Echocardiography in the time of Covid-19: Ultrasound enhancing agents save time and augment diagnostic information

BACKGROUND

There are currently no clear guidelines regarding the use of ultrasound enhancing agents (UEAs) with transthoracic echocardiography (TTE) for patients hospitalized with Covid-19. We investigated whether the performance of TTE with UEAs provides more diagnostic information and allows for shorter acquisition time compared to unenhanced TTE imaging in this patient population.

METHODS

We analyzed the TTEs of 107 hospitalized Covid-19 patients between April and June 2020 who were administered UEAs (Definity®, Lantheus). The time to acquire images with and without UEAs was calculated. A level III echocardiographer determined if new, clinically significant findings were visualized with the addition of UEAs.

RESULTS

There was a mean of 11.84±3.59 UEA cineloops/study vs 20.74±8.10 non-UEA cineloops/study (p < 0.0001). Mean time to acquire UEA cineloop images was 72.28±28.18 s/study compared to 188.07±86.04 s/study for non-UEA cineloop images (p < 0.0001). Forty-eight patients (45%) had at least one new finding on UEA imaging, with a total of 62 new findings seen. New information gained with UEAs was more likely to be found in patients with acute respiratory distress syndrome (21 vs 9, p < 0.001) and in those on mechanical ventilation (21 vs 15, p = 0.046).

CONCLUSIONS

TTE with UEAs required less time and fewer cineloop images compared to non-UEA imaging in patients hospitalized with Covid-19. Additionally, Covid-19 patients with severe respiratory disease benefited most with regard to new diagnostic information. Health care personnel should consider early use of UEAs in select hospitalized Covid-19 patients in order to reduce exposure and optimize diagnostic yield.

Speech production accuracy in children with Down syndrome: relationships with hearing, language, and reading ability and change in speech production accuracy over time

BACKGROUND

This study examines speech production accuracy in children with Down syndrome and concurrent relationships with hearing, language and reading ability. It also examines change in speech production accuracy over a 21-month period.

METHODS

A group of 50 children with Down syndrome (aged 5-10 years) completed measures of speech accuracy, non-verbal IQ, reading (single-word reading, letter-sound knowledge and phoneme blending) and language (expressive and receptive vocabulary and receptive grammar). Hearing was assessed by parental report. Speech accuracy was reassessed 21 months later.

RESULTS

Although there was considerable variability in the sample, speech was characterised by high levels of errors. There were no effects of gender, hearing status or non-verbal IQ on speech production accuracy. In contrast, speech production accuracy was significantly related to age and to measures of receptive vocabulary, phoneme blending and word reading. There was no significant improvement in speech production accuracy over time.

CONCLUSIONS

Children with Down syndrome experience difficulties producing accurate sounds in speech. These difficulties are related to age and to vocabulary and reading skills and persist over time, highlighting the need for intensive targeted speech intervention in this group of children.

A Study of GP Workload and Satisfaction

Aims In this novel study in the Irish setting, we quantified the number items managed per General Practitioner (GP) consult, how each item is managed, and impact on a GP's job satisfaction. Methods Participating GPs at two surgeries completed a questionnaire - integrated into the practice management software - after each consultation that satisfied the inclusion criteria during a four-week period. Results Due to feasibility constraints, 500 of 857 (58.3%) completed questionnaires were randomly selected for our sample. GPs manage an average of 1.76 items per consultation. Older patients presented with more items. Greater number of presenting items led to less being managed on the day 71% (n=5) for 5 items vs. 95.2% (n= 246) for 1 item, longer consultation duration (mean = 14.63 minutes (4-45) and decreased GP satisfaction, mean 8/10 (2-10). Conclusion Increasing the number of items in a GP consultation has a statistically significant effect on duration of consultation, how each item is managed, and even GP satisfaction.

Substance use amongst adult patients admitted to an irish acute mental health unit

Introduction

Comorbid substance misuse in mental illness presents a significant challenge to mental health services. It may lead to higher rates of relapse, hospital admissions and poorer treatment outcomes. Up to 47% of inpatients in Irish mental health units may experience substance misuse. Despite the Irish government’s ‘Vision for Change’ policy (2006), access to specialised services remains variable.

Objectives

Evaluate: -prevalence of substance misuse at an Irish mental health unit. -quality and detail of the recorded substance misuse history. -access to specialised services for patients experiencing substance misuse.

Methods

A retrospective chart review of inpatients in a mental health unit over 12 months, was completed. Information recorded included: demographic details, diagnosis, substance use history; access to substance misuse services. Microsoft Excel was utilised for data input and analysis.

Results

267 patients were admitted over twelve months. Substance misuse was the primary diagnosis of 6% and the secondary diagnosis of 67%. 46% of patients reported current substance misuse, 52% reported historical substance misuse. Frequency and quantity of use was documented in 65% and 48% of cases respectively. 4% of patients with a substance misuse history were in current contact with addiction services.

Conclusions

Although 46% of patients reported substance misuse, only 4% were in contact with specialised addiction services. This highlights a significant unmet need. There was variability in the quality of the recorded substance misuse history. In order to fully understand comorbid substance misuse, this be addressed. The addition of a more formatted substance misuse section, to admission proformas, may help to alleviate this issue.

