardiac arrest survivors: the CT-FIRST trial

Background

Patients surviving an out-of-hospital cardiac arrest (OHCA) commonly present without an obvious etiology, but computed tomography (CT) can provide rapid, comprehensive anatomic evaluation of potential OHCA causes.

Purpose

To assess the diagnostic capabilities of whole body CT imaging in OHCA survivors.

Methods

From 11/2015 to 2/2018, the CT-FIRST (CT Feasibility In Resuscitated patient for Sudden death Triage) protocol enrolled 104 OHCA survivors without obvious OHCA cause to an early (<6 hours from hospital arrival) dual source Sudden Death CT (SDCT) scan protocol that included a non-contrast head, ECG-gated cardiac/thoracic angiography, and non-gated venous phase abdominal CT's. Cardiac CT analysis was blinded, but other SDCT findings were clinically available. Patients needing urgent cardiac catheterization or hemodynamically unable to tolerate CT were excluded. Primary endpoints were SDCT diagnosis compared to OHCA causes from adjudicated record review, and any significantly altered therapy based on SDCT. Acute coronary syndrome by SDCT was conservatively assumed if >50% stenosis was identified in major coronary artery(ies).

Results

SDCT scans identified 39% (41/104) of all OHCA causes and 95% (41/43) of causes potentially identifiable with SDCT (Table). No inappropriate treatments resulted from SDCT findings. SDCT changed or expedited treatments in 21/23 (95%) patients, including antibiotics, anticoagulants, and invasive evaluations or treatments. SDCT found or confirmed resuscitation complications including liver/spleen laceration (n=5), pneumothorax (n=7), and hemopericardium (n=1).

N=104 OHCA Cause SDCT Diagnosis of OHCA Cause N (%) N (%) Acute coronary syndrome 13 (13%) 13 (100%) Cardiomyopathy 8 (8%) 7 (88%) Pneumonia 11 (11%) 11 (100%) Hemorrhagic stroke 3 (3%) 3 (100%) Pulmonary embolism 4 (3%) 4 (100%) Perforated viscus 2 (2%) 2 (100%) Gut necrosis 1 (1%) 1 (100%) Pulmonary hemorrhage 1 (1%) 1 (100%) Substance use 22 (21%) 0 (0%) Unknown 7 (7%) 0 (0%) Other 32 (31%) 0 (0%)

Conclusion

This pilot study suggests the SDCT protocol has considerable promise to diagnose OHCA causes and complications of resuscitation, as well as change clinical treatment.

Acknowledgement/Funding

Medic One Foundation

The role of colonoscopic screening in acromegaly revisited: review of current literature and practice guidelines

INTRODUCTION

Acromegaly is a chronic, debilitating and disfiguring condition with a significantly increased morbidity and mortality due to cardiovascular, as well as respiratory complications. Patients with acromegaly are usually diagnosed at the age of 40, however, the duration of symptoms can vary from 5 to 10 years before the formal diagnosis is confirmed. Recent advances in the field of acromegaly have improved survival significantly. A strong association between acromegaly and premalignant colonic lesions and colon cancer has been highlighted. Furthermore, patients with acromegaly have a greater lifetime risk of malignant transformation and a far worse overall prognosis from colorectal cancer, which is now considered a major disease related complication.

MATERIALS AND METHODS

A comprehensive search strategy was applied for the Medline/PubMed electronic database from its inception until April 2014. We considered all human research articles published in English, not classified as case report, editorial, comment, letter, or news.

CONCLUSION

Specific recommendations for large bowel endoscopic screening in patients with acromegaly have been proposed. In this comprehensive review we discuss the current state of knowledge and evidence on colonoscopic screening in patients with acromegaly illustrated by a case of aggressive colorectal cancer presenting late in a young woman with difficult to control acromegaly.

