Point-of-care ultrasound assessment of a swollen limb following snakebite envenomation - an adjunct to avoid fasciotomy

SUMMARY

Acute limb compartment syndrome can occur with cytotoxic snake envenomation. Ultrasound (US) assessment of the affected limb has been suggested as an adjunct to the administration of snakebite polyvalent antivenom to ameliorate the systemic and local effects. US may also aid in the diagnosis of compartment syndrome and the need for fasciotomy to prevent limb loss. This report presents an adult male who had severe soft tissue swelling from a puff adder bite to the wrist and highlights the use of US in assessing and monitoring the degree of swelling in subcutaneous and fascial compartments of the arm. This US monitoring in conjunction with frequent physical examination avoided the need for a fasciotomy and its attendant morbidity, resulting in complete resolution of the swelling and full recovery of limb function.

POS1343 TREATMENT OF RESISTANT RAYNAUD’S PHENOMENON WITH SINGLE-PORT THORACOSCOPIC SYMPATHICOTOMY: ONE-YEAR FOLLOW-UP

Background

Raynaud’s phenomenon (RP) usually results in discoloration of the extremities when provoked by cold or emotional stress [1]. Some patients do not respond to conventional therapies, such as lifestyle interventions and vasodilatory medication. These patients are confronted with limited options for treatment. In a previous study we have shown that minimally invasive Single-Port Thoracoscopic Sympathicotomy (SPTS) objectively and subjectively improves treatment-resistant RP, after one month [2]. This procedure for treatment-resistant RP is minimally invasive and potentially highly effective, because it specifically targets the sympathetic nerve at the third rib (R3), while leaving the ganglia untouched [3]. The procedure was only performed on the left side in the pilot study, which objectively resulted in improvement of left-hand perfusion in all patients after one month, when compared to the right hand. Furthermore, patient satisfaction after surgery was high and RP attacks of the left hand were less frequent and of shorter duration. Previous studies have shown that long-term effects of conventional sympathectomy is stable in the long run in the majority of patients [4, 5]. We have previously published the one-month results of SPTS for treatment-resistant RP in a concise report [2]. In the current study we sought to report the one-year follow-up results of SPTS for treatment-resistant RP in the same cohort of patients.

Objectives

Follow-up of patients with treatment-resistant Raynaud’s phenomenon (RP) one-year after single-port thoracoscopic sympathicotomy (SPTS).

Methods

Eight patients (six males, two females, median age of 45 years) with treatment-resistant RP underwent left-sided SPTS at the third rib (R3), unilaterally. Perfusion was assessed with a cooling and recovery procedure at baseline and one year after SPTS. Furthermore, laser speckle contrast analysis, pulse wave velocity, heart rate variability and nailfold capillaroscopy were performed. In addition, questionnaires were taken, and number and duration of RP attacks were reported over a 2-week period.

Results

One year after SPTS the duration of the attacks of was reduced with 1.9 hours in the left hand versus 0.9 hours in the right hand. Furthermore, three aspects of the questionnaire showed a significant improvement (role limitations due to physical health (p=0.017), pain (p=0.027) and physical functioning (p=0.025)). The total area under the curve of the total cooling and recovery procedure of the left hand was larger one year after surgery (101 (75–140) at baseline versus 118 (95–190) one year post-operatively, p=0.012), implying a better perfusion in the fingers. This was mainly due to the improvement during the recovery phase (21 (1–41) at baseline versus 38 (24–43) one year post-operatively, p=0.028).

Conclusion

One year after unilateral R3 SPTS there is clear benefit with regard to the majority of outcome variables, though some effects seem to attenuate. Long-term effects and five-year follow-up results will be investigated in an on-going study.

References

[1]Herrick AL. The pathogenesis, diagnosis and treatment of Raynaud phenomenon. Nat Rev Rheumatol. 2012;8(8):469-79.

[2]van Roon AM, Kuijpers M, van de Zande SC, Abdulle AE, van Roon AM, Bos R, et al. Treatment of resistant Raynaud’s phenomenon with single-port thoracoscopic sympathicotomy: a novel minimally invasive endoscopic technique. Rheumatology (Oxford). 2020;59(5):1021-5.

[3]Kuijpers M, Klinkenberg TJ, Bouma W, DeJongste MJ, Mariani MA. Single-port one-stage bilateral thoracoscopic sympathicotomy for severe hyperhidrosis: prospective analysis of a standardized approach. J Cardiothorac Surg. 2013;8:216.

[4]Coveliers HM, Hoexum F, Nederhoed JH, Wisselink W, Rauwerda JA. Thoracic sympathectomy for digital ischemia: a summary of evidence. J Vasc Surg. 2011;54(1):273-7.

[5]Sayers RD, Jenner RE, Barrie WW. Transthoracic endoscopic sympathectomy for hyperhidrosis and Raynaud’s phenomenon. Eur J Vasc Surg. 1994;8(5):627-31.