Characterization of Myocardial Injury in Patients With COVID-19

BACKGROUND

Myocardial injury is frequent among patients hospitalized with coronavirus disease-2019 (COVID-19) and is associated with a poor prognosis. However, the mechanisms of myocardial injury remain unclear and prior studies have not reported cardiovascular imaging data.

OBJECTIVES

This study sought to characterize the echocardiographic abnormalities associated with myocardial injury and their prognostic impact in patients with COVID-19.

METHODS

We conducted an international, multicenter cohort study including 7 hospitals in New York City and Milan of hospitalized patients with laboratory-confirmed COVID-19 who had undergone transthoracic echocardiographic (TTE) and electrocardiographic evaluation during their index hospitalization. Myocardial injury was defined as any elevation in cardiac troponin at the time of clinical presentation or during the hospitalization.

RESULTS

A total of 305 patients were included. Mean age was 63 years and 205 patients (67.2%) were male. Overall, myocardial injury was observed in 190 patients (62.3%). Compared with patients without myocardial injury, those with myocardial injury had more electrocardiographic abnormalities, higher inflammatory biomarkers and an increased prevalence of major echocardiographic abnormalities that included left ventricular wall motion abnormalities, global left ventricular dysfunction, left ventricular diastolic dysfunction grade II or III, right ventricular dysfunction and pericardial effusions. Rates of in-hospital mortality were 5.2%, 18.6%, and 31.7% in patients without myocardial injury, with myocardial injury without TTE abnormalities, and with myocardial injury and TTE abnormalities. Following multivariable adjustment, myocardial injury with TTE abnormalities was associated with higher risk of death but not myocardial injury without TTE abnormalities.

CONCLUSIONS

Among patients with COVID-19 who underwent TTE, cardiac structural abnormalities were present in nearly two-thirds of patients with myocardial injury. Myocardial injury was associated with increased in-hospital mortality particularly if echocardiographic abnormalities were present.

Abnormal left ventricular global longitudinal strain by speckle tracking echocardiography in COVID-19 patients

COVID-19 infection can affect the cardiovascular system. We sought to determine if left ventricular global longitudinal strain (LVGLS) is affected by COVID-19 and if this has prognostic implications. Materials & methods: Retrospective study, with LVGLS was measured in 58 COVID-19 patients. Patients discharged were compared with those who died. Results: The mean LV ejection fraction (LVEF) and LVGLS for the cohort was 52.1 and -12.9 ± 4.0%, respectively. Among 30 patients with preserved LVEF(>50%), LVGLS was -15.7 ± 2.8%, which is lower than the reference mean LVGLS for a normal, healthy population. There was no significant difference in LVGLS or LVEF when comparing patients who survived to discharge or died. Conclusion: LVGLS was reduced in COVID-19 patients, although not significantly lower in those who died compared with survivors.

COVID-19 infection can affect the cardiovascular system including the heart muscle. Myocardial strain measures the function of the heart muscle at cell level and can pick up unusual heart function before routine measurements. Ejection fraction (how hard the heart muscle is squeezing) can be seen with our own eyes, but strain cannot and needs special techniques to see it. In this study we wanted to find out what was the strain on COVID-19 patients and if there was a relationship between strain and the outcome of the patients (if they were able to recover from COVID-19). The important finding of our study is that strain was low in all patients with COVID-19 infection regardless of routine measurements when compared with patients without the infection. However, in this study we found no correlation between the low strain and the result of the infection for the COVID-19 patients.

A superconducting thermal switch with ultrahigh impedance for interfacing superconductors to semiconductors

A number of current approaches to quantum and neuromorphic computing use superconductors as the basis of their platform or as a measurement component, and will need to operate at cryogenic temperatures. Semiconductor systems are typically proposed as a top-level control in these architectures, with low-temperature passive components and intermediary superconducting electronics acting as the direct interface to the lowest-temperature stages. The architectures, therefore, require a low-power superconductor-semiconductor interface, which is not currently available. Here we report a superconducting switch that is capable of translating low-voltage superconducting inputs directly into semiconductor-compatible (above 1,000 mV) outputs at kelvin-scale temperatures (1K or 4 K). To illustrate the capabilities in interfacing superconductors and semiconductors, we use it to drive a light-emitting diode (LED) in a photonic integrated circuit, generating photons at 1K from a low-voltage input and detecting them with an on-chip superconducting single-photon detector. We also characterize our device's timing response (less than 300 ps turn-on, 15 ns turn-off), output impedance (greater than 1MΩ), and energy requirements (0.18fJ/μm2,3.24mV/nW).

Sorbents can tailor nitrogen release from organic wastes to match the uptake capacity of crops

