Personality traits moderate associations between word recall and subjective memory

Cognitive gerontology research requires consideration of performance as well as perceptions of performance. While subjective memory is positively associated with memory performance, these correlations typically are modest in magnitude, leading to the need to consider whether certain people may show weaker or stronger linkages between performance and perceptions. The current study leveraged personality (NEO Big Five), memory performance (i.e., word recall), and perceptions of memory ability (i.e., metamemory in adulthood and memory decline) data from the St. Louis Personality and Aging Network (SPAN) study (n = 774, mean age: 71.52 years). Extraversion and conscientiousness held the most consistent associations with the cognitive variables of interest, as both traits were positively associated with metamemory and word recall, but negatively associated with subjective decline. Moreover, extraversion moderated associations between word recall and both memory capacity and complaints, insofar that objective-subjective associations were weaker for those adults higher in extraversion. These findings highlight the need to understand how personality influences the sources of information employed for subjective cognitive beliefs.

Associations between COVID-19 and putative markers of neuroinflammation: A diffusion basis spectrum imaging study

COVID-19 remains a significant international public health concern. Yet, the mechanisms through which symptomatology emerges remain poorly understood. While SARS-CoV-2 infection may induce prolonged inflammation within the central nervous system, the evidence primarily stems from limited small-scale case investigations. To address this gap, our study capitalized on longitudinal UK Biobank neuroimaging data acquired prior to and following COVID-19 testing (N = 416 including n = 224 COVID-19 cases; Mage = 58.6). Putative neuroinflammation was assessed in gray matter structures and white matter tracts using non-invasive Diffusion Basis Spectrum Imaging (DBSI), which estimates inflammation-related cellularity (DBSI-restricted fraction; DBSI-RF) and vasogenic edema (DBSI-hindered fraction; DBSI-HF). We hypothesized that COVID-19 case status would be associated with increases in DBSI markers after accounting for potential confound (age, sex, race, body mass index, smoking frequency, and data acquisition interval) and multiple testing. COVID-19 case status was not significantly associated with DBSI-RF (|β|'s < 0.28, pFDR >0.05), but with greater DBSI-HF in left pre- and post-central gyri and right middle frontal gyrus (β's > 0.3, all pFDR = 0.03). Intriguingly, the brain areas exhibiting increased putative vasogenic edema had previously been linked to COVID-19-related functional and structural alterations, whereas brain regions displaying subtle differences in cellularity between COVID-19 cases and controls included regions within or functionally connected to the olfactory network, which has been implicated in COVID-19 psychopathology. Nevertheless, our study might not have captured acute and transitory neuroinflammatory effects linked to SARS-CoV-2 infection, possibly due to symptom resolution before the imaging scan. Future research is warranted to explore the potential time- and symptom-dependent neuroinflammatory relationship with COVID-19.

Associations between COVID-19 and putative markers of neuroinflammation: A diffusion basis spectrum imaging study

COVID-19 remains a significant international public health concern. Yet, the mechanisms through which symptomatology emerges remain poorly understood. While SARS-CoV-2 infection may induce prolonged inflammation within the central nervous system, the evidence primarily stems from limited small-scale case investigations. To address this gap, our study capitalized on longitudinal UK Biobank neuroimaging data acquired prior to and following COVID-19 testing (N=416 including n=224 COVID-19 cases; Mage=58.6). Putative neuroinflammation was assessed in gray matter structures and white matter tracts using non-invasive Diffusion Basis Spectrum Imaging (DBSI), which estimates inflammation-related cellularity (DBSI-restricted fraction; DBSI-RF) and vasogenic edema (DBSI-hindered fraction; DBSI-HF).We hypothesized that COVID-19 case status would be associated with increases in DBSI markers after accounting for potential confound (age, sex, race, body mass index, smoking frequency, and data acquisition interval) and multiple testing. COVID-19 case status was not significantly associated with DBSI-RF (|β|'s<0.28, pFDR >0.05), but with greater DBSI-HF in left pre- and post-central gyri and right middle frontal gyrus (β's>0.3, all pFDR=0.03). Intriguingly, the brain areas exhibiting increased putative vasogenic edema had previously been linked to COVID-19-related functional and structural alterations, whereas brain regions displaying subtle differences in cellularity between COVID-19 cases and controls included regions within or functionally connected to the olfactory network, which has been implicated in COVID-19 psychopathology. Nevertheless, our study might not have captured acute and transitory neuroinflammatory effects linked to SARS-CoV-2 infection, possibly due to symptom resolution before the imaging scan. Future research is warranted to explore the potential time- and symptom-dependent neuroinflammatory relationship with COVID-19.

Reliability of diurnal salivary cortisol metrics: A meta-analysis and investigation in two independent samples

Stress-induced dysregulation of diurnal cortisol is a cornerstone of stress-disease theories; however, observed associations between cortisol, stress, and health have been inconsistent. The reliability of diurnal cortisol features may contribute to these equivocal findings. Our meta-analysis (5 diurnal features from 11 studies; total participant n = 3307) and investigation (15 diurnal cortisol features) in 2 independent studies (St. Louis Personality and Aging Network [SPAN] Study, n = 147, ages 61-73; Minnesota Longitudinal Study of Risk and Adaptation [MLSRA] Study, n = 90, age 37) revealed large variability in the day-to-day test-retest reliability of diurnal features derived from salivary cortisol data (i.e., ICC = 0.00-0.75). Collectively, these data indicate that some commonly used diurnal cortisol features have poor reliability that is insufficient for individual differences research (e.g., cortisol awakening response) while others (e.g., area under the curve with respect to ground) have fair-to-good reliability that could support reliable identification of associations in well-powered studies.