Aerodynamic levitator furnace for measuring thermophysical properties of refractory liquids

The development of novel contactless aerodynamic laser heated levitation techniques is reported that enable thermophysical properties of refractory liquids to be measured in situ in the solid, liquid, and supercooled liquid state and demonstrated here for alumina. Starting with polished crystalline ruby spheres, we show how, by accurately measuring the changing radius, the known density in the solid state can be reproduced from room temperature to the melting point at 2323 K. Once molten, by coupling the floating liquid drop to acoustic oscillations via the levitating gas, the mechanical resonance and damping of the liquid can be measured precisely with high-speed high-resolution shadow cast imaging. The resonance frequency relates to the surface tension, the decay constant to the viscosity, and the ellipsoidal size and shape of the levitating drop to the density. This unique instrumentation enables these related thermophysical properties to be recorded in situ over the entire liquid and supercooled range of alumina, from the boiling point at 3240 K, until spontaneous crystallization occurs around 1860 K, almost 500 below the melting point. We believe that the utility that this unique instrumentation provides will be applicable to studying these important properties in many other high temperature liquids.

Creating an e-learning module from learning objects using a commentary or 'personal learning assistant'

The use of learning objects (LOs), small chunks of learning stored digitally and reused or referenced to support learning, was described as a promising approach to the creation of e-learning modules or programmes. In practice, however, the early enthusiasm has waned and the approach has not been widely adopted. It is argued that this was due, at least in part, to a neglect of the pedagogy and an emphasis on the technical aspects of interoperability and reusability. This article describes a practical approach to constructing a learning module using LOs where a commentary links LOs selected for inclusion in the programme. The commentary tells the story of the e-learning module and provides the learner with a context for an LO. It can be viewed as a 'personal learning assistant' that advises students about the management of their learning and relates the e-learning module to the overall learning outcomes for the curriculum. The commentary also allows the lecturer to comment on LOs selected for inclusion in the programme which otherwise might have to be adapted or excluded when the programme was constructed. The use of a commentary to link and introduce LOs has been successfully adopted in the development of e-learning programmes. Teachers are encouraged to consider the approach and to look again at the use of LOs to create e-learning resources.

Self-harm, capacity, and refusal of treatment: implications for emergency medical practice. A prospective observational study

OBJECTIVES

In the context of increasing attention to the rights of adults to make treatment decisions for themselves, this study investigated, among patients who have engaged in self-harm (i) the extent of valid decision making; (ii) the impact of mental disorders; and (iii) the effect of systematically providing relevant clinical information.

DESIGN

A prospective observational study.

SETTING

The emergency department of a large teaching hospital in southeast England.

PARTICIPANTS

Seventy one adult men and women who had presented for treatment following self-harm.

MAIN OUTCOME MEASURES

Semi-structured interviews were used to make clinical judgements about participants' capacity to consent before, and following, the presentation of simple written information about the proposed treatment(s). Demographic data, and data about mental disorder and alcohol misuse, were also collected.

RESULTS

Based on accepted legal criteria, only 28/71 (39.4%) of the patients were judged to have capacity to consent to the proposed intervention(s) initially. However, the number of patients judged to have capacity improved significantly (p<0.001) after the presentation of written information, to 45/71 (63.4%). Those judged incapable were significantly more likely (p<0.01) to refuse treatment. Continuing incapacity was significantly associated only with cognitive impairment (p<0.001) and/or severe psychiatric disturbance (p<0.01).

CONCLUSIONS

Consistent with current views, capacity is not static, even among patients who have engaged in self-harm, but can be improved through a simple intervention. The findings are consistent with recent guidance about supporting this vulnerable group of patients, many of whom are ambivalent about treatment.