Delivering nutrients from mineral or organic fertilizers out of synchrony with crop uptake causes inefficiencies and pollution. We explore methodologies for evaluating sorbents as additives to organic agricultural wastes to retain nitrogen in an exchangeable form and deliver at rates that approximate the uptake capacity of roots. Focussing on ammonium (NH₄⁺) as the main inorganic nitrogen form in the studied wastes (sugarcane mill mud, poultry litter), we tested geo-sorbents and biochar for their ability to retain NH₄⁺. Sorption capacity was ranked palagonite < bentonite, biochar, vermiculite < chabazite, clinoptilolite (5.7 to 24.3 mg NH₄⁺ g^-1 sorbent). Sorbent-waste formulations were analysed for sorption capacity, leaching and fluxes of NH₄⁺. Ammonium-sorption capacity broadly translated to sorbent-waste formulations with clinoptilolite conferring the strongest NH₄⁺ attenuation (80%), and palagonite the lowest (7%). A 1:1 ratio of sorbent:waste achieved stronger sorption than a 0.5:1 ratio, and similar sorption as a 1:1.5 ratio. In line with these results, clinoptilolite-amended wastes had the lowest in situ NH₄⁺ fluxes, which exceeded the NH₄⁺ uptake capacity (I_max) of sugarcane and sorghum roots 9 to 84-fold, respectively. Less efficient sorbent-waste formulations and un-amended wastes exceeded I_max of crop roots up to 274-fold. Roots preferentially colonized stronger sorbent-waste formulations and avoided weaker ones, suggesting that lower NH₄⁺ fluxes generate a more favourable growth environment. This study contributes methodologies to identify suitable sorbents to formulate organic wastes as next-generation fertilizers with view of a crop's nutrient physiology. Efficient re-purposing of wastes can improve nutrient use efficiency in agriculture and support the circular nutrient economy.

Perception of Special Needs Dentistry education and practice amongst Australian dental auxiliary students

INTRODUCTION

The role of dental auxiliaries in collaborative care of patients with special needs is compelling. This study was undertaken to investigate the perceptions of Special Needs Dentistry (SND) education and practice amongst students enrolled in Australian programmes in dental auxiliary, namely dental hygiene, dental therapy and oral health therapy (DH/DT/OHT).

MATERIALS AND METHODS

All Australian institutions offering DH/DT/OHT programmes (n = 14) were invited to participate in a self-administered questionnaire survey, conducted online, involving students across all academic years. Twelve institutions agreed to participate, but only five institutions were included in the final analysis, with a student response rate of 31.1%. Answers to open-ended questions were coded and grouped for measurement of frequencies. Quantitative data were analysed via chi-squared and Fisher's exact tests (significance taken as P < .05).

RESULTS

The majority of students could not define SND (87.0%) were not aware of the existence of this specialty (53.5%) and did not have clinical experience treating patients with special needs (68.9%). Nevertheless, they felt comfortable and positive about treating these patients independently. Most agreed that they should receive clinical and didactic education in SND, with many of them expressing interest in pursuing a specialty training in this field.

CONCLUSION

DH/DT/OHT students' comfort levels, positive attitudes and supportiveness for SND suggested positive implications for these practitioners to partake in multidisciplinary management of patients with special needs, thus indicating the need for standardised training requirements and practice guidelines in this area of care.

Predicting drug resistance in adult patients with generalized epilepsy: A case-control study

OBJECTIVES

Using an adult cohort of patients with generalized epilepsy, we aimed to identify risk factors for development of drug-resistant epilepsy (DRE), which if identifiable would allow patients to receive earlier treatment and more specifically individualized treatment plans.

METHODS

For the case-control study, 118 patients with generalized epilepsy (GE) between the ages of 18 and 75 were included after selection from a database of 800 patients referred from throughout the Saskatchewan Epilepsy Program. Definitions were used in accordance with ILAE criteria. The odds ratio and its confidence interval were calculated. We performed a logistic regression analysis.

RESULTS

Forty-four (37%) patients fulfilled the definition of DRE (cases), and seizures in 74 (63%) patients were not intractable (controls). Patients with DRE were significantly younger than the controls at the onset of epilepsy (6.6 vs. 18.8 years, p=<0.001). Significant variables on univariate analysis were the following: epilepsy diagnosed prior to 12 years (OR: 12.1, CI: 4.8-29.9, p<0.001), previous history of status epilepticus (OR: 15.1, CI: 3.2-70.9, p<0.001), developmental delay (OR: 12.6, CI: 4.9-32, p<0.001), and cryptogenic epilepsy (OR: 10.5, CI: 3.9-27.8, p<0.001). Our study showed some protective factors for DRE such as a good response to first AED, idiopathic etiology, and history of febrile seizures. In the logistic regression analysis, two variables remained statistically significant: developmental delay and more than one seizure type.

CONCLUSION

Our study has identified a set of variables that predict DRE in patients with generalized epilepsy. Risk factors identified in our study are similar to those previously identified in pediatric studies, however, our study is specifically tailored to adult patients with generalized epilepsy.

A validation of the new definition of drug-resistant epilepsy by the International League Against Epilepsy

OBJECTIVE

To establish applicability, the recently proposed International League Against Epilepsy (ILAE) consensus on drug-resistant epilepsy (DRE) requires testing in clinical and research settings. This study evaluates the reliability and validity of these criteria in a clinical population.

METHODS

In phase I, two independent evaluators reviewed 97 randomly selected medical records of patients with epilepsy at two separate intervals. Both ILEA consensus and standard diagnostic criteria were employed. Kappa, weighted kappa, and intraclass correlation coefficient (ICC) were used to determine interobserver and intraobserver variability. In phase II, ILAE consensus criteria were applied to 250 patients with epilepsy to determine risk factors associated with development of DRE and to calculate point prevalence.