A Phenome-Wide Association Study (PheWAS) of Late Onset Alzheimer Disease Genetic Risk in Children of European Ancestry at Middle Childhood: Results from the ABCD Study

Genetic risk for Late Onset Alzheimer Disease (AD) has been associated with lower cognition and smaller hippocampal volume in healthy young adults. However, whether these and other associations are present during childhood remains unclear. Using data from 5556 genomically-confirmed European ancestry youth who completed the baseline session of the ongoing the Adolescent Brain Cognitive DevelopmentSM Study (ABCD Study®), our phenome-wide association study estimating associations between four indices of genetic risk for late-onset AD (i.e., AD polygenic risk scores (PRS), APOE rs429358 genotype, AD PRS with the APOE region removed (ADPRS-APOE), and an interaction between ADPRS-APOE and APOE genotype) and 1687 psychosocial, behavioral, and neural phenotypes revealed no significant associations after correction for multiple testing (all ps > 0.0002; all pfdr > 0.07). These data suggest that AD genetic risk may not phenotypically manifest during middle-childhood or that effects are smaller than this sample is powered to detect.

Sense of purpose as a potential buffer between mental health and subjective cognitive decline

OBJECTIVES

Purposeful adults may experience greater cognitive resilience because sense of purpose may help buffer against the effects of depressive symptoms and loneliness. We also evaluated whether these associations differed by race.

DESIGN

This study uses a wave of self-report data from the SPAN study of psychosocial aging.

SETTING

Participants come from a representative sample of older adults in St. Louis.

PARTICIPANTS

Participants (N = 595) ages range from 65 to 78 (Mage = 71.46), with 18.3% of participants identifying as Black/African-American.

MEASURES

Sense of purpose was assessed with the Life Engagement Test, depressive symptoms with the Beck Depression Inventory-II, loneliness with the UCLA Loneliness Scale, and subjective cognitive decline with the AD-8.

RESULTS

Correlational analyses supported predictions that sense of purpose was negatively related to subjective cognitive decline, whereas depressive symptoms and loneliness were positively related (|r|s > .30, ps < .001). For loneliness, but not depression, this association was moderated by sense of purpose (b = -0.43, p < .001). A relatively high sense of purpose attenuated associations between loneliness and subjective cognitive decline. A three-way race × purpose × loneliness interaction (b = -0.25, p = .021) revealed that the buffering effects of sense of purpose on subjective cognitive decline were stronger for Black adults.

DISCUSSION

This study provided partial support for the buffering hypothesis, showing that sense of purpose may help mitigate the cognitive decrements associated with loneliness. Future research needs to consider how purpose-promoting programs may support healthy cognitive aging, particularly among Black older adults and those who experience greater social isolation.

Tropical parasitic itch in returned travellers and immigrants from endemic areas

Itch is the most common skin symptom among tropical parasitic diseases (TPD), but there are limited data about its characteristics in these conditions. In dermatology practices and travellers' health clinics in the developed world, itch is a common complaint among travellers returning from endemic areas, as well among migrants arriving from endemic areas, where they may have been exposed to TPD. Studying aspects of pruritus among TPD may lead to improvements in prompt, accurate diagnosis and management of these conditions. This review examines the major itch-inducing TPDs, including schistosomiasis, echinococcosis, onchocerciasis, scabies, cutaneous larva migrans, larva currens, African trypanosomiasis, dracunculiasis and other causes of travel associated pruritus. We focus on the link between pruritus and other symptoms, aetiology, clinical staging and therapeutic options for these parasitic illnesses. Because some tropical parasitic diseases can present with significant pruritus, we attempt to identify aspects of the pruritus that are characteristic of-or unique to-specific conditions. These diagnostic insights may help clinicians create a rational and focused differential diagnosis and help determine optimal disease management pathways. In this sense, management involves treating the individual, seeking epidemiologically linked cases, preventing recurrences or relapses, and reducing spread of the disease.

Protocol paper: Multi-site, cluster-randomized clinical trial for optimizing functional outcomes of older cancer survivors after chemotherapy

BACKGROUND

Cancer survivors over the age of 65 have unique needs due to the higher prevalence of functional and cognitive impairment, comorbidities, geriatric syndromes, and greater need for social support after chemotherapy. In this study, we will evaluate whether a Geriatric Evaluation and Management-Survivorship (GEMS) intervention improves functional outcomes important to older cancer survivors following chemotherapy.