Prion protein (PrP) gene polymorphisms associated with natural scrapie cases and their flock-mates in Ireland

The PrP genotypes associated with natural scrapie in Ireland were determined and a comparison was made between genotypes found in scrapie-infected sheep and those found in healthy animals from scrapie-infected flocks. Seven PrP genotypes were identified in scrapie-infected animals: VV(136)RR(154)QQ(171),VA(136)RR(154)QQ(171),VA(136)RR(154)QR(171),VA(136)RR(154)QH(171),AA(136)RR(154)QQ(171),AA(136)RR(154)QH(171) and AA(136)RR(154)HH(171). Of 11 scrapie-infected flocks, 15 genotypes were identified in the healthy flock-mates. The genotypes identified in scrapie-affected animals were also all identified in healthy flock-mates. In 9 of the 11 flocks studied, the genotype frequencies among scrapie-infected animals were significantly different from those among healthy flock-mates. The results show that there is a significant risk of developing the clinical signs of scrapie associated with particular PrP genotypes in the Irish sheep population. The association between the V(136)R(154)Q(171) allele and scrapie was evident, as was the association between A(136)R(154)R(171) and resistance to developing the clinical signs of scrapie. The presence of the A(136)H(154)Q(171) allele in the flocks examined resulted in a decreased risk of developing scrapie compared to the presence of the A(136)R(154)Q(171).

A mass in the liver

We report a case of alveolar echinococcosis. To our knowledge this is the first report of human alveolar echinococcosis to be confirmed in the UK and if contracted in Afghanistan the first report for that country.

A family of closely related bovine viral diarrhea virus recombinants identified in an animal suffering from mucosal disease: new insights into the development of a lethal disease in cattle

Induction of lethal mucosal disease (MD) in cattle is linked to the generation of cytopathogenic (cp) bovine viral diarrhea virus (BVDV) in animals persistently infected with a noncytopathogenic BVDV. In most cases the cp variants are generated by recombination with cellular or viral sequences. BVDV was obtained from the serum of an MD animal and propagated in tissue culture without plaque purification. Analysis of cDNA clones established from RNA of these cells showed that apparently a variety of different viral RNAs were present. Seven of the cDNA clones contained a cellular sequence coding for light chain 3 (LC3) of microtubule-associated proteins 1A and 1B. This insertion had already been found in the cp virus JaCP obtained from the same animal and isolated by plaque purification. Analysis of further plaque-purified cp viruses showed that the diseased animal contained a family of closely related cp BVDV recombinants. A set of viruses with different duplications of viral sequences in their genomes and a variety of defective viral RNAs with deletions were found that all contained the LC3* insertion. For all the recombinants the 3' recombination sites and, in all but one case, also the 5' recombination sites between cellular and viral sequence were identical. Variation between the individual deduced genome structures resulted from different duplications or deletions of viral sequences located upstream of the cellular insertion. These results suggest that within the animal a primary recombinant with a genome containing the LC3* insertion was generated. In a trimming process a set of secondary virus recombinants was generated from this hypothetical primary recombined RNA. These secondary recombinants display genome structures that represent variations of the basic scheme already present in the primary recombinant. Apparently this trimming process that finally led to an outbreak of MD lasted a long time since recombined RNA with the basic genome structure of the cp viruses could be demonstrated in samples already taken a long time before outbreak of the disease.

Significant association of cagA positive Helicobacter pylori strains with risk of premature myocardial infarction

OBJECTIVE

To investigate whether genetic diversity of Helicobacter pylori influences its association with coronary heart disease, and specifically whether the risk is confined to infection with the more virulent strains bearing the cytotoxin associated gene-A (cagA) antigen.

DESIGN AND SETTING

Case-control study in hospital admitting unselected patients with myocardial infarction.

METHODS AND SUBJECTS

Serological status for cagA and H pylori were determined in 342 cases of acute myocardial infarction and 214 population based control subjects free of clinical coronary heart disease.

RESULTS

38.0% of cases and 30.8% of controls were cagA seropositive (odds ratio 1.38, 95% confidence interval (CI) 0.94 to 2.01, p = 0.08). In subjects < 65 years old (153 cases, 153 controls), cagA seropositivity was associated with a 1.80-fold increase (95% CI 1.07 to 3.03, p = 0.02) in myocardial infarction risk, which increased further to 2.25-fold (95% CI 1.12 to 4.53, p = 0.01) in subjects < 55 years. There was no significant association of cagA status with classical coronary heart disease risk factors. H pylori seropositivity was present in 60.2% of cases and 53.7% of controls (odds ratio 1.12, 95% CI 0.83 to 1.51, p = 0.43). H pylori seropositivity was not increased in young cases and did not show any interaction with age.