RESULTS

The interobserver agreement of the four definitions was as follows: Berg (0.56), Kwan and Brodie (0.58), Camfield and Camfield (0.69), and ILAE (0.77). The intraobserver agreement of the four definition was as follows: Berg (0.81), Kwan and Brodie (0.82), Camfield and Camfield (0.72), and ILAE (0.82). The prevalence of DRE was the following: with the Berg's definition was 28.4%, Kwan and Brodie 34%, Camfield and Camfield 37%, and with ILAE was 33%.

SIGNIFICANCE

This is first study to establish reliability and validity of ILAE criteria for the diagnosis of DRE. This new definition compares favorably with previously established constructs, which continue to retain clinical significance.

Hemiarthroplasty and total hip arthroplasty for treating primary intracapsular fracture of the hip: a systematic review and cost-effectiveness analysis

BACKGROUND

Hip fracture is a common problem in people aged > 60 years. The treatment options for individuals with high pre-fracture mobility, function and independence are hemiarthroplasty (HA) and total hip arthroplasty (THA).

OBJECTIVE

The aim of this report is to assess the clinical effectiveness and cost-effectiveness evidence of THA compared with HA in patients with displaced intracapsular fracture who are cognitively intact with high pre-fracture mobility or function.

DATA SOURCES

A systematic search was made of 11 databases of published and unpublished literature from their inception to december 2010: MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Biological Science Citation Index, Social Science Citation Index, Conference Proceedings Citation Index - Science, UK Clinical Trials Research Network and the National Research Register archive, Current Controlled Trials and ClinicalTrials.gov.

REVIEW METHODS

A systematic review of randomised controlled trials (RCTs) to assess the effectiveness of THA compared with HA in terms of dislocations, revisions, pain and function, and quality of life. Meta-analysis, independent subgroup analyses and exploratory cost-effectiveness modelling were performed.

RESULTS

The literature search identified 532 unique citations, of which eight RCTs with almost 1000 participants satisfied the criteria for the effectiveness review. Meta-analysis found a statistically significant increased risk of dislocation for patients treated with THA compared with HA (p = 0.01), but a reduced risk of revision (p = 0.0003). There were no differences in terms of mortality. In all trials, individuals treated with THA reported better function and mobility and less pain than those treated with HA. Four trials reporting utility data found similar trends. Sensitivity analyses indicated that there were no statistically significant differences in outcomes based on follow-up, study quality, surgical approach taken, type of head or the use of cement. Four papers reported a cost-utility analysis or the cost-effectiveness of THA compared with HA. Exploratory modelling was undertaken that showed that THA is likely to be cost-effective compared with HA even when the limitations of the data and methodology are considered.

LIMITATIONS

The costs and disutilities associated with revisions and dislocations were not included in the economic evaluation.

CONCLUSIONS

THA appears to be more cost-effective than HA. It is likely that THA will be associated with increased costs in the initial 2-year period, but lower longer-term costs, owing to potentially lower revision rates. However, these longer-term costs have not been modelled. The capacity and experience of surgeons to perform THA have not been explored and these would need to be addressed at local level were THA to become recommended for active, elderly patients in whom THA is not contraindicated. Further studies examining the impact of surgeon experience on performing the two procedures may offer more robust evidence on outcomes.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Overexpression of transforming growth factor-beta1 in fetal monkey lung results in prenatal pulmonary fibrosis

Altered transforming growth factor (TGF)-β expression levels have been linked to a variety of human respiratory diseases, including bronchopulmonary dysplasia and pulmonary fibrosis. However, a causative role for aberrant TGF-β in neonatal lung diseases has not been defined in primates. Exogenous and transient TGF-β1 overexpression in fetal monkey lung was achieved by transabdominal ultrasound-guided fetal intrapulmonary injection of adenoviral vector expressing TGF-β1 at the second or third trimester of pregnancy. The lungs were then harvested near term, and fixed for histology and immunohistochemistry. Lung hypoplasia was observed where TGF-β1 was overexpressed during the second trimester. The most clearly marked phenotype consisted of severe pulmonary and pleural fibrosis, which was independent of the gestational time point when TGF-β1 was overexpressed. Increased cell proliferation, particularly in α-smooth muscle actin-positive myofibroblasts, was detected within the fibrotic foci. But epithelium to mesenchyme transdifferentiation was not detected. Massive collagen fibres were deposited on the inner and outer sides of the pleural membrane, with an intact elastin layer in the middle. This induced fibrotic pathology persisted even after adenoviral-mediated TGF-β1 overexpression was no longer evident. Therefore, overexpression of TGF-β1 within developing fetal monkey lung results in severe and progressive fibrosis in lung parenchyma and pleural membrane, in addition to pulmonary hypoplasia.

Lessons from eleven primary health care nursing innovations in New Zealand

INTRODUCTION

In New Zealand in 2003, 11 primary health care (PHC) nursing innovation projects and an evaluation of the initiative were funded by the Ministry of Health to develop and explore the ways new models of nursing practice could help address health inequalities and contribute to PHC.

DESIGN AND METHODS

A research-and-development approach was used in the evaluation. Data were gathered from interviews with national stakeholders, workshops with personnel from all projects, visits to each project site and case studies of four projects. Analysis involved assessing each project individually as well as the projects as a whole.

CONTEXT

The initiative was one of many international and local PHC developments in this period designed to reduce health inequalities and improve patient care and health outcomes.

FINDINGS

Each project was developed from a different starting point; was located in different parts of the health system; and had different levels of funding. Some were principally focused on leading nursing development; others focused on developing nursing practice. Each involved influencing or providing nursing services, nurse education, leadership and service integration. Most projects progressed well, but some had limited success.