METHODS

A cluster-randomized trial will be conducted in approximately 30 community oncology practices affiliated with the University of Rochester Cancer Center (URCC) National Cancer Institute Community Oncology Research Program (NCORP) Research Base. Participating sites will be randomized to the GEMS intervention, which includes Advanced Practice Practitioner (APP)-directed geriatric evaluation and management (GEM), and Survivorship Health Education (SHE) that is combined with Exercise for Cancer Patients (EXCAP©®), or usual care. Cancer survivors will be recruited from community oncology practices (of participating oncology physicians and APPs) after the enrolled clinicians have consented and completed a baseline survey. We will enroll 780 cancer survivors aged 65 years and older who have completed curative-intent chemotherapy for a solid tumor malignancy within four weeks of study enrollment. Cancer survivors will be asked to choose one caregiver to also participate for a total up to 780 caregivers. The primary aim is to compare the effectiveness of GEMS for improving patient-reported physical function at six months. The secondary aim is to compare effectiveness of GEMS for improving patient-reported cognitive function at six months. Tertiary aims include comparing the effectiveness of GEMS for improving: 1) Patient-reported physical function at twelve months; 2) objectively assessed physical function at six and twelve months; and 3) patient-reported cognitive function at twelve months and objectively assessed cognitive function at six and twelve months. Exploratory health care aims include: 1) Survivor satisfaction with care, 2) APP communication with primary care physicians (PCPs), 3) completion of referral appointments, and 4) hospitalizations at six and twelve months. Exploratory caregiver aims include: 1) Caregiver distress; 2) caregiver quality of life; 3) caregiver burden; and 4) satisfaction with patient care at six and twelve months.

DISCUSSION

If successful, GEMS would be an option for a standardized APP-led survivorship care intervention.

TRIAL REGISTRATION

ClinicalTrials.govNCT05006482, registered on August 9, 2021.

Inflammation is associated with future depressive symptoms among older adults

Inflammation has been reliably associated with depression. However, the directionality of this association is poorly understood, with evidence that elevated inflammation may promote and precede the development of depression, as well as arise following its expression. Using data from older adults (N ​= ​1,072, ages 60-73) who participated in the ongoing longitudinal St. Louis Personality and Aging Network (SPAN) study, we examined whether inflammatory markers (interleukin-6: IL-6, C-reactive protein: CRP, and tumor necrosis factor α: TNFα) and depression were prospectively predictive of one another. Fasting serum samples and self-reports of depressive symptoms (Beck Depression Inventory-II) were obtained from participants at 2 sessions approximately 2 years apart. Structural equation models as well as regressions that accounted for a host of potentially confounding covariates and depression at baseline revealed that baseline IL-6 and CRP, but not baseline TNFα were associated with elevated depressive symptoms at the follow-up session (IL-6: β ​= ​0.080, p ​= ​0.036; CRP: β ​= ​0.083, p ​= ​0.03; TNFα: β ​= ​0.039, p ​= ​0.314). However, there was no association between baseline depressive symptoms and follow-up inflammatory markers (βs ​= ​-0.12 to -0.006, all ps ​> ​0.05). Collectively, these data suggest that inflammation prospectively predicts depression, but depression does not predict inflammation in older age. These data add to a growing literature suggesting that inflammatory signaling may plausibly promote the development of depression.

Long-lasting Behavioral and Neuroanatomical Effects of Postnatal Valproic Acid Treatment

Valproic acid (VPA) administered to mice during the early postnatal period causes social, cognitive, and motor deficits similar to those observed in humans with autism spectrum disorder (ASD). However, previous studies on the effects of early exposure to VPA have largely focused on behavioral deficits occurring before or during the juvenile period of life. Given that ASD is a life-long condition, the present study ought to extend our understanding of the behavioral profile following early postnatal VPA into adulthood. Male mice treated with VPA on postnatal day 14 (P14) displayed increased aggression, decreased avoidance of the open arms in the elevated plus maze, and impaired reversal learning in the Y maze. This may indicate a disinhibited or impulsive phenotype in male, but not female, mice treated with VPA during the second week of postnatal life. Decreased dendritic spine density and dendritic spine morphological abnormalities in the mPFC of VPA-treated mice may be indicative of PFC hypofunction, consistent with the observed behavioral differences. Since these types of long-lasting deficits are not exclusively found in ASD, early life exposure to VPA may reflect dysfunction of a neurobiological domain common to several developmental disorders, including ASD, ADHD, and conduct disorder.

Valproic acid induces nuclear factor erythroid 2-related factor 2 expression in fetal and neonatal brains but not in adult brain: evidence of the gamma-aminobutyric acid-shift hypothesis

The gamma-aminobutyric acid (GABA)-shift hypothesis proposes that GABA agonist action is excitatory early in development and transitions to an inhibitory role later in life. In experiment 1, the nonspecific GABA agonist, valproic acid (VPA), was administered to pregnant C57BL/6 mice on embryonic day 13. Fetal and maternal brains were harvested 2 h post-VPA exposure and assayed for nuclear factor erythroid 2-related factor 2 (NRF2) and H3 expression through western blot analysis. In experiment 2, VPA was administered to neonatal pups on P14 and adult mice on P60. In both experiments, it was observed that NRF2 expression was increased in fetal and neonatal brains, but not in the adult brain. Because NRF2 expression is activated by oxidative stress, these results imply support of the GABA-shift hypothesis in that VPA may exert its developmental damage in the fetal and neonatal periods through excitotoxicity.

