Effects of smartphone application-based cognitive training at home on cognition in community-dwelling non-demented elderly individuals: A randomized controlled trial

INTRODUCTION

We investigated whether cognitive function improves in elderly individuals after Application-based Cognitive Training at Home (ACTH) for 12 months.

METHODS

A total of 389 non-demented elderly volunteers aged over 60 years were recruited and randomly assigned to the intervention or control group. The intervention group underwent daily ACTH (with regular feedback from the administrator) and monthly offline cognitive training in groups for 12 months. All participants received a computerized cognitive test battery called Inbrain Cognitive Screening Test (Inbrain-CST) at baseline and 6 and 12 months. The primary outcome was the change in the total composite score of Inbrain-CST, and secondary outcomes included changes in composite scores in five cognitive domains of Inbrain-CST.

RESULTS

The intervention group outperformed the control group in terms of the total score (P = .001) and subscores of language (P < .001) and memory (P < .001) domains at 12 months.

DISCUSSION

ACTH improved global cognition in community-dwelling non-demented elderly individuals.

Pseudophoenix ekmanii (Arecaceae) seeds at suboptimal temperature show reduced imbibition rates and enhanced expression of genes related to germination inhibition

Pseudophoenix ekmanii is a critically endangered palm species that can be found in the southeast of the Dominican Republic. The temperatures to which P. ekmanii seeds are exposed upon dispersal range from 32 to 23 °C (max and min) and can reach a low of approximately 20 °C in January. Our aim was to analyse the effect of suboptimal (20 °C) and optimal (30 °C) germination temperature on seed imbibition, moisture content, embryo growth and gene expression patterns in this tropical palm species. Seed imbibition was tracked using whole seeds, while moisture content was assessed for individual seed sections. Embryo and whole seed size were measured before and after full imbibition. For transcriptome sequencing, mRNA was extracted from embryo tissues only and the resulting reads were mapped against the Elaeis guineensis reference genome. Differentially expressed genes were identified after statistical analysis and subsequently probed for enrichment of Gene Ontology categories 'Biological process' and 'Cellular component'. Our results show that prolonged exposure to 20 °C slows whole seed and embryo imbibition and causes germination to be both delayed and inhibited. Embryonic transcriptome patterns associated with the negative regulation of germination by suboptimal temperature include up-regulation of ABA biosynthesis genes, ABA-responsive genes, as well as other genes previously related to physiological dormancy and inhibition of germination. Thus, our manuscript provides the first insights into the gene expression patterns involved in the response to suboptimal temperature during seed imbibition in a tropical palm species.

Tuberculosis infection via the emergency department among inpatients in South Korea: a propensity score matched analysis of the National Inpatient Sample

BACKGROUND

Emergency departments (EDs) carry a high risk of infectious disease transmission and have also been implicated in tuberculosis (TB) outbreaks.

AIM

To determine if patients who visit EDs have an increased risk of TB infection. Using South Korean inpatient sample data (2012), the risk of TB occurrence during 90 days after hospitalization for patients admitted via EDs was compared with that for patients admitted via outpatient clinics.

METHODS

The data of the 2012 Health Insurance Review and Assessment Service - National Inpatient Sample were used. TB diagnosis was based on International Classification of Diseases Version 10 [all TB (A15-A19), pulmonary TB (A15-A16) and extrapulmonary TB (A17-A18)].

FINDINGS

After propensity score matching using the demographic and clinical characteristics of the patients, 191,997 patients (64,017 patients admitted via EDs and 127,908 patients admitted via outpatient clinics) were included in this study. There was no significant difference in baseline patient characteristics between the two groups. The percentage of patients with TB admitted via EDs was higher than that of patients admitted via outpatient clinics. The likelihood of active TB occurrence was 30% higher for all TB [hazard ratio (HR) 1.30; 95% confidence interval (CI) 1.12-1.52] and pulmonary TB (HR 1.30; 95% CI 1.10-1.53) in patients admitted via EDs compared with patients admitted via outpatient clinics; this difference was significant. However, no difference in the occurrence of extrapulmonary TB was observed between the two groups.

CONCLUSIONS

The likelihood of TB infection was greater in patients admitted via EDs than in patients admitted via outpatient clinics.

Delivery of rural and remote health care via a broadband Internet Protocol network – views of potential users

summary

We asked the views of potential users of a proposed Canadian broadband Internet Protocol (IP) network for health, the Alberta SuperNet. The three user groups were drawn from the public, provider and private sectors. In all, 35 health-sector participants were selected (17 government, nine health-care organizations, five providers/ practitioners and four private sector). The questionnaire was Web-based, semistructured and self-administered. It consisted of four major areas: value, readiness, effect on usual care and limitations. A total of 28 (80%) individuals responded to the questionnaire: 21 (81%) were from the public sector (three provincial, nine regional and nine organizational), three (60%) were from the provider sector and four (100%) were from the private sector. Overall, the items related to health services and health human resources were considered to be the most valuable to rural communities. Respondents identified the expansion of telehealth services as the most important, except those from the private sector, who ranked this a close second. The health system's move to the use of electronic health records was ranked second in importance by all respondents. The private-sector respondents viewed all user groups to be generally less ready (mean score 2.5 on a seven-point scale from 1 = not ready to 7 = ready), while the public-sector respondents were the most optimistic (mean score 4.0). Specific socioeconomic impact data were limited. The top-ranked disadvantage of the 10 suggested was that ‘Changes in health-service delivery practices and/or processes will be required’.