Disclosure of Interests

None declared

Individual-specific changes in circadian rest-activity rhythm and sleep in symptom-free patients tapering their antidepressant medication

Introduction

Group-level studies showed cross-sectional and prospective between-person associations between circadian rest-activity rhythms (RAR), physical activity (PA), sleep, and depressive symptoms. However, whether these associations replicate at the within-person level remains unclear. Therefore, it is clinically relevant to investigate these associations within persons and study whether changes in depressive symptoms are related to changes in circadian rhythm and sleep variables.

Objectives

To identify changes in circadian rhythm elements in proximity to a transition in depressive symptoms, whether changes are less frequent in individuals without compared to those with transitions, and whether there are individual differences in the direction of change of circadian rhythm variables.

Methods

Data of remitted individuals tapering antidepressants were used: 12 with and 14 without a transition in depressive symptoms. RAR, PA, and sleep variables were calculated as predictors from four months of actigraphy data. Transitions in depressive symptoms were based on weekly SCL-90 scores and evaluation interviews. Kernel Change Point analyses were used to detect change points (CPs) and CP timing in circadian rhythm variables for each individual separately.

Results

In 67% of individuals with depressive symptoms transitions, CPs were identified in proximity to symptom transitions. CPs were detected less frequently in the no-transition group with 7 CPs in 14 individuals, compared to transition groups with 10 CPs in 12 individuals. For several RAR and sleep variables, consistent changes were detected in expected directions.

Conclusions

Circadian rhythm variables provide potentially clinically relevant information although their patterns around transitions are highly person-specific. Future research is needed to disentangle which variables are predictive for which patients.

Disclosure

No significant relationships.

Anticipating transitions in mental health in at-risk youth: A large-scale diary study into early warning signals

Introduction

Transitions in mental health, such as the onset or sudden progression of psychopathology, are difficult to foresee. If mental health behaves like other complex systems, drops in mental health may be anticipated by early warning signals (EWS), which manifest in the dynamics of time series data.

Objectives

This study aimed to establish the sensitivity and specificity of EWS as personalized risk markers for sudden drops mental health.

Methods

Individuals (N=122, mean age 23.6 ±0.7 years, 57% males) at increased risk for psychopathology completed daily questionnaires on mental states for six consecutive months. Transitions in mental health were identified by change point analyses. EWS, operationalized as rising trends in the autoregressive coefficient of 36 negative mental states, were identified using generalized additive models.

Results

EWS were found for 59% of individuals with a drop in mental health, and for 47% without such a drop (sensitivity: 0-.12; specificity: .88-1). There were considerable individual differences in the prevalence, strength, and timing of EWS.

Conclusions

EWS might be informative of impeding transitions, yet they are also highly conservative. Present findings may inspire future research into the prerequisites for detecting EWS in the context of mental health, for instance with respect to the stability of pre- and post-transition phases, the magnitude of transitions, and the timescale at which EWS manifest. An improved understanding of the dynamics that govern psychopathology could ultimately allow us to determine whether a specific individual at a specific moment in time is at risk for a sudden onset or progression of mental health problems.

Theta/SMR Neurofeedback Training Works Well for Some Forensic Psychiatric Patients, But Not for Others: A Sham-Controlled Clinical Case Series

Electroencephalographic (EEG) neurofeedback could be a promising treatment for forensic psychiatric patients. Increasing evidence shows some patients are unable to regulate cortical activity. Before neurofeedback can be applied successfully, research is needed to investigate the interpersonal mechanisms responsible for patients' ability to respond to neurofeedback. A single-case experimental design allows for close monitoring of individual patients, providing valuable information about patients' response to the intervention and the time frame in which changes in clinical symptoms can be observed. Four patients with Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) substance use disorder and various comorbidities participated in a sham-controlled clinical case study. Self-report level of impulsivity and craving were assessed. Results indicate that one patient showed more improvements on behavioral measures after the neurofeedback training than did the others. This patient reported less impulsivity and reduced levels of self-reported craving. However, these findings could not be attributed to the neurofeedback intervention. The findings suggest that there is insufficient evidence for the beneficial effects of a theta/sensorimotor rhythm (SMR) neurofeedback intervention on measures of impulsivity and craving, and that there may be great interindividual differences in patients' ability to regulate cortical activity.

Growth signals employ CGGBP1 to suppress transcription of Alu-SINEs

CGGBP1 (CGG triplet repeat-binding protein 1) regulates cell proliferation, stress response, cytokinesis, telomeric integrity and transcription. It could affect these processes by modulating target gene expression under different conditions. Identification of CGGBP1-target genes and their regulation could reveal how a transcription regulator affects such diverse cellular processes. Here we describe the mechanisms of differential gene expression regulation by CGGBP1 in quiescent or growing cells. By studying global gene expression patterns and genome-wide DNA-binding patterns of CGGBP1, we show that a possible mechanism through which it affects the expression of RNA Pol II-transcribed genes in trans depends on Alu RNA. We also show that it regulates Alu transcription in cis by binding to Alu promoter. Our results also indicate that potential phosphorylation of CGGBP1 upon growth stimulation facilitates its nuclear retention, Alu-binding and dislodging of RNA Pol III therefrom. These findings provide insights into how Alu transcription is regulated in response to growth signals.