LESSONS

Lessons are on many levels, and include those related to: developing successful innovation; the importance of nursing leadership; developing the nursing workforce; and advancing nursing practice.

CONCLUSION

The funding of the innovative projects enabled nurses to pioneer developments. Such funding is important, as it paves the way for change and provides an opportunity for reflection and new learnings.

OpenPET: A Flexible Electronics System for Radiotracer Imaging

We present the design for OpenPET, an electronics readout system designed for prototype radiotracer imaging instruments. The critical requirements are that it has sufficient performance, channel count, channel density, and power consumption to service a complete camera, and yet be simple, flexible, and customizable enough to be used with almost any detector or camera design. An important feature of this system is that each analog input is processed independently. Each input can be configured to accept signals of either polarity as well as either differential or ground referenced signals. Each signal is digitized by a continuously sampled ADC, which is processed by an FPGA to extract pulse height information. A leading edge discriminator creates a timing edge that is "time stamped" by a TDC implemented inside the FPGA. This digital information from each channel is sent to an FPGA that services 16 analog channels, and information from multiple channels is processed by this FPGA to perform logic for crystal lookup, DOI calculation, calibration, etc. As all of this processing is controlled by firmware and software, it can be modified / customized easily. The system is open source, meaning that all technical data (specifications, schematics and board layout files, source code, and instructions) will be publicly available.

Lack of clinical predictors of optimal V-V delay in patients with cardiac resynchronization devices

INTRODUCTION

Cardiac resynchronization therapy (CRT) is a well-established therapy for patients with moderate-to-severe heart failure (HF), left ventricular dysfunction with an ejection fraction <or= 35% and a QRS on the surface electrocardiogram of >or=130 msec. Device optimization is often performed, adjusting the timing of RV and LV stimulation to produce a pacing sequence that yields the best global cardiac performance. However, no standard guidelines exist for optimization and many invasive and non-invasive techniques have been employed with mixed results. The aim of the present study was to determine whether there are any clinical predictors of the optimal V-V settings in patients implanted with CRT devices.

METHODS AND RESULTS

We prospectively evaluated 47 consecutive patients with HF who were referred to our device optimization clinic. The mean patient age was 64.9 +/- 12.7 years. Patients were in both sinus rhythm (83%) and atrial fibrillation. Prior to device implant, 51% of patients had left bundle branch block (LBBB), 17% had intra-ventricular conduction delay (IVCD) and 21% were RV paced. Sixty-two percent were male, the mean QRS duration was 152 +/- 29 ms, mean LVEF 26 +/- 8% and 60% had a non-ischemic cardiomyopathy. Overall, 82% of patients required sequential pacing with 69% requiring LV pre-excitation to produce the best global cardiac function as determined by aortic velocity time integrals (VTI). In our cohort, none of the clinical characteristics evaluated, including etiology of the cardiomyopathy, QRS duration, LVEF, pre-implant rhythm or AV delay were predictive of an optimal simultaneous or sequential V-V setting.

CONCLUSIONS

None of the clinical variables tested in our analysis predicted optimal RV-LV settings. Our results suggest that individual optimization and programming of V-V settings is necessary. The inability to predict optimal settings likely reflects the unique characteristics of each patient and supports the need for individualized programming of each device.

A study of complicated grief symptoms in people with intellectual disabilities

INTRODUCTION

Previous studies have shown a significant association between familial bereavement and the onset of challenging behaviours and psychopathology in people with intellectual disabilities (ID). However, little work has been done to accurately describe the specific symptoms of grief, in particular symptoms of complicated grief in this population. Consensus criteria for the diagnosis of complicated grief have been drawn up and tested for validity in the general population.

AIMS

To examine the occurrence of symptoms of complicated grief, and to explore the relationships between complicated grief and bereavement experience.

METHOD

A bereavement history questionnaire and a newly developed measure examining for symptoms of complicated grief were administered to a group of carers of people with mild or moderate ID, who had experienced a parental bereavement within the previous 2 years. The questionnaires were also administered to a matched comparison group, who had not been bereaved.

RESULTS/CONCLUSIONS

This carer-based comparison study has revealed that bereaved individuals with ID experience complicated grief symptoms following the death of a parent, with one-third of the bereaved group experiencing 10 or more clinically apparent symptoms. In addition, complicated grief symptoms were more likely to occur with higher rates of bereavement ritual involvement. These findings have both clinical and research implications.