Community-based sampling methods for surveillance of the Chagas disease vector, Triatoma dimidiata (Hemiptera: Reduviidae: Triatominae)

In Guatemala, the most widespread vector of Trypanosoma cruzi (Kinetoplastida: Trypanosomatidae), the causative agent of Chagas disease, is Triatoma dimidiata (Latreille) (Hemiptera: Reduviidae: Triatominae). T. dimidiata is native to Guatemala and is present in both domestic and sylvatic habitats. Consequently, control of T. dimidiata is difficult because after successful elimination from homes, individual insects can recolonize homes from the surrounding environment. Therefore, intensive long-term surveillance of this species is essential to ensure adequate control is achieved. Manual inspection for signs of infestation, the current method used to monitor Triatominae throughout Central and South America, is labor and time-consuming, so cost-effective alternatives are needed. The current study compared the effectiveness of the current method of surveillance of T. dimidiata with community-based techniques of G6mez-Nuñez sensor boxes, collection and observation of bugs by householders, and presence of triatomine-like feces on walls. Although manual inspection was the most sensitive method when used alone, collection by householders also was sensitive and specific and involved less effort. Sensor boxes were not sensitive indicators of T. dimidiata infestation when used alone. Two recorded variables, visual inspection for feces and the sighting of bugs by householders, were sensitive and specific indicators of infestation, and in combination with collection by householders and sensor boxes these methods were significantly more likely to detect infestations than manual inspection alone. A surveillance program that combines multiple community-based techniques should have low cost and involve minimal effort from the government and at the same time promote sustainable community involvement in disease prevention.

Risk factors for domestic infestation by the Chagas disease vector, Triatoma dimidiata in Chiquimula, Guatemala

In Guatemala prior to control initiatives, the main vectors of Trypanosoma cruzi, the causative agent of Chagas disease, were Rhodnius prolixus and Triatoma dimidiata. This study conducted in 2006 in the department of Chiquimula recorded a high level of T. dimidiata infestation and an absence of R. prolixus in all surveyed communities. In Guatemala, the presence of T. dimidiata as domestic, peridomestic and sylvatic populations results in control difficulties as houses are re-infested from the surrounding environment. Entomological surveys, the current method used to select houses in need of control efforts, are labour intensive and time consuming. A time- and cost-effective way to prioritize houses for evaluation and subsequent treatment is the stratification of houses based on the risk of triatomine infestation. In the present study, 17 anthropogenic risk factors were evaluated for associations with house infestation of T. dimidiata including: wall, floor and roof type. There was an increased likelihood of domestic infestation with T. dimidiata associated with the presence of dirt floors (18/29; OR 8.075, 95% CI 2.13-30.6), uncoated bajareque walls (12/17; OR 4.80, 95% CI 1.35-17.1) and triatomine-like faeces on walls (16/26; OR 3.89, 95% CI 1.19-12.7). These factors could be used to target control of T. dimidiata to communities with an increased risk of being infested.

A reappraisal of functional reconstruction of extension of the knee following quadriceps resection or loss

The current indications for functional restoration of extension of the knee following quadriceps resection or loss require reappraisal. The contribution of pedicled and free functional muscle transfer is likely to be over-emphasised in many studies, with good functional outcomes predominantly reported only in the context of cases with residual quadriceps function. In cases with total quadriceps resection or loss, all forms of reconstruction perform poorly. Furthermore, in smaller resections with loss of two or fewer components of the quadriceps, minimal impairment of function occurs in the absence of functional reconstruction, suggesting that functional restoration may not be warranted. Thus there is a paradox in the current approach to quadriceps reconstruction, in that small resections are likely to be over-treated and large resections remain under-treated. This review suggests a shift is required in the approach and rationale for reconstructing functional extension of the knee after quadriceps resection or loss. A classification based on current evidence is suggested that emphasises more clearly the indications and rationale for functional transfers.

Factors predicting deviation from an enhanced recovery programme and delayed discharge after laparoscopic colorectal surgery

AIM

The study aimed to identify factors that predict postoperative deviation from an enhanced recovery programme (ERP) and/or delayed discharge following colorectal surgery.

METHOD

Data were prospectively collected from all patients undergoing elective laparoscopic colorectal resection between January 2006 and December 2009. They included Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) variables, body mass index (BMI), sex, preoperative serum albumin, pathology, conversion from a laparoscopic to an open approach and postoperative length of hospital stay.