Modeling salinization and recovery of road salt-impacted lakes in temperate regions based on long-term monitoring of Lake George, New York (USA) and its drainage basin

Road salt mitigates winter highway icing but accumulates in watershed soils and receiving waters, affecting soil chemistry and physical, biological, and ecological processes. Despite efforts to reduce salt loading in watersheds, accumulated cations and Cl^- continue to impact tributaries and lakes, and the recovery process is not well understood. Lake George, New York (USA) is typical of many temperate lakes at risk for elevated Cl^- concentrations from winter deicing; the lake salt concentration increased by ~3.4% year^-1 since 1980. Here, we evaluated the ionic composition in Finkle Brook, a major watershed draining to Lake George, studied intermittently since 1970 and typical of other salt-impacted Lake George tributaries. Salt loading in the Lake George basin since the 1940s displaced cations from exchange sites in basin soils; these desorbed cations follow a simple ion-exchange model, with lower sodium and higher calcium, magnesium and potassium fluxes in runoff. Reduced salt application in the Finkle Brook watershed during the low-snow winter of 2015-2016 led to a 30-40% decline of Cl^- and base cations in the tributary, implying a Cl^- soil half-life of 1-2 years. We developed a conceptual model that describes cation behavior in runoff from a watershed that received road salt loading over a long period of time, and then recovery following reduced salt loading. Next, we developed a dynamic model estimating time to steady-state for Cl^- in Lake George with road salt loading starting in 1940, calibrating the model with tributary runoff and lake chemistry data from 1970 and 1980, respectively, and forecasting Cl^- concentrations in Lake George based on various scenarios of salt loading and soil retention of Cl^-. Our Lake George models are readily adaptable to other temperate lakes with drainage basins where road salt is applied during freezing conditions and paved roads cover a portion of the watershed.

Family caregiver descriptions of stopping chemotherapy and end-of-life transitions

PURPOSE

The purpose of this study was to describe family caregivers' perspectives of the final month of life of patients with advanced cancer, particularly whether and how chemotherapy was discontinued and the effect of clinical decision-making on family caregivers' perceptions of the patient's experience of care at the end of life (EOL).

METHODS

Qualitative descriptive design using semi-structured interviews collected from 92 family caregivers of patients with end-stage cancer enrolled in a randomized clinical trial. We used a phased approach to data analysis including open coding, focused coding, and within and across analyses.

RESULTS

We identified three patterns of transitions characterizing the shift away from active cancer treatment: (1) "We Pretty Much Knew," characterized by explicit discussions about EOL care, seemingly shared understanding about prognosis and seamless transitions from disease-oriented treatment to comfort-oriented care, (2) "Beating the Odds," characterized by explicit discussions about disease-directed treatment and EOL care options, but no shared understanding about prognosis and often chaotic transitions to EOL care, and (3) "Left to Die," characterized by no recall of EOL discussions with transitions to EOL occurring in crisis.

CONCLUSIONS

As communication and palliative care interventions continue to develop to improve care for patients with advanced cancer, it is imperative that we take into account the different patterns of transition and their unique patient and caregiver needs near the end of life. Our findings reveal considerable, and potentially unwarranted, variation in transitions from active treatment to death.

Solitary Violaceous Nodule on the Face

REPORT OF A CASE

A 77-year-old man had an asymptomatic preauricular papule for several years. He had no prior skin cancers. The lesion was a solitary, smooth, well-circumscribed, plum-colored dermal nodule, 1.5 cm in diameter (Fig 1). He also had prominent midfacial sebaceous hyperplasia. No lymphadenopathy was noted, and the examination of his ears, nose, and throat was unremarkable. A shave biopsy was performed and the specimen submitted for routine (Figs 2 and 3) and special stains. What is your diagnosis?

DIAGNOSIS

Dermal cylindroma (also known as cylindroma, dermal eccrine cylindroma, Spiegler's tumor, turban tumor, and tomato tumor).

COMMENT

This distinctive but uncommon skin tumor was first described by Ancell in 18421 and given the name cylindrom ("cylindroma") by Billroth in 1859.2 The qualifier dermal cylindroma distinguishes this tumor from adenoid cystic carcinoma of the salivary glands, also called cylindroma. Cylindromas are usually firm, smooth, pink-to-red dermal.

Changing climate and sea level alter Hg mobility at Lake Tulane, Florida, U.S

Between 45,000 cal years BP and the beginning of the Holocene, the accumulation rate for Hg in sediments of Lake Tulane, Florida ranged from ≈2 to 10 μg m(-2) yr(-1), compared with 53 μg Hg m(-2) yr(-1) in the 1985-1990 period of anthropogenic input. The locality experienced regional draw-down of the water table during the Wisconsinan glaciation, which lowered global sea level by nearly 130 m. Natural atmospheric deposition of Hg to the surrounding area resulted in long-term (ca. 100,000 years) sequestration of this atmospheric flux of Hg, primarily by adsorption in the oxic Al- and Fe-hydroxide-rich sandy subsoil. Global sea level rise during deglaciation led to a rising regional water table, flooding the oxidized soils surrounding Tulane. Iron and adsorbed Hg were mobilized by reductive dissolution and transported by groundwater flow to Lake Tulane and ultimately to the accumulating sediment. The accumulation rate of Hg (and Fe) increased rapidly about 16,000 cal years BP, peaked at nearly 60 μg Hg m(-2) yr(-1) ca. 13,000-14,000 cal years BP, declined sharply during the Younger Dryas, and then increased sharply to a second 60 μg Hg m(-2) yr(-1) peak about 5000 cal years BP. Thereafter, it declined nearly to background by 900 cal years BP. In similar geologic situations, rapid modern sea level rise will initiate this process globally, and may mobilize large accumulations of Hg and lesser amounts of As, and other redox sensitive metals to groundwater and surface water.