CONCLUSIONS

The association of chronic H pylori infection with risk of myocardial infarction appears to be restricted to cagA bearing strains. The association is age dependent and stronger in younger subjects. Genetic heterogeneity of H pylori may explain some of the discordant findings with regard to the association of H pylori with coronary heart disease.

A rapid and sensitive PCR-based diagnostic assay to detect bovine herpesvirus 1 in routine diagnostic submissions

We describe a rapid, sensitive and specific polymerase chain reaction (PCR) assay for the detection of BHV1 DNA in a range of routine diagnostic submissions without the need for prior virus isolation. The assay, which is based on the selected amplification of a portion of the viral tk gene, detected both BHV1.1 and BHV1.2 subtypes in a panel of 15 characterised field isolates, and its sensitivity was estimated to be <0.125 TCID(50). BHV2, alcephaline herpesvirus, BHV4, equine herpesvirus 1 (EHV1), EHV4 and pseudorabies virus were not detected confirming the specificity of the assay. One hundred and five diagnostic submissions, including tissues, nasal secretions and nasal swabs were taken from cattle with respiratory disease and tested using the routine methods of virus isolation (VI) and the fluorescent antibody test (FAT), and the results were compared with those obtained by PCR. The PCR assay detected BHV1 DNA in all samples that were positive by VI. BHV1 DNA was also detectable by PCR in raw and extended semen samples at a sensitivity of 1 TCID(50) per 50microl. The assay also detected BHV5, permitting differentiation between it and BHV1 by virtue of the size of the amplified PCR product. The PCR assay is more sensitive and independent of sample quality than either virus isolation or FAT, and it is faster than virus isolation. The sample preparation method is simple with few steps involved. There are no extra post-amplification blotting/hybridisation steps and the assay is not based on a nested PCR strategy that might otherwise exacerbate the problem of oversensitivity/contamination in the routine use of such a test in a diagnostic laboratory. This assay would permit discrimination between those animals naturally infected with wild type BHV1 and those vaccinated with tk-BHV1 strains.

The capacity of people with a 'mental disability' to make a health care decision

BACKGROUND

Based on the developing clinical and legal literature, and using the framework adopted in draft legislation, capacity to make a valid decision about a clinically required blood test was investigated in three groups of people with a 'mental disability' (i.e. mental illness (chronic schizophrenia), 'learning disability' ('mental retardation', or intellectual or developmental disability), or, dementia) and a fourth, comparison group.

METHODS

The three 'mental disability' groups (N = 20 in the 'learning disability' group, N = 21 in each of the other two groups) were recruited through the relevant local clinical services; and through a phlebotomy clinic for the 'general population' comparison group (N = 20). The decision-making task was progressively simplified by presenting the relevant information as separate elements and modifying the assessment of capacity so that responding became gradually less dependent on expressive verbal ability.

RESULTS

Compared with the 'general population' group, capacity to make the particular decision was significantly more impaired in the 'learning disability' and 'dementia' groups. Importantly, however, it was not more impaired among the 'mental illness' group. All the groups benefited as the decision-making task was simplified, but at different stages. In each of the 'mental disability' groups, one participant benefited only when responding did not require any expensive verbal ability.

CONCLUSIONS

Consistent with current views, capacity reflected an interaction between the decision-maker and the demands of the decision-making task. The findings have implications for the way in which decisions about health care interventions are sought from people with a 'mental disability'. The methodology may be extended to assess capacity to make other legally-significant decisions.