RESULTS

There were 176 patients (90 women) of mean age 68 years. Fifteen (9%) operations were converted from laparoscopic to open. The remainder were completed laparoscopically. Fifty-five (31%) deviated from the ERP, with most failing multiple elements. The most common reason was failure to mobilize, which often occurred in conjunction with paralytic ileus or analgesic failure. Factors independently predicting ERP deviation on multivariate analysis were pathology and intra-operative complications. The median length of stay was 5 days. Sixty-four (36%) patients had a prolonged length of stay that was predicted by age, number of procedures and ERP deviation.

CONCLUSION

Pathology and intra-operative complications are independent predictors of ERP deviation. Prolonged length of stay can be predicted by age, multiple procedures and ERP deviation. Failure to mobilize should be considered as a red flag sign prompting further investigation following colorectal resection.

Plasma ghrelin levels and their relationship with gastric emptying in patients with dysmotility-like functional dyspepsia

BACKGROUND/AIMS

Ghrelin affects gastric motility. However, little is known about the role of ghrelin in the pathophysiology of functional dyspepsia (FD). We investigated plasma ghrelin levels and their relationship with gastric emptying time in dysmotility-like FD patients.

METHODS

42 patients with dysmotility-like FD and 14 healthy volunteers were enrolled in the study. Gastric half-emptying time was measured using a radiolabeled meal. Plasma total ghrelin levels before and after the meal were determined using a radioimmunoassay kit.

RESULTS

Preprandial ghrelin levels were significantly lower in FD patients than in controls. Postprandial ghrelin levels were similar between the two groups. Abnormally low preprandial ghrelin levels were observed in 7 out of 42 patients, in whom significant postprandial decrease of ghrelin levels was absent. Delayed gastric emptying was observed in 5 out of 7 patients with abnormally low ghrelin levels. Pre- or postprandial ghrelin levels were not significantly correlated with gastric half-emptying time, both in the patient group and in the control group.

CONCLUSIONS

Abnormally low preprandial ghrelin levels and absence of significant postprandial decrease of ghrelin levels are present in a subset of dysmotility-like FD patients. Further investigation on the pathogenetic implication of these alterations in FD is required.

Novel action of gastric proton pump inhibitor on suppression of Helicobacter pylori induced angiogenesis

BACKGROUND

Although activation of mitogen activated protein kinases (MAPKs) by Helicobacter pylori infection is associated with induction of host angiogenesis, which may contribute to H pylori associated gastric carcinogenesis, the strategy for its prevention has not been identified. As we previously reported a strong inhibitory action of gastric proton pump inhibitors (PPIs) on MAPK extracellular signal regulated kinase (ERK)1/2 phosphorylation, we investigated whether PPIs could suppress the H pylori induced angiogenesis via inhibition of MAPK ERK1/2.

METHODS

To address the relationship between H pylori infection and angiogenesis, comparative analysis of density of CD34(+) blood vessel was performed in tissues obtained from 20 H pylori positive gastritis and 18 H pylori negative gastritis patients. Expression of hypoxia inducible factor 1 (HIF-1alpha) and vascular endothelial growth factor (VEGF) was tested by reverse transcription-polymerase chain reaction and secretion of interleukin 8, and VEGF was measured by ELISA. To evaluate the direct effect of H pylori infection on the tubular formation of human umbilical vein endothelial cells (HUVEC), an in vitro angiogenesis assay was employed. Activation of MAPK and nuclear factor kappaB (NFkappaB) was detected by immunoblotting.

RESULTS

H pylori positive gastritis patients showed a higher density of CD34(+) blood vessels (mean 40.9 (SEM 4.4)) than H pylori negative gastritis patients (7.2+/-0.8), which was well correlated with expression of HIF-1alpha. Conditioned media from H pylori infected gastric epithelial cells directly induced tubular formation of HUVEC and the increase of in vitro angiogenesis was suppressed by PPI treatment. Infection of H pylori significantly upregulated expression of HIF-1alpha and VEGF in gastric epithelial cells and expression of proangiogenic factors was mediated by MAPK activation and partially responsible for NFkappaB activation. PPIs effectively inhibited the phosphorylation of MAPK ERK1/2 that is a principal signal for H pylori induced angiogenesis.

CONCLUSIONS

The fact that PPIs could downregulate H pylori induced angiogenesis indicates that antiangiogenic treatment using a PPI could be a promising protective therapeutic approach for H pylori associated carcinogenesis.

Incorporating ethics in priority setting: a case study of a regional health board in Canada

The authors were involved in developing an ethical framework to assist the Queens Region Board (Prince Edward Island, Canada) set priorities in health and health care. Two and one half years after the adoption of this framework, the authors undertook an evaluation of the framework. This paper will discuss: (a) the historical background of regionalization in Canada, and in particular the circumstances leading up to the institution of regional boards in Prince Edward Island; (b) the sorts of ethical issues facing the Queens Regional Board; (c) issues arising in connection with the use and development of ethics frameworks for managing ethical issues in priority setting; (d) the framework adopted by the Queens Board and the process that led to its development; (e) issues arising as concerns implementation of the framework; (f) questions and issues pertinent to other boards and bodies considering similar initiatives.