TGF-beta signaling promotes survival and repair in rat alveolar epithelial type 2 cells during recovery after hyperoxic injury

Hyperoxic rats treated with inosine during oxygen exposure have increased levels of active transforming growth factor (TGF)-beta in the bronchoalveolar lavage (BAL), yet alveolar epithelial type 2 cells (AEC2) isolated from these animals demonstrate less hyperoxia-induced DNA damage and increased expression of active Smad2. To determine whether TGF-beta1 signaling per se protected AEC2 against hyperoxic damage, freshly isolated AEC2 from hyperoxic rats were incubated with TGF-beta1 for 24 h and assayed for DNA damage by fluorescein-activated cell sorter analysis of TdT-mediated dUTP nick end labeling. TGF-beta1 was protective over a concentration range similar to that in BAL of inosine-treated hyperoxic animals (50-5,000 pg/ml). TGF-beta1 also augmented hyperoxia-induced DNA repair activity and cell migration, stimulated autocrine secretion of fibronectin, accelerated closure of a monolayer scratch wound, and restored hyperoxia-depleted VEGF secretion by AEC2 to normoxic levels. The TGF-beta receptor type I activin-like kinase-4, -5, and -7 inhibitor peptide SB-505124 abolished the protective effect of TGF-beta on hyperoxic DNA damage and increased TdT-mediated dUTP nick end labeling in normoxic cells. These data suggest that endogenous TGF-beta-mediated Smad signaling is required for AEC2 homeostasis in vitro, while exogenous TGF-beta1 treatment of hyperoxia-damaged AEC2 results in a cell that is equipped to survive, repair, migrate, secrete matrix, and induce new blood vessel formation more efficiently than AEC2 primed by hyperoxia alone.

The prevalence of features of attention deficit hyperactivity disorder in a special school in Ireland

BACKGROUND

The prevalence of features of attention deficit hyperactivity disorder (ADHD) in children with intellectual disabilities (ID) in Irish schools is unknown. The aim of this study was to examine the prevalence of features of ADHD in a special school, in order to ascertain the number of children who may need further assessment for ADHD. The study also explores the reliability of the Conners Teachers Rating Scale in this population.

METHOD

All teachers in a special school for children with ID were asked to complete the Conners Teachers Rating Scale and the Attention-Distractibility, Inhibition-Excitation Classroom Assessment Rating Scale, for those children whose parents had consented for them to take part in this study. Consent was obtained for 84 children a response rate of 71%, between the ages of 5 and 18 (mean = 10.5 years; SD = 3.7).

RESULTS

The Conners Teachers Rating Scale was found to be internally reliable and had a normal distribution with our results. Overall, 55.9% of participants (47/84) had markedly elevated scores (T > 69) for at least one of the target subscales, which were the 'Hyperactivity', 'Inattention' and the 'ADHD Index' subscales of the Conners Teachers Rating Scales. In addition, the findings would suggest that the Conners Teachers Rating Scale can be a useful screening tool in the population of school children with ID.

CONCLUSIONS

The study suggests that ADHD may be under diagnosed in children with ID. This has practical implications for the mental health needs of these children. It is recommended that further studies are carried out to determine the prevalence of ADHD in this population.

Parkinson's disease patients who fracture their neck of femur: a review of outcome data

Parkinson's disease patients are at increased risk of falls and osteoporosis. They present a challenge to those who treat them for fracture neck of femur. There are conflicting views as to whether they have a worse prognosis, compared to age matched controls. This review discusses their care, including surgical approach and technique, to post-operative management and complications. It highlights the limitations in evidence and the need for further research.

Immediate upright post-treadmill exercise echocardiographic imaging

Using standard treadmill exercise techniques, it has been shown that postexercise echocardiographic imaging can be performed safely and effectively while a patient is still standing on the treadmill. Furthermore, upright imaging can be initiated earlier and completed at a higher heart rate than standard supine imaging. Patients who can ambulate but with decreased agility and maneuverability and who would otherwise have been denied treadmill tests may be eligible for upright poststress imaging.

A prospective study of ultrasound screening for molar pregnancies in missed miscarriages

OBJECTIVE

To examine the relationship between ultrasound and histological features in the screening for molar changes in missed miscarriage.

METHODS

A prospective cohort study was conducted on all missed miscarriages, with features suspicious of molar pregnancy, on transvaginal ultrasound and/or on histological examination over a 5-year period. All cases of molar pregnancy diagnosed histologically were examined and cross-referenced with cases diagnosed on ultrasound and with the supplementary report from the regional referral center. When available, maternal serum beta-human chorionic gonadotropin (hCG) levels were recorded.

RESULTS

Fifty-one cases of suspected molar pregnancy were referred to the regional center for further histological opinion and follow-up, and five cases were subsequently excluded from the final analysis because of the diagnosis of hydropic abortion (HA). In 33 cases a molar pregnancy was suspected at the initial scan. Of these, 26 (78.8%) were confirmed on histology, resulting in a 56% detection rate using ultrasound alone. In 15 cases hCG results were available, of which nine were greater than two multiples of the median.

CONCLUSIONS

The diagnosis of both complete (CHM) and partial (PHM) hydatidiform moles in first-trimester miscarriages is difficult. hCG is significantly higher in both CHM and PHM and, in conjunction with transvaginal ultrasound, could provide the screening test required to enable clinicians to counsel women more confidently towards non-surgical methods of management of their miscarriage, where histopathological examination is not available.