Insertion of a sequence encoding light chain 3 of microtubule-associated proteins 1A and 1B in a pestivirus genome: connection with virus cytopathogenicity and induction of lethal disease in cattle

Pestiviruses represent the first RNA viruses for which recombination with cellular protein-coding sequences has been reported. As a result of such recombinations cytopathogenic (cp) pestiviruses can develop from noncytopathogenic (noncp) viruses. In the case of bovine viral diarrhea virus (BVDV), the generation of cp mutants is linked to the induction of the lethal syndrome mucosal disease (MD) in cattle. The cp BVDV JaCP was isolated from an animal which had come down with MD. The genome of JaCP contains a novel kind of cellular insertion (LC3*) which is flanked by duplicated pestivirus sequences. Neither insertion nor duplication is present in the genome of the accompanying noncp virus JaNCP. As part of the viral polyprotein, the insertion in the JaCP genome is translated into a polypeptide almost identical to a fragment of light chain 3, a subunit of the microtubule-associated proteins 1A and 1B from the rat. Transient-expression studies revealed that the LC3* sequence is able to induce an additional cleavage of the viral polyprotein. The respective cleavage occurs directly downstream of the LC3*-encoded sequence and is not dependent on the NS3 serine protease. Insertion of LC3* into an infectious noncp pestivirus cDNA clone without duplicated viral sequences resulted in recovery of a defective cp virus able to replicate only in the presence of a noncp helper virus. In contrast, introduction of both insertion and duplication led to an autonomously replicating cp virus.

Establishment of serial persistent infections with bovine viral diarrhoea virus in cattle and sheep and changes in epitope expression related to host species

A pestivirus was transmitted by contact from a persistently infected (P.I.) bullock to pregnant sheep. This resulted in the birth of P.I. lambs, one of which in turn was able to transmit virus by contact to pregnant cattle. Two of these animals gave birth to P.I. calves, from one of which the virus was again transmitted by contact with pregnant sheep, leading to another generation of P.I. lambs. The expression of one or more epitopes on the E2 glycoprotein of the viruses isolated from this series of alternate cattle-sheep transmissions appeared to depend on the host species. Thus, several monoclonal antibodies which bound strongly to, and neutralised, viruses isolated from the bovine hosts, failed to bind or neutralise in the case of sheep isolates. The viral consensus sequences of the E2 gene as well as parts of the 5' untranslated region and of the Npro and capsid genes were compared between the different isolates. This revealed a high degree of genetic stability. However, a single codon change at amino acid position 9 of the E2 gene correlated with and was able to cause the loss of particular epitopes.

Labeling of proteins by organometallic complexes of rhenium. (I). Synthesis and biological activity of the conjugates

We describe herein a totally new pathway for the introduction of rhenium in the form of low oxidation state organometallic complexes covalently attached to various proteins. The synthesis of several rhenium conjugates takes advantage of the specificity of N-succinimidyl esters for amino residues. Conjugation experiments were carried out under various conditions, and analysis of the conjugates was performed by FT-IR spectroscopy. Yields were optimized and reached 50%. Furthermore, the conjugate resulting from the coupling of N-succinimidyl 4-[eta 5-cyclopentadienylrhenium tricarbonyl] 4-oxobutanoate to an anti-hTSH monoclonal antibody retained a satisfactory immunoreactivity. Finally, IR detection of conjugates adsorbed onto nitrocellulose membranes was achieved and response was found to be related to the coupling extent of the conjugate.

A truncated form of fibroblast growth factor receptor 1 inhibits signal transduction by multiple types of fibroblast growth factor receptor

A truncated form of the type 1 fibroblast growth factor receptor (FGFR1) lacking most of its cytoplasmic domain was tested for its ability to inhibit signal transduction by each of three different wild-type FGFRs (FGFR1, 2, and 3). When the truncated FGFR1 was expressed in Xenopus oocytes in excess of each wild-type FGFR, mobilization of intracellular calcium mediated by the wild-type FGFRs was completely blocked. The truncated FGFR did not inhibit signal transduction by the co-expressed platelet-derived growth factor beta-receptor. A form of truncated FGFR1 which lacked the first immunoglobulin-like domain also inhibited signal transduction by wild-type FGFRs. Truncated FGFR formed complexes with wild-type FGFR in the presence of basic FGF in intact cells. These observations were consistent with the hypothesis that the truncated FGFR interacted with wild-type FGFRs to form nonfunctional heterodimers, thus eliminating the signaling by the wild-type FGFRs. The observation that signaling by multiple types of FGFR can be blocked by a single type of truncated FGFR suggests that the different types of FGFR can interact with each other in ligand-mediated complexes. These findings provide a molecular basis for inhibiting the actions of FGFs in vivo.