Different role of functional domains of hTR in DNA binding to telomere and telomerase reconstruction

Even if template sequence of hTR played an essential role in telomere binding, a 326 nucleotide fragment of hTR containing template, pseudoknot, and CR4-5 domains is critical for both binding with telomeric DNA and reconstitution of telomerase activity. A functional study with antisense oligonucleotides suggested that targeted disruption of the template region efficiently abrogated both telomeric DNA binding and telomerase activity, whereas disruption of the CR4-5 region induced only loss of telomerase activity. hTR interacts with telomeric DNA via structural region composed of the template, pseudoknot, and CR4-5 domains, however, each structural domain plays a distinct role in telomere binding and telomerase activity reconstitution.

Acute opioid withdrawal on accidental injection of naltrexone

We report two 16-year-old female intravenous drug users who, after making purchases from street suppliers, both presented with symptoms of acute opioid withdrawal. Urine toxicology revealed naltrexone, a long-acting opioid antagonist used in detoxification and maintenance therapy in opioid dependence. While the safety and efficacy of opiate antagonist treatment is being debated, the present case highlights the vulnerability of this young population. The recent availability of non-prescribed opiate antagonists suggests that both health professionals and young people themselves need to be aware of their effects.

Adolescent admissions to a tertiary paediatric hospital: a dynamic pattern

INTRODUCTION

Adolescent inpatient facilities emerged in Australia in the 1980s to cater for an increasing number of young people with chronic illness and disability. Yet, there is minimal published data on the number of young people admitted to hospital within these units, their unit of admission, length of stay or reason for admission. A 12-year audit of adolescents admitted to a tertiary hospital with a dedicated adolescent unit and adolescent medicine programme in Victoria, Australia, was conducted to review the pattern of hospitalisation in young people in order to provide data to assist healthcare policy and planning agendas.

MATERIALS AND METHODS

Admissions to the Royal Children's Hospital in Victoria, Australia, of adolescents aged 10 years and above were reviewed over a 12-year period from 1990 to 2001. We identified the annual number of adolescents admitted, the proportion of adolescents admitted to the Adolescent Inpatient Unit (ward) and annual admissions under the Adolescent Medicine Unit (department).

RESULTS

Adolescents now constitute nearly 30% of all admissions at this children's hospital. Over this period, admissions to the Adolescent Inpatient Unit have nearly doubled and annual admissions under the Adolescent Medicine Unit rose from 38 to 288. The majority of adolescents were admitted under specialty medical and surgical units.

CONCLUSIONS

The knowledge that nearly one in three admissions to this tertiary children's hospital is over 10 years old should help promote the development of planning and policy agendas that better balance both health and developmental priorities in this age group.

Strategies to promote better outcomes in young people with chronic illnesses

INTRODUCTION

This paper aims to provide an overview of chronic illness and disability in young people, focusing on the developmental needs of young people and the impact of chronic illness on adolescence. The emotional well-being of the young person with chronic illness is explored and strategies that promote better health outcomes for the young person through health, family and school settings are discussed.

METHODS

Literature was searched using Medline from 1980 to 2002 using the keywords chronic illness, chronic disease, disability, psychological, social, outcomes and transition. Articles were also hand searched from retrieved articles.

CONCLUSIONS

Young people with chronic illness have the same developmental needs as other adolescents. Traditional health care is focused on disease outcomes; however, young people do not necessarily share the same focus. Improving health outcomes for young people involves health professionals having an understanding of adolescent development and broadening the medical perspective to incorporate the developmental perspective. Building competence in young people with chronic illness, strengthening connectedness within the family, school and peer group and building the capacity of the health care team in different settings will provide opportunities to enhance resilience in young people with chronic illness. In doing so, their health outcomes will hopefully also be improved.

Membrane blebbing during apoptosis results from caspase-mediated activation of ROCK I

The execution phase of apoptosis is characterized by marked changes in cell morphology that include contraction and membrane blebbing. The actin-myosin system has been proposed to be the source of contractile force that drives bleb formation, although the biochemical pathway that promotes actin-myosin contractility during apoptosis has not been identified. Here we show that the Rho effector protein ROCK I, which contributes to phosphorylation of myosin light-chains, myosin ATPase activity and coupling of actin-myosin filaments to the plasma membrane, is cleaved during apoptosis to generate a truncated active form. The activity of ROCK proteins is both necessary and sufficient for formation of membrane blebs and for re-localization of fragmented DNA into blebs and apoptotic bodies.

Alternative splicing of the neurotrophin-3 gene gives rise to different transcripts in a number of human and rat tissues

The mouse neurotrophin-3 (NT-3) gene has been shown to contain two exons (exon 1A and exon 1B) upstream of the single coding exon (exon 2). These upstream exons are alternatively spliced to the coding exon, generating two different NT-3 transcripts. We investigated whether alternative splicing of two upstream exons also occurs in the human and rat NT-3 gene. It was found that the human and rat NT-3 gene also contains two exons upstream of the main coding exon and that alternative splicing of these upstream exons generates two different NT-3 transcripts : transcript 1A and transcript 1B (TR1B). These two transcripts were widely expressed in several human and rat tissues. Also, a third transcript, transcript 1A1C, derived from splicing of exon 1A to exon 1B before splicing to the coding exon was seen in a small number of rat tissues. Previous quantification of neurotrophin-3 mRNA has not been transcript-specific. Here we describe a transcript-specific semiquantitative RT-PCR method allowing the quantification of TR1B in human tissues. We show that this is the major NT-3 transcript and that expression of this transcript was much higher in the adult when compared with the corresponding fetal tissues.