In vivo inosine protects alveolar epithelial type 2 cells against hyperoxia-induced DNA damage through MAP kinase signaling

Inosine, a naturally occurring purine with anti-inflammatory properties, was assessed as a possible modulator of hyperoxic damage to the pulmonary alveolar epithelium. Rats were treated with inosine, 200 mg/kg ip, twice daily during 48-h exposure to >90% oxygen. The alveolar epithelial type 2 cells (AEC2) were then isolated and cultured. AEC2 isolated from inosine-treated hyperoxic rats had less DNA damage and had increased antioxidant status compared with AEC2 from hyperoxic rats. Inosine treatment during hyperoxia also reduced the proportion of AEC2 in S and G2/M phases of the cell cycle and increased levels of the DNA repair enzyme 8-oxoguanine DNA glycosylase. Bronchoalveolar lavage (BAL) recovered from hyperoxic, inosine-treated rats contained threefold higher levels of active transforming growth factor-beta than BAL from rats exposed to hyperoxia alone, and Smad2 was activated in AEC2 isolated from these animals. ERK1/2 was activated both in freshly isolated and 24-h-cultured AEC2 by in vivo inosine treatment, whereas blockade of the MAPK pathway in vitro reduced the protective effect of in the vivo inosine treatment. Together, the data suggest that inosine treatment during hyperoxic exposure results in protective signaling mediated through pathways downstream of MEK. Thus inosine may deserve further evaluation for its potential to reduce hyperoxic damage to the pulmonary alveolar epithelium.

BMP4 signaling induces senescence and modulates the oncogenic phenotype of A549 lung adenocarcinoma cells

Lung cancer is the most common visceral malignancy in males, with rapidly increasing incidence in females, and a devastatingly poor prognosis. Transforming growth factor (TGF)-beta has been shown to induce senescence in A549 lung cancer cells, and both TGF-beta and bone morphogenetic protein (BMP) 2 can suppress the transformed phenotype of A549 cells in vitro. We examined the effects of BMP4, another member of the TGF-beta superfamily, on specific oncogenic properties of A549 cancer cells. When A549 cancer cells were treated continuously with 100 ng/ml of BMP4, a senescent phenotype was observed after 2 wk of treatment. The BMP-treated cells appeared larger than untreated cells, grew more slowly, had more senescence-associated beta-galactosidase activity, and had less telomerase activity, as measured by the telomeric repeat amplification protocol assay. Invasion through Engelbreth Holm-Swarm matrix was inhibited in the senescent cell population. Senescent BMP4-treated cells had lower ERK activation, VEGF expression, and Bcl2 expression than wild-type cells, consistent with a less proliferative, less angiogenic phenotype with increased susceptibility to death by apoptosis. BMP4 treatment also resulted in sustained elevation of Smad1. In vivo xenograft studies in the flanks of nude mice confirmed that the BMP-treated cells were significantly less tumorigenic than untreated cells. Direct overexpression of Smad1 using adenoviral constructs resulted in cell death within 5 days. These studies suggest that BMP4 pathway signaling can induce senescence and thus negatively regulate the growth of A549 lung cancer cells.

The Hopes and Fears of In Utero Gene Therapy for Genetic Disease—A Review

Somatic gene delivery in utero is a novel approach to gene therapy for genetic disease. It is based on the concept that application of gene therapy vectors to the fetus in utero may prevent the development of early disease related tissue damage, may allow targeting of otherwise inaccessible organs, tissues and still expanding stem cell populations and may also provide postnatal tolerance against the therapeutic transgenic protein. This review outlines the hypothesis and scientific background of in utero gene therapy and addresses some of the frequently expressed concerns raised by this still experimental, potentially preventive gene therapy approach. We describe and discuss the choice of vectors, of animal models and routes of administration to the fetus. We address potential risk factors of prenatal gene therapy such as vector toxicity, inadvertent germ line modification, developmental aberration and oncogenesis as well as specific risks of this procedure for the fetus and mother and discuss their ethical implications.

Dynamics of metalloproteinase-2 and -9, TGF-beta, and uPA activities during normoxic vs. hyperoxic alveolarization

The final stage of lung development, alveolarization, continues after birth in humans and rodents. Clinical interventions, such as oxygen therapy, in the first week of life can adversely impact alveolar formation. We compared alveolarization in the rat neonate under normal vs. hyperoxic conditions, examining gelatinase, transforming growth factor (TGF)-beta, and the protease urokinase-type plasminogen activator (uPA) activities in whole lung and cultured type II alveolar epithelial cells (AEC2). The dynamic induction of gelatinase, TGF-beta, and uPA activities seen in neonatal lungs during the first days of life was significantly impacted by hyperoxia. In whole lung, gelatinase and TGF-beta activities were increased, while uPA activity was decreased. At the level of the epithelium, AEC2 isolated from hyperoxic rat pups early in life secreted less active TGF-beta, less active gelatinases, and less active uPA than control neonatal AEC2. AEC2 from hyperoxic pups also expressed increased levels of proliferating cell nuclear antigen early in life compared with control neonatal AEC2, suggesting that oxygen-induced proliferation and/or repair were occurring. The developmental profile of neonatal lung was perturbed within a day of initiating oxygen treatment, suggesting that putative palliative treatments should be coadministered with oxygen therapy.

Do lung remodeling, repair, and regeneration recapitulate respiratory ontogeny?