Comparative analysis of monoclonal antibodies against pestiviruses: report of an international workshop

Thirty-three pestivirus strains were grown in cell culture and characterized by immunostaining with 19 monoclonal antibodies (MAbs) raised against hog cholera virus (HCV), with 42 MAbs against bovine viral diarrhoea virus (BVDV) and with 13 MAbs against border disease virus (BDV). Seven MAbs reacted with all pestivirus strains tested, eight MAbs detected only the seven HCV strains, three detected only the 16 BVDV strains. No MAb was found that was specific for BDV. BVDV and BDV strains were broadly cross-reactive with the MAbs, indicating a close relationship between these two species, whereas HCV strains were characterized as distinct from BVDV and BDV.

High Performance Liquid Chromatographic Determination of Intermediates and Reaction By-Products in FD&C Yellow No. 5: Collaborative Study

Eight laboratories participated in a collaborative study of an ion exchange high performance liquid chromatographic procedure for determining the intermediates and 2 reaction by-products in FD&C Yellow No. 5: phenylhydrazine-p-sulfonic acid (PHSA), sulfanilic acid (SA), l-(4-sulfophenyl)-3- carboxy-5-hydroxypyrazolone (PyT), l-(4-sulfophenyl) - 3 -ethylcarboxy-5-hydroxypyrazolone (EEpyT), and 4,4'-(diazoamino)-dibenzenesulfonic acid (DAADBSA). The repeatability and reproducibility standard deviations (absolute) found in the study were 0.0134 and 0.0263 for PHSA at the 0.1% level, 0.0246 and 0.0256 for SA at the 0.2% level, 0.0124 and 0.0149 for EEpyT at the 0.1% level, 0.0212 and 0.0258 for PyT at the 0.2% level, and 0.0234 and 0.0373 for DAADBSA at the 0.2% level. The method was adopted official first action.

High Performance Liquid Chromatographic Determination of Intermediates and Two Reaction By-Products in FD&C Red No. 40: Collaborative Study

Nine laboratories participated in a collaborative study of an ion exchange high performance liquid chromatographic procedure for determining the intermediates and 2 reaction by-products in FD&C Red No. 40: cresidine sulfonic acid (CSA), Schaeffer’s Salt (SS), 4,4’-(diazoamino)bis(5-methoxy-2-methylbenzenesulfonic acid) (DMMA), and 6,6’-oxybis(2- naphthalenesulfonic acid) (DONS), respectively. The repeatability and reproducibility standard deviations (absolute) found in the study were 0.012 and 0.019 for CSA at the 0.2% level, 0.004 and 0.006 for DMMA at the 0.1% level, 0.067 and 0.087 for DONS at the 1% level, and 0.015 and 0.020 for SS at the 0.3% level, respectively. The method has been adopted official first action.

High Performance Liquid Chromatographic Determination of Sulfanilic Add, Schaeffer’s Salt, 4,4´-(Diazoamino)-DibenzenensuIfonic Acid, and 6,6´-Oxybis(2-Naphthalenesulfonic Acid) in FD&C Yellow No. 6: Collaborative Study

Eight laboratories participated in a collaborative study of a high performance liquid chromatographic procedure for determining sulfanilic acid, Schaeffer's salt, 4,4´-(diazoamino)-dibenzenesulfonic acid (DAADBSA), and 6,6´-oxybis(2-naphthalenesulfonic acid) (DONS) in FD&C Yellow No. 6. The standard deviations for one analysis in any one laboratory for sulfanilic acid at 0.2%, Schaeffer's salt at 0.26%, DAADBSA at 0.1%, and DONS at 1.0% were 0.015%, 0.014%, 0.018%, and 0.077%, respectively. The method has been adopted as official first action.

Histological and histochemical observations on the myenteric and submucous plexuses of mammals

Images