Role of caspase-3 in apoptosis of colon cancer cells induced by nonsteroidal anti-inflammatory drugs

Epidemiological studies have demonstrated that nonsteroidal anti-inflammatory drugs (NSAIDs) decrease the incidence of and mortality from colon cancer. In addition, NSAIDs reduce the number and the size of polyps in patients with familial adenomatous polyposis. The mechanisms responsible for the antineoplastic effect of NSAIDs are not yet completely understood, but one of the possible mechanisms is an induction of apoptosis. We explored the role of caspase-3, a major apoptosis-executing enzyme, in NSAID-induced apoptosis of colon cancer cell line HT-29. Treatment of HT-29 cells with indomethacin induced a dramatic increase in caspase-3-like protease activity measured by a cleavage of the fluorogenic substrate Ac-DEVD-AMC. Western blot analysis showed that indomethacin treatment led both to decrease in procaspase-3 and to cleavage of its substrate poly(ADP-ribose) polymerase (PARP). Furthermore, the caspase-3-like protease inhibitor Ac-DEVD-CHO attenuated indomethacin-induced DNA fragmentation dose dependently. However, mRNA expression of CASP genes was not affected by the addition of indomethacin, highlighting the importance of posttranslational modification of this enzyme for the activation. These results suggest that NSAIDs, including indomethacin, induce apoptosis in colon cancer cells through a caspase-3 dependent mechanism which may contribute to the chemopreventive functions of these agents.

Staphylococcus lugdunensis: report of first case of skin and soft tissue infection in Singapore

We report the first case of skin and soft tissue infection due to Staphylococcus lugdunensis in Singapore. This is a coagulase negative Staphylococcus species known to cause a wide variety of more serious infections--brain abscess, sepsis, chronic osteomyelitis and infective endocarditis.

Autologous transfusion in obstetrics

AIM OF STUDY

To assess the safety of blood collection for autologous transfusion in pregnant women and the effects of the procedure on the fetus.

METHOD

Prospective study involving obstetric patients undergoing elective lower segment Caesarean section (LSCS) between 1993 and 1994 were recruited for autologous transfusion. Continuous cardiotocograph monitoring was carried out throughout the duration of the procedure and the fetal haemodynamics was studied before and after by doppler blood flow ultrasound.

RESULTS

The results show that there was no fetal deceleration or increased uterine activity as monitored by cardiotocography. The mean pulsatility index (PI) for the umbilical artery before the procedure was 0.9560 and after was 0.0820 which is a significant difference (p value = 0.035).

CONCLUSION

Autologous blood collection seems to be a safe procedure for both the mother and the fetus. However, autologous transfusion remains an unpopular choice amongst pregnant women.

Epidemiological surveillance of melioidosis in Singapore

During the period 1989 to 1996, a total of 372 cases of melioidosis, with 147 deaths, were reported, giving a mean annual incidence rate of 1.7 per 100,000 population and a case-fatality rate of 39.5%. Majority (89%) of the clinical cases were confirmed by culture of Burkholderia pseudomallei, while the others were presumptive cases based on a single blood specimen with an indirect haemaglutination (IHA) antibody titre of > or = 1:16. The highest incidence rate was reported in those aged 45 years and above (5.7 per 100,000 population), males (2.8 per 100,000 population), and Indian ethnic group (3.0 per 100,000 population). Cases were distributed throughout the island all year round. There was no correlation with rainfall. Most of the cases (77.4%) had other concurrent medical conditions, the most common being diabetes mellitus (57.5%). Factors significantly associated with a higher case-fatality rate were age (55 years and above), septicaemia, smoking history and heart or renal failure. The overall case-fatality rate has been declining from 60% in 1989 to 27% in 1996 due to a greater awareness among medical practitioners to diagnose and treat the disease early. The overall seroprevalence of IHA antibody (titre of > or = 1:16) among asymptomatic population groups was 0.2%. B. pseudomallei isolated from clinical specimens were sensitive to imipenem (100%), ceftazidime (99.1%), piperacillin (99.7%), ampicillin-clavulanate (98.5%), minocycline (97.4%), chloramphenicol (94.3%), doxycycline (94.3%) and tetracycline (93.9%). Of 395 samples of soil collected during epidemiological investigation of reported cases, 1.8% were positive for B. pseudomallei.

Ecthyma gangrenosum in a patient with hypogammaglobulinemia

Ecthyma gangrenosum is a characteristic skin lesion that is caused by Pseudomonas aeruginosa (P. aeruginosa) in the majority of cases. Systemic P. aeruginosa usually complicates debilitating conditions like leukaemia, burns and cystic fibrosis. We report a patient with underlying hypogammaglobulinemia who developed ecthyma gangrenosum secondary to P. aeruginosa septicaemia, which was potentially life-threatening. Recognition of the characteristic skin lesions with prompt initiation of appropriate antibiotics and intravenous immunoglobulins were life-saving. A review of the English literature reports three other cases of ecthyma gangrenosum in patients with underlying hypogammaglobulinemia.