The evolution of the science of Bear Brook Watershed in Maine, USA

The Bear Brook Watershed in Maine (BBWM), USA is a paired watershed study with chemical manipulation of one watershed (West Bear = WB) while the other watershed (East Bear = EB) serves as a reference. Characterization of hydrology and chemical fluxes occurred in 1987-1989 and demonstrated the similarity of the ca. 10 ha adjacent forested watersheds. From 1989-2010, we have added 1,800 eq (NH(4))(2)SO(4) ha(-1) y(-1) to WB. EB runoff has slowly acidified even as atmospheric deposition of SO4(-2) has declined. EB acidification included decreasing pH, base cation concentrations, and alkalinity, and increasing inorganic Al concentration, as SO4(-2) declined. Organic Al increased. WB has acidified more rapidly, including a 6-year period of increasing leaching of base cations, followed by a long-term decline of base cations, although still elevated over pretreatment values, as base saturation declined in the soils. Sulfate in WB has not increased to a new steady state because of increased anion adsorption accompanying soil acidification. Dissolved Al has increased dramatically in WB; increased export of particulate Al and P has accompanied the acidification in both watersheds, WB more than EB. Nitrogen retention in EB increased after 3 years of study, as did many watersheds in the northeastern USA. Nitrogen retention in WB still remains at over 80%, in spite of 20+ years of N addition. The 20-year chemical treatment with continuous measurements of critical variables in both watersheds has enabled the identification of decadal-scale processes, including ecosystem response to declining SO4(-2) in ambient precipitation in EB and evolving mechanisms of treatment response in WB. The study has demonstrated soil mechanisms buffering pH, declines in soil base saturation, altered P biogeochemistry, unexpected mechanisms of storage of S, and continuous high retention of treatment N.

An overview of the management of morbid obesity

Obesity is a modern-day epidemic with serious physical, psychological and economic implications for the patients. Tackling obesity is now a priority for most healthcare providers. Managing such patients can be complex, emotional, time consuming and often frustrating. Obesity surgery, in its various forms, has revolutionised this struggle. With appropriate selection of patients, adequate resources and a multidisciplinary team involvement, obesity can now effectively be "cured". It is vital that those who deal with obese patients know how to access these services and understand the processes involved in the journey from initial assessment to postoperative follow-up. Obesity surgery has a major impact in reducing obesity-related comorbidities such as diabetes and hypertension and contributes to society by returning patients to work. Prevention must be at the heart of any strategy to manage obesity, but, for established cases, surgery is taking centre stage and will continue to flourish as new techniques and procedures are developed.

Complications of bariatric surgery: presentation and emergency management--a review

INTRODUCTION

The prevalence of obesity surgery is increasing rapidly in the UK as demand rises. Consequently, general surgeons on-call may be faced with the complications of such surgery and need to have an understanding about how to manage them, at least initially. Obesity surgery is mainly offered in tertiary centres but patients may present with problems to their local district hospital. This review summarises the main complications that may be encountered.

MATERIALS AND METHODS

A full literature search was carried out looking at articles published in the last 10 years. Keywords for search purposes included bariatric, surgery, complications, emergency and management.

CONCLUSIONS

Complications of bariatric surgery have been extensively written about but never in a format that is designed to aid the on-call surgeon. The intricate details and rare complications have been excluded to concentrate on those symptoms and signs that are likely to be encountered by the emergency team.

Controls on mercury and methylmercury deposition for two watersheds in Acadia National Park, Maine

Throughfall and bulk precipitation samples were collected for two watersheds at Acadia National Park, Maine, from 3 May to 16 November 2000, to determine which landscape factors affected mercury (Hg) deposition. One of these watersheds, Cadillac Brook, burned in 1947, providing a natural experimental design to study the effects of forest type on deposition to forested watersheds. Sites that face southwest received the highest Hg deposition, which may be due to the interception of cross-continental movement of contaminated air masses. Sites covered with softwood vegetation also received higher Hg deposition than other vegetation types because of the higher scavenging efficiency of the canopy structure. Methyl mercury (MeHg) deposition was not affected by these factors. Hg deposition, as bulk precipitation and throughfall was lower in Cadillac Brook watershed (burned) than in Hadlock Brook watershed (unburned) because of vegetation type and watershed aspect. Hg and MeHg inputs were weighted by season and vegetation type because these two factors had the most influence on deposition. Hg volatilization was not determined. The total Hg deposition via throughfall and bulk precipitation was 9.4 microg/m(2)/year in Cadillac Brook watershed and 10.2 microg/m(2)/year in Hadlock Brook watershed. The total MeHg deposition via throughfall and bulk precipitation was 0.05 microg/m(2)/year in Cadillac Brook watershed and 0.10 microg/m(2)/year in Hadlock Brook watershed.