Herein we posit that modeling of the lungs during morphogenesis, repair, and regeneration is tightly coordinated by conserved stimulatory and inhibitory signaling mechanisms, including specific transcriptional factors, cytokines, peptide growth factors, proteases, and matrix elements. This evolutionary-developmental (evo-devo) functional conservation has been extended to morphogenesis of the respiratory tracheae in Drosophila. Fifty or more genes direct fruit fly tracheal organogenesis. Among them, hedgehog, patched, smoothened, cubitus interruptus, branchless, breathless, sprouty, decapentaplegic, and mad are functionally conserved between flies, mice, and humans. For example, fibroblast growth factor (FGF) signaling is essential, not only for fly trachea and mouse bronchial branching morphogenesis, but also for postnatal modeling and repair of alveoli. Likewise, sprouty family genes act as inducible negative regulators of FGF signaling, which in part may determine interbranch length during bronchial development. Alveolar epithelial survival, migration, and proliferation during remodeling after hyperoxic injury also require FGF signaling. In addition, FGF signaling appears to regulate a small (< 5%) population of putative alveolar stem/ progenitor cells that express telomerase and are relatively resistant to hyperoxic apoptosis. We speculate that genes in evo-devo functionally conserved signaling pathways such as FGF-FGF receptor-Sprouty may provide novel therapeutic targets to augment lung repair and induce lung regeneration.

Counting and cardinal understanding in children with Down syndrome and typically developing children

This study compares the procedural counting ability (independently and with parental support) and conceptual understanding of cardinality of a group of children with Down syndrome and a group of typically developing children, matched for non-verbal mental age. Participants were 23 children with Down syndrome (chronological age range: 3.5-7 years; mental age range: 2.5-4 years) and 20 typically developing children (chronological age range: 2-4 years; mental age range: 2.5-4 years), and their main caregiver. The children were asked to count sets of toys (assessing procedural counting skills) and to give sets of toys (assessing understanding of cardinality), with set sizes between 2 and 18 items. The counting task was performed in two conditions, with and without parental support. The children were also asked to say the count word sequence aloud, to assess sequence production independent from object counting. The typically developing children produced significantly more number words altogether, longer standard number sequences and could count larger sets than the children with Down syndrome. Support from an adult improved performance on the count task significantly for both groups of children, and there was no significant difference between the groups in the degree of improvement, i.e. the zone of proximal development. No significant differences were found between the frequency of children (approximately one third) in each group who used counting to solve the give task, indicating an understanding of cardinality.

Migration and gelatinases in cultured fetal, adult, and hyperoxic alveolar epithelial cells

Alveolar epithelial cell (AEC) migration mediated by matrix metalloproteinases (MMPs) is required for lung development and repair after injury such as hyperoxia. Of specific interest in lung remodeling are the gelatinases, which are upregulated in AEC after hyperoxia. We correlated migration and gelatinase production in AEC cultured from fetal, adult, and hyperoxic rats. Fetal AEC (19-20 days) had higher MMP-2 and MMP-9 gelatinase expression than adult AEC, with fivefold higher MMP-9 activity, and were migratory through gelatin, responding to epidermal growth factor, keratinocyte growth factor, and fibroblast growth factor-10. MMP-2 and MMP-9 expression and migratory activity could be detected from the time of plating. In contrast, adult AEC migrated and expressed MMP-2 and MMP-9 proteins only after 48 h of culture. AEC from hyperoxic rats were significantly more migratory through gelatin than control adult AEC, with significantly higher MMP-9 activity. Inhibition of MMPs with doxycycline reduced the migration of AEC from hyperoxic rats to the level of control adult AEC. Fibronectin-cultured "hyperoxic" AEC acquired a temporary capacity for migration similar to the A549 lung cancer cell line, which is both highly migratory and invasive and is derived from the AEC type 2 lineage. These data suggest that MMP activity is associated with a migratory phenotype in fetal, hyperoxic, and transformed AEC in vitro, and we speculate that MMPs may play a key mechanistic role in AEC migration in vivo during lung development and repair.

GLUTEAL COMPARTMENT SYNDROME AFTER TOTAL KNEE ARTHROPLASTY WITH EPIDURAL POSTOPERATIVE ANALGESIA

We describe two patients who developed gluteal compartment syndrome after total knee arthroplasty (TKA) carried out under epidural analgesic infusion and light sedation. To our knowledge, this occurrence has not been described previously after TKA.

Gluteal compartment syndrome after total knee arthroplasty with epidural postoperative analgesia

We describe two patients who developed gluteal compartment syndrome after total knee arthroplasty (TKA) carried out under epidural analgesic infusion and light sedation. To our knowledge, this occurrence has not been described previously after TKA.

Nongenomic estrogen action in human lung myofibroblasts

Recent studies have suggested that the antiproliferative effects of E2 may be mediated through a nongenomic action. Herein, we asked whether nongenomic estrogen action regulates phosphorylation of Raf1 and ERK1/2 mitogen-activated protein (MAP) kinase in lung myofibroblasts. We demonstrated that lung myofibroblasts, incubated in the presence of E2, showed a rapid phosphorylation on serine-259 of Raf1 and tyrosine-204 of ERK1/2 MAP kinase at 15 min, by approximately 3- and 5-fold, respectively. This phosphorylation was followed by dephosphorylation between 30 and 60 min. Western blot analysis showed that E2 regulates tyrosine phosphorylation of four main cytoplasmic proteins in lung myofibroblasts, of 42, 44, 70 and 100 kDa. Furthermore, our results indicated that E2 inhibits cell proliferation (BrdU index) in lung myofibroblasts by approximately 30% (P < 0.01). These data provide evidence that nongenomic action of E2, regulates both serine and tyrosine phosphorylation of cytoplasmic proteins in lung myofibroblasts, including Raf1 and ERK1/2 MAP kinase, which may regulate proliferation in lung myofibroblasts.