Somatic mutations in the p53 tumor suppressor gene in rheumatoid arthritis synovium

The factors that regulate the perpetuation and invasiveness of rheumatoid synovitis have been the subject of considerable inquiry, and the possibility that nonimmunologic defects can contribute to the disease has not been rigorously addressed. Using a mismatch detection system, we report that synovial tissue from the joints of severe chronic rheumatoid arthritis patients contain mutant p53 transcripts, which were not found in skin samples from the same patients or in joints of patients with osteoarthritis. Mutant p53 transcripts also were identified in synoviocytes cultured from rheumatoid joints. The predicted amino acid substitutions in p53 were identical or similar to those commonly observed in a variety of tumors and might influence growth and survival of rheumatoid synoviocytes. Thus, mutations in p53 and subsequent selection of the mutant cells may occur in the joints of patients as a consequence of inflammation and contribute to the pathogenesis of the disease.

A nationwide outbreak of coconut-associated paratyphoid A fever in Singapore

A large outbreak of 167 cases of paratyphoid A was reported in Singapore during the period 15 February to 4 May 1996. Cases were distributed all over the country and no specific food establishment was implicated. The attack rate was highest among the Indian ethnic group between the ages of 25 and 34 years. A case-control study showed that consumption of a variety of food items in which imported deshelled coconut was used as an ingredient was statistically significantly associated with the illness (P < 0.001). As soon as the vehicle of transmission was suspected, the import of deshelled coconut was banned. No further cases were reported four weeks after the ban. The outbreak highlighted the need to maintain a high degree of vigilance against the introduction of infectious diseases through imported food.

Apoptosis in rheumatoid arthritis: p53 overexpression in rheumatoid arthritis synovium

DNA damage induces p53 tumor suppressor gene expression and protein production, which in turn facilitates DNA repair or apoptosis. Wild-type p53 protein has a short half-life, so it is rarely detected in non-neoplastic tissue. Because DNA fragmentation is abundant in the intimal lining in rheumatoid arthritis (RA) synovial tissue (ST) using in situ end-labeling (Firestein GS, Yeo M, Zvaifler NJ: Apoptosis in rheumatoid arthritis synovium. J Clin Invest 1995, 96:1631-1638), we assessed ST p53 expression. Immunohistochemical analysis of fixed RA synovium using antibody PAb 1801 showed prominent p53 staining in the cytoplasm and nuclei of intimal lining cells. Noninflammatory and osteoarthritis (OA) ST had significantly less p53 in the lining. These data were confirmed by Western blot analysis of ST extracts, with abundant p53 found in RA compared with OA. p53 expression in cultured fibroblast-like synoviocytes (FLS) was then examined. Flow cytometry on permeabilized cells showed that RA FLS constitutively express p53 protein. Western blots showed that RA FLS expressed significantly more p53 than either OA FLS or dermal fibroblasts. Immunohistochemistry of FLS cultured in chamber slides localized the p53 to the cytoplasm of most resting FLS, with nuclear staining in only 10.7 +/- 2.4%. Exposure to hydrogen peroxide for increased nuclear staining to 70.7 +/- 12.8% after 8 hours (P = 0.003). These data indicate that p53 is overexpressed in RA ST in the intimal lining, which is the primary site of DNA damage, and is constitutively expressed by FLS.

Intimacy in the patient-physician relationship. Committee on Ethics of the College of Family Physicians of Canada

Family physicians have privileged access to the intimate lives of their patients. Such access is essential for good patient-physician relationships. However, intimate access renders patients vulnerable to harm and places a tremendous burden of trust upon physicians. Physicians earn this trust by exercising care in drawing and preserving the boundary between appropriate and inappropriate intimacy.

Ethics for regional boards

When regional health boards choose how to allocate limited resources on the public's behalf, they are exercising ethical judgment. When board members are familiar with the study of ethics and the tools it has produced, they are able to make informed and consistent ethical choices. One board in P.E.I. drew upon ethical principles to first codify its core values, and then develop a process for making decisions which conformed to those values. As boards across Canada assume greater authority and responsibility for public health, a clear understanding of ethical principles can guide their difficult choices.