Use of Br and Se in peat to reconstruct the natural and anthropogenic fluxes of atmospheric Hg: A 10000-year record from Caribou Bog, Maine

Using Br and Se as reference elements, the natural and anthropogenic fluxes of atmospheric Hg were reconstructed for the past 10,000 years using peat cores from Caribou Bog, ME. In the ombrotrophic peat layers, the average background Hg accumulation rate (AR) was 1.7 +/- 1.3 microg m(-2) year(-1) which is comparable with the natural rate of atmospheric Hg accumulation reported in other retrospective studies. The average Hg AR determined using all peat samples dating from preindustrial times, including minerotrophic peat, was slightly greater (3.1 +/- 2.3 microg m(-2) year(-1)) which may reflect differences in canopy interception due to the changes in plant communities, aquatic inputs, or possibly climatic factors. The maximum Hg AR (32 microg m(-2) year(-1)) occurred ca. 1961 A.D. In samples predating the settlement by Europeans, there is a linear correlation between the AR of Hg and those of Br and Se; this relationship allows both Br and Se to be used to calculate the natural AR of Hg (Hgnat). The difference between Hg AR and Hg(nat) is the Hg AR in excess of background (Hg(ex)). Because Hg(ex) was positive only after ca. 1840 A.D., it is assumed to represent the anthropogenic Hg component. By the late 19th century, Hg(ex) deposition was equal to the natural flux. At the peak in Hg deposition in 1961 A.D., Hgex made up >90% of total atmospheric Hg deposition. The AR in the uppermost peat decreased to 25% of peak values by 2000 A.D.

Does changing the configuration of a motor racing circuit make it safer?

OBJECTIVES

To assess the pattern of injuries presenting to a racing circuit medical centre in two three-year periods before and after two chicanes were built into the track.

METHODS

Medical centre records were used to identify all patients assessed during the two time periods. Those referred to hospital were categorised by injury severity into three groups.

RESULTS

The proportions of those attending the medical centre that were referred and admitted to hospital were the same in both periods (12-13% and 3% respectively). During the two study periods, the risk of a severe injury for a car driver decreased from 0.1% to 0.03% (p<0.05). For a motorcyclist, similar values were 0% and 0.2% (not significant).

CONCLUSIONS

Chicanes have improved the safety of the racing circuit for car drivers, reducing the risk of injury.

Development and Experience with an Algorithm to Evaluate Suspected Smallpox Cases in the United States, 2002-2004

Concerns that smallpox, an eradicated disease, might reappear because of a bioterror attack and limited experience with smallpox diagnosis in the United States prompted us to design a clinical algorithm. We used clinical features of classic smallpox to classify persons presenting with suspected smallpox rashes into 3 categories: those with high, those with moderate, and those with low risk of having smallpox. The classification guides subsequent diagnostic strategies, limiting smallpox laboratory testing to high-risk persons to minimize the number of false-positive test results. From January 2002 through June 2004, the Centers for Disease Control and Prevention (CDC) received 43 consultations regarding suspected smallpox cases. No patient was at high risk for having smallpox. One patient was tested for the presence of variola virus. Varicella was the diagnosis for 23 cases (53%). The algorithm worked well to guide clinical and public health responses to suspected smallpox cases. The poster is available from CDC, and an interactive version and laboratory protocol are available at http://www.bt.cdc.gov/agent/smallpox/diagnosis/riskalgorithm/index.asp. We recommend use of the algorithm in the United States and elsewhere.

The role of preoperative TIPSS to facilitate curative gastric surgery

The use of TIPSS to facilitate radical curative upper gastrointestinal surgery has not been reported. We describe a case in which curative gastric resection was performed for carcinoma of the stomach after a preoperative TIPSS and embolization of a large gastric varix in a patient with portal hypertension.

Development of an ombrotrophic peat bog (low ash) reference material for the determination of elemental concentrations

Given the increasing interest in using peat bogs as archives of atmospheric metal deposition, the lack of validated sample preparation methods and suitable certified reference materials has hindered not only the quality assurance of the generated analytical data but also the interpretation and comparison of peat core metal profiles from different laboratories in the international community. Reference materials play an important role in the evaluation of the accuracy of analytical results and are essential parts of good laboratory practice. An ombrotrophic peat bog reference material has been developed by 14 laboratories from nine countries in an inter-laboratory comparison between February and October 2002. The material has been characterised for both acid-extractable and total concentrations of a range of elements, including Al, As, Ca, Cd, Cr, Cu, Fe, Hg, Mg, Mn, Na, Ni, P, Pb, Ti, V and Zn. The steps involved in the production of the reference material (i.e. collection and preparation, homogeneity and stability studies, and certification) are described in detail.

Impact of endoscopic ultrasonography on the management of idiopathic pancreatitis

Background

Conventional ultrasonography may fail to detect small stones responsible for acute pancreatitis, leading to a false diagnosis of idiopathic pancreatitis and exposing 33–66 per cent of these patients to the risk of a recurrent attack from untreated gallstone disease. The aim of this study was to assess whether identification of a potential aetiology in patients with ‘idiopathic’ pancreatitis, using endoscopic ultrasonography (EUS), had any effect on outcome.

Methods

EUS was performed following a diagnosis of idiopathic pancreatitis, using the GF UM-20 echoendoscope (Olympus). The presence of gallstones or other pathology was determined and any appropriate treatment was provided. The frequency of attacks of pancreatitis before and after treatment of the presumed cause was calculated.