Changing trends in the antimicrobial susceptibility of clinical isolates of Acinetobacter baumannii

Acinetobacter baumannii has recently emerged as an important nosocomial pathogen because of its resistance to the majority of commonly used antimicrobial agents. Therefore, the pattern of isolation of Acinetobacter baumannii in our laboratory and the in vitro susceptibilities to various antimicrobial agents were studied. One hundred and two clinical isolates of previously identified Acinetobacter calcoaceticus var. anitratus from different patients were collected from the Diagnostic Bacteriology section of the Department of Pathology, Singapore General Hospital. The strains were reclassified according to recent taxonomic changes using phenotypic tests and tested for beta-lactamase production using Cefinase disks. In vitro sensitivities to various antimicrobial agents were determined using the disk diffusion method. Of the 103 A. calcoaceticus var. anitratus species, 99 were identified as A. baumannii, 2 as A. junii and 1 as A. haemolyticus. Majority of the A. baumannii isolates were from wound sites (63.6%) and from patients in the general wards (70.7%). beta-lactamase activity was present in all these isolates. The most active agent against all A. baumannii isolates was imipenem. However, 14 of the strains were resistant to imipenem, 8 of which came from the burns ward. Two-thirds of isolates from burn patients were completely resistant to all the antimicrobial agents tested. Almost all isolates previously identified as A. calcoaceticus var. anitratus in our laboratory are A. baumannii strains. Imipenem is the most effective antimicrobial agent; however, the high rate of imipenem resistance especially among burn patients is a source of major concern.

Apoptosis in rheumatoid arthritis synovium

RA synovial tissue (ST) was studied to determine if and where apoptosis occurs in situ. Genomic DNA was extracted from 5 RA and 1 osteoarthritis ST samples. Agarose gel electrophoresis demonstrated DNA ladders characteristic for apoptosis from each tissue. In situ and labeling (ISEL) was used to identify DNA strand breaks consistent with apoptosis in frozen sections. 12 RA and 4 osteoarthritis ST were studied by ISEL and all were positive, but only 2 of 4 normal tissues were positive. The primary location of apopotic cells was the synovial lining. Some sublining cells were also positive, but lymphoid aggregate staining was conspicuously absent. Immunohistochemistry and ISEL were combined and showed that the lining cells with DNA strand breaks were mainly macrophages, although some fibroblastlike cells were also labeled. Sublining cells with fragmented DNA included macrophages and fibroblasts, but T cells in lymphoid aggregates, which expressed large amounts of bcl-2, were spared. DNA strand breaks in cultured fibroblastlike synoviocytes was assessed using ISEL. Apoptosis could be induced by actinomycin D, anti-fas antibody, IL-1, and TNF-alpha but not by IFN-gamma. Fas expression was also detected on fibroblast-like synoviocytes using flow cytometry. Therefore, DNA strand breaks occur in synovium of patients with arthritis. Cytokines regulate this process, and the cytokine profile in RA (high IL-1/TNF; low IFN-gamma) along with local oxidant injury might favor induction of apoptosis.

Genetics of high level penicillin resistance in clinical isolates of Streptococcus pneumoniae

Mosaic penicillin-binding proteins (PBP) 1A, 2X and 2B genes were cloned from four clinical isolates of Streptococcus pneumoniae with levels of susceptibility to penicillin ranging from 1.5 to 16 micrograms benzylpenicillin ml-1. In each instance it was possible to transform either the penicillin-sensitive laboratory strain R6 or a sensitive clinical isolate 110K/70 to the full level of penicillin resistance with these three penicillin-binding proteins alone. Until now it has not been possible to clearly determine whether alterations to PBP1A, 2X and 2B alone were sufficient to attain high level penicillin resistance.

Comparison of Pseudomonas pseudomallei from humans, animals, soil and water by restriction endonuclease analysis

Pseudomonas pseudomallei isolates from 62 human, 17 animal, 3 soil and 3 water samples were examined by genomic DNA digestion with PstI. Five major (RE I, II, III, IV, V) reproducible restriction patterns were observed, with most (56/62) of the human isolates displaying RE I (30/62), II (5/62), III (15/62), IV (4/62), V (2/62), and the animal (16/17), soil (2/3), water (3/3) isolates showing predominantly RE II profiles. Six human and one soil isolates showed patterns different from those of RE I to V. Restriction endonuclease analysis may be applied in epidemiological studies of melioidosis.

A practical approach to lifestyle change counselling in primary care

Many contemporary medical conditions have been found to be the consequence of lifestyle choices. These adverse habit patterns have their origin in the individuals family and/or natural social network. Primary care practitioners frequently interact with their patients for the purpose of helping them resolve medical problems by clarifying issues or presenting different options. In lifestyle related conditions, the initiation and maintenance of possible behaviour changes is usually the optimal resolution. How people intentionally change well-established behaviour patterns is still not well understood, and most clinicians are not confident in their ability to help patients alter adverse behaviours. Several studies provide support for a 'stage-matched framework' of behaviour change that integrates readiness for change with intervention processes from various theoretical models. This article provides a brief overview of the current thinking with respect to self-initiated and professionally facilitated behaviour change, and then describes a generic five-step approach to individualized lifestyle counselling for use in primary care clinical settings.