Results

Of 20 patients with idiopathic pancreatitis, evidence of gallstone disease (e.g. stones, microlithiasis) was seen in 12 patients leading to endoscopic sphincterotomy and/or cholecystectomy in nine. Pancreatic disease was seen in three patients, of whom one underwent pancreatic duct stenting. One patient underwent cholecystectomy for recurrent pain, despite a normal EUS result, with a diagnosis of acalculous cholecystitis. No pathology was seen in a further four patients. The frequency of attacks of pancreatitis was 1·1 per patient-year before treatment versus 0 per patient-year after treatment (P &lt; 0·0001). The overall morbidity rate from investigation and treatment was 0·05 per cent. This resulted from one episode of post-ERCP pancreatitis following endoscopic sphincterotomy, which resolved rapidly with conservative treatment.

Conclusion

EUS is able to detect pancreatic and biliary abnormalities that are not visible with conventional ultrasonography and can guide appropriate treatment. EUS should be performed before a diagnosis of idiopathic pancreatitis is made, to reduce the risk of recurrent pancreatitis from unrecognized gallstones or other pathology.

An assessment of clinical guidelines for the management of acute pancreatitis

BACKGROUND

Recent guidelines have been issued for the management of acute pancreatitis. The aim of this study was to audit the management of acute pancreatitis in one district general hospital, to determine the problems and benefits associated with the implementation of such guidelines.

METHODS

Data were collected over the period 1991-1995 for all patients diagnosed as having acute pancreatitis who were admitted to one district general hospital. Data regarding severity grading, determination of aetiology and treatment of mild and severe pancreatitis were analysed in conjunction with the recommendations issued by the British Society of Gastroenterology Working Party on the management of acute pancreatitis in 1995.

RESULTS

A total of 210 patients were admitted on 263 occasions; 16% of cases were severe but severity prediction was inaccurate. 56.1% had gallstone pancreatitis and 20.9% had idiopathic pancreatitis. Definitive treatment of gallstones was within the recommended time limit in only 70.1%. 27 patients experienced recurrent attacks of pancreatitis before definitive treatment of their gallstones, due either to inadequate investigation for gallstones after suboptimal ultrasound examination (n = 12) or to inappropriate delay before definitive treatment of gallstones (n = 15). Recommendations for the management of severe cases with early ITU/HDU admissions and CT scanning were not followed. 28 day mortality was 6.3%, median age of those dying was 80.5 years.

CONCLUSIONS

Acceptable mortality can be achieved for acute pancreatitis despite failure to implement BSG guidelines for the management of severe acute pancreatitis. Inadequate investigation and treatment of gallstone disease leads to an unacceptable incidence of recurrent acute pancreatitis.

Working toward consensus: providers' strategies to shift patients from curative to palliative treatment choices

End-of-life decision making is a complex phenomenon and providers, patients, and families often have different views about the appropriateness of treatment choices. The results presented here are part of a larger grounded-theory study of reconciling decisions near the end of life. In particular, we examined how providers (N = 15) worked near the end of patients' lives toward changing the treatment decisions of patients and families from those decisions that providers described as unrealistic (i.e., curative) to those that providers described as more realistic (i.e., palliative). According to providers, shifting patients' and families' choices from curative to palliative was usually accomplished by changing patients' and families' understanding of the patient's overall "big picture" to one that was consistent with the providers' understanding. Until patients and families shifted their understanding of the patient's condition-the big picture-they continued to make what providers judged as unrealistic treatment choices based on an inaccurate understanding of what was really going on. These unrealistic choices often precluded possibilities for a "good death." According to providers, the purpose of attempting to shift the patient or proxy's goals was that realistic goals lead to realistic palliative treatment choices that providers associated with a good death. In this article we review strategies used by providers when they believed a patient's death was imminent to attempt to shift patients' and families' understandings of the big picture, thus ultimately shifting their treatment decisions.

Endoscopic ultrasonography in the evaluation of idiopathic acute pancreatitis

BACKGROUND

'Idiopathic' pancreatitis may be diagnosed when gallstones are excluded by transabdominal ultrasonography and less common causes are not implicated by history or other investigations. Transabdominal ultrasonography may not, however, detect small stones responsible for acute pancreatitis. The aim of this study was to determine if endoscopic ultrasonography (EUS) is able to identify undetected gallstones in cases of 'idiopathic' pancreatitis.

METHODS

Consecutive patients presenting with 'idiopathic' pancreatitis were assessed using EUS for the presence of gallstones or other potential causes of the attack. A control group was also imaged.

RESULTS

Forty-four patients with 'idiopathic' pancreatitis were assessed. Ten had suffered earlier attacks of pancreatitis before this study. EUS revealed proven pathology in 18 patients. Unconfirmed pathology was evident in 14. No abnormality was seen in only nine patients. EUS failed in one patient and there were two possible false-positive results.

CONCLUSION

EUS is able to identify significant pathology in patients in whom a diagnosis of 'idiopathic' pancreatitis has been made following standard investigations. Patients with untreated gallstones are at risk of recurrent attacks. Idiopathic pancreatitis should not be diagnosed unless EUS has been performed.

Facilitating end-of-life decision-making: strategies for communicating and assessing

End-of-life decision-making is often a difficult process and one that many elderly patients and their families will undergo. The grounded theory study of nurses, physicians, and family members (n = 20) reported in this article examined provider behaviors that facilitated the process of decision-making near the end of patients' lives. According to participants, providers who are experienced and comfortable are more likely to engage in communication and assessment strategies that facilitate end-of-life decision-making. Communication strategies included: being clear, avoiding euphemisms, spelling out the goals and expectations of treatment, using words such as "death" and "dying," and being specific when using such words as "hope" and "better." Assessment strategies included: assessing patients' physical conditions and end-of-life wishes, patients' and family members' understandings of the disease and prognosis, and their expectations and goals. An important first step for improved care is making explicit the provider's communicating and assessing strategies that facilitate end-of-life decision-making.

Federally qualified health centers: surviving Medicaid managed care, but not thriving

This article reviews the experiences of federally qualified health centers (FQHCs) in Hawaii, Rhode Island, and Tennessee before and after Medicaid managed care demonstrations began. Adapting to managed care proved challenging, but all FQHCs survived. Overall, FQHCs performed better financially than anticipated, partly because demonstrations expanded coverage to previously uninsured individuals, and because FQHCs in two States formed plans that paid FQHCs more than other plans. Service encounters declined; it is unclear if this is negative, since it may indicate more efficient care delivery. In some cases, supportive State policies aided FQHCs' survival. Continued adaptation is critical for FQHCs' longer term prospects.

Did the Medicaid expansions for children displace private insurance? An analysis using the SIPP

Using data from the 1990 panel of the Survey of Income and Program Participation (SIPP), we address the question: Did the Medicaid expansions for children cause declines in private coverage? We use a multivariate approach that attributes a displacement effect to declines in private coverage for children targeted by the Medicaid expansions exceeding declines for a comparison group of older low-income children. We find that 23% of the movement from private coverage to Medicaid due to the expansions was attributable to displacement. There is no evidence of displacement among those starting uninsured, leading to an overall displacement effect of 4%.

Staging of rectosigmoid neoplasia with colonoscopic endoluminal ultrasonography

BACKGROUND

The accurate staging of colorectal neoplasia may aid the stratification of patients for adjuvant treatment. At present the mural extent of neoplasia proximal to the mid rectum is difficult to determine. Prediction of mural invasion could help identify patients suitable for radical resection, minimal access surgery or endoscopic treatment. Colonoscopic endoluminal ultrasonography (EUS) was used in a prospective study to determine the stage of rectosigmoid neoplasia in 121 patients.

METHODS

Mural tumour (T) stage was designated by EUS as uT0/1-uT4 in 121 patients. Nodal (N) staging was performed in 39 cases. EUS staging was compared with histological stage (pT and pN) in 93 patients who underwent resection.

RESULTS

Mural staging of disease using colonoscopic EUS showed good correlation with histo-pathological stage (kappa = 0.85 (95 per cent confidence interval 0.76-0.95)). Overall pT and pN stage accuracy of EUS was 92 and 65 per cent respectively.

CONCLUSION

EUS accurately assessed tumour stage although node staging remained suboptimal. Colonoscopic EUS may aid the selection of treatment in patients with rectosigmoid neoplasia.

What are the requirements for medical cover at motor racing circuits?

Motor racing is perceived as a dangerous sport but few data are available on the incidence and nature of injuries sustained. The medical service requirement at one regional motor racing circuit was assessed by determining the incidence of injuries, the medical interventions required and the need for hospital referral and admission over a 5-year period. Five hundred and twenty-one patients, including support staff and spectators, attended the medical centre, of whom 14% were referred to hospital and 4% required admission. Each competitor had a 4% chance of requiring on-circuit medical attention, 0.6% chance of hospital referral and 0.17% chance of admission per race. Most major accidents involved more than two drivers. Twenty sustained major trauma including five pelvic fractures and two intraabdominal haemorrhages. Emergency intervention included intubation and ventilation in five. There were three deaths from a total of 9000 competitors (mortality rate 0.033%). This study shows that despite the nature of the sport, the mortality rate remains low with prompt skilled medical intervention. Medical personnel should include those competent in dealing with minor medical complaints as well as those with advanced airway management and resuscitation skills. Although national motor sport guidelines recommend a minimum of two attending doctors this would have been insufficient for multivehicle accidents.

Telemedicine in Micronesia

Distance and isolation profoundly affect the delivery of health care in the islands of Micronesia. The lack of specialty services on most of the islands has led to a costly off-island referral system that strains health care budgets. Care providers there have incorporated advances in telecommunications to create a telemedicine network amongst themselves and with a tertiary care hospital in Hawaii. They developed an interactive video conferencing system, a still-image transmission network, and a data transfer network for use principally in patient care and continuing education. Patients now receive earlier evaluation by off-island specialists as part of an effort to improve the appropriateness of off-island referrals. Regularly scheduled medical lectures are broadcast from Pohnpei, a main island, to physicians in several more remote locations. Transmission costs are kept low by using, when possible, preexisting public-service satellites, such as the PEACESAT system that serves the entire Pacific basin. The telemedicine system is evolving, and its success depends greatly on the cooperative relationships among the partners.

The dermatologist's Baedeker. Preparation for medical assistance missions

Dermatologists often participate in medical assistance missions in developing nations, achieving both humanitarian and personal objectives. This term outreach mission abroad and will serve as a guide for preparing oneself, personally and professionally, for the practical and philosophical aspects of humanitarian assistance. It will help one participate in such an endeavor in a safe, comfortable, healthy, productive, and enjoyable manner.