Lectin typing of methicillin-resistant Staphylococcus aureus from Singapore, England and Wales, and Denmark

Methicillin-resistant Staphylococcus aureus (MRSA) isolates from a possible outbreak in Singapore (84) were examined together with all MRSA isolated in Denmark in 1986-1990 (58) and 14 distinct epidemic and 10 distinct single hospital strains from England and Wales. All 84 Singapore isolates were phage typed routinely and 52 isolates were further analysed together with the Danish isolates with an additional set of experimental phages and by lectin typing. The British strains, previously phage typed in the same way, were lectin typed. The following lectins were used: wheat-term agglutinin, soy-bean agglutinin, tomato lectin and Concanavalin-A. Routine phage typing of the Danish isolates showed that 41 isolates belonged to 19 different types; 17 isolates were non-typable (NT). Addition of experimental phage typing and lectin typing enhanced discrimination to 47 types. The 24 British strains could be divided into eight [corrected] "lectin types". Sixty-one of the isolates from Singapore were non-typable by phage typing; the remaining 23 strains belonged to five types. Further examination of 52 isolates with the experimental set of phages and by lectin typing gave 14 closely related types; 48% of these isolates belonged to only two types.

Pulsed-field gel electrophoresis for differentiation of hospital isolates of Klebsiella pneumoniae

Restriction enzyme analysis by pulsed-field gel electrophoresis (PFGE) was developed for differentiation of hospital isolates of Klebsiella pneumoniae. Restriction patterns generated by SpeI digestion of genomic DNAs of 36 isolates from patients in two major teaching hospitals established 34 PFGE types. All strains were typable by this technique and the SpeI restriction patterns were reproducible, stable and easy to interpret. As PFGE profiles generated were heterogenous, the incidence of cross-infection appeared to be low in each of the hospitals. The higher discriminatory power of PFGE when compared to conventional restriction endonuclease analysis (REA) suggests that this technique will be very useful for epidemiological investigations of nosocomial K. pneumoniae outbreaks.

Prolegomena to any future code of ethics for bioethicists

A major facet of the bioethics phenomenon in North America has been the emergence of a new profession on the healthcare turf: a growing number of people calling themselves or being called “bioethicists.” Bioethicists are plying their trade mainly as ethics consultants in hospital settings and as researchers and educators with university affiliations. Other more questionable affiliations can easily be imagined: Bioethicist for a controversial transplant program? For a lobby or advocacy group? For a pharmaceutical company?

Serodiagnosis of melioidosis in Singapore by the indirect haemagglutination test

Melioidosis is endemic in Singapore, with diagnosis dependent upon both bacteriological culture and serodiagnosis. Using the polysaccharide (melioidin)-sensitized turkey red cells in the indirect haemagglutination test (IHAT), 20 (100%) of the Pseudomonas pseudomallei culture-positive cases were detectable by the IHAT with titles ranging from 1:16 to 1:32, 768. Eight of these patients who died within a few days after the IHAT was performed had titres ranging from 1:16 to 1:1028. Five culture-negative patients, with clinical symptoms suggestive of melioidosis infection and who responded to treatment with ceftazidime, showed IHA titres between 1:64 and 1:8,192. One hundred and twenty one sera from patients with pneumonia, abscesses, or diabetes mellitus were IHAT negative. The IHAT showed good specificity since negative titres were seen in tests using sera from 2 patients with culture-positive Pseudomonas aeruginosa and 4 patients positive for Legionella. IHAT negative results were obtained from tests of 50 normal blood donors and 50 sewerage workers. Of 683 national servicemen tested, 5 (0.73%) had IHAT titres ranging from 1:16 to 1:128. Unlike hyperendemic areas such as Thailand where interpretation of IHAT is seriously hampered by IHA titres found in one-third to half of the population, serodiagnosis of melioidosis by the sensitive IHAT may be employed in Singapore as a routine procedure since background IHA titres are low.

Blood pressure screening clinics: an opportunity for health promotion

A blood pressure clinic was organized in a newly developed community in an urban setting. While the primary purpose was to measure and interpret blood pressure (BP), special emphasis was placed on creating awareness of normal/abnormal BP. The study was also designed to identify health education activities performed by nurses in a BP clinic. Following an orientation program and using standardized protocol, volunteer nurses screened 671 adults with a mean age of 43.7 years. The additional activities performed by nurses are described and include 72 documented instances of health teaching, 111 referrals for elevated BP, and 32 referrals for other health problems. The results indicate that nurses provided valuable services in meeting consumer health care needs, and suggest that a BP clinic can be an effective and efficient vehicle for health promotion activities.

Integration of nursing theory and nursing ethics

Nursing theory and nursing ethics are the two main areas of inquiry in nursing scholarship today. Each addresses common themes and each, in its own way, speaks not only about but for nursing. In spite of this commonality there is remarkably little dialogue between them. Both theory and ethics shall benefit from increased integration.

Pharyngitis 1987: a survey of physicians' attitudes and practices in southern Alberta

A questionnaire survey concerning Streptococcal pharyngitis was completed by 85 southern Alberta family physicians. The data revealed a significant trend to overtreat pharyngitis with antibiotics because of the unreliability of clinical diagnosis and the lack of diagnostic manoeuvres with suitable ability to influence management. These data and a further questionnaire survey directed to the appreciation of other bacterial pharyngitides, demonstrate the importance of laboratory reports in biasing treatment, and further suggest that significant overtreatment of non-Streptococcal pharyngitis also occurs.