[Adequacy of treatment for chronic anxiety or depression; an exploratory study of treatment practice]

Many patients with anxiety or depression receiving specialised outpatient treatment at mental health centres do not fully recover. Relapse and chronic course are common. This raises questions about the adequacy of the treatment they receive.<br/> AIM: To obtain insight into the type and length of the treatment given to patients with chronic anxiety or depression.<br/> METHOD: We collected data as part of a national study involving 12 mental health trusts. To be included in the study, patients had to satisfy certain criteria: they had to have received specialised treatment for anxiety or depression for at least two years and there had to be concerns whether these patients would benefit from further treatment in this setting. We gathered information about patient characteristics, diagnosis and treatment history.<br/> RESULTS: On the basis of our selection criteria, 268 patients participated in our study; 65% of the patients were female. Patients were grouped in three categories: 67% were suffering from major depression, 25% from anxiety disorder and 8% from comorbid anxiety and depression. On average, patients had been treated for six years. More than one third of patients had received poor-quality treatment: treatment in the form of psychotherapy and/or pharmacotherapy had not been carried out in accordance with treatment guidelines.<br/> CONCLUSION: In practice, much current treatment falls short of expectations. In particular, pharmacotherapy for depression needs to be improved. Longer periods of treatment should be evaluated at least once every six months.

[Tailored pharmacotherapy. Consultations about medication in a care programme for depression]

BACKGROUND

Despite the increasing rationalisation of mental health care, there are no specific recommendations regarding the number of contacts between a patient and a psychiatrist for the pharmacotherapy that forms part of the combined outpatient treatment (antidepressants and psychotherapy) of depression.

AIM

To consider the possibility of drawing up an advisory document regarding frequency, number and duration of consultations about medication in combined treatment for depression.

METHOD

We reviewed the literature and had qualitative interviews with psychiatrists and trainees in psychiatric residency.

RESULTS

The literature focuses predominantly on diagnostics and patient characteristics that determine the amount of care required. Advice on medication and pharmacotherapy is provided only by experts. According to the interviews, in psychiatric practice many factors influence the number and duration of consultations. Nevertheless, a distinctive pattern emerged.

CONCLUSION

Regarding medication in the acute treatment phase, five or six visits to a psychiatrist are sufficient for most patients. Extra consultations have to be arranged for smaller groups of less stable patients and for crisis-prone patients.

A call for benchmarking transposable element annotation methods

DNA derived from transposable elements (TEs) constitutes large parts of the genomes of complex eukaryotes, with major impacts not only on genomic research but also on how organisms evolve and function. Although a variety of methods and tools have been developed to detect and annotate TEs, there are as yet no standard benchmarks-that is, no standard way to measure or compare their accuracy. This lack of accuracy assessment calls into question conclusions from a wide range of research that depends explicitly or implicitly on TE annotation. In the absence of standard benchmarks, toolmakers are impeded in improving their tools, annotators cannot properly assess which tools might best suit their needs, and downstream researchers cannot judge how accuracy limitations might impact their studies. We therefore propose that the TE research community create and adopt standard TE annotation benchmarks, and we call for other researchers to join the authors in making this long-overdue effort a success.

Seclusion as a necessary vs. an appropriate intervention: a vignette study among mental health nurses

In a vignette study, mental health nurses were asked to score vignettes on necessity and appropriateness using a Likert scale. Sixty-nine clinical nurses from four mental health institutes scored 64 vignettes on necessity (there is no alternative) and appropriateness (seclusion supports patients' treatment) of seclusion simultaneously. Data analysis focused on the differences between both scores, and included general linear model analysis, t-test statistics and Kendall's tau. The t-test resulted in a significantly higher score on necessity than on appropriateness. Differences between both scores could be explained for 32% by a combination of nurse characteristics and vignette variables. Necessity and appropriateness were found to be strongly associated with each other, showing that underpinning patterns were largely the same. This research enhances the understanding of underlying factors that influence the decision of nurses to use seclusion. This is essential for the development of interventions aimed at the reduction of seclusion use in mental health practice.

Gibbon genome and the fast karyotype evolution of small apes

Gibbons are small arboreal apes that display an accelerated rate of evolutionary chromosomal rearrangement and occupy a key node in the primate phylogeny between Old World monkeys and great apes. Here we present the assembly and analysis of a northern white-cheeked gibbon (Nomascus leucogenys) genome. We describe the propensity for a gibbon-specific retrotransposon (LAVA) to insert into chromosome segregation genes and alter transcription by providing a premature termination site, suggesting a possible molecular mechanism for the genome plasticity of the gibbon lineage. We further show that the gibbon genera (Nomascus, Hylobates, Hoolock and Symphalangus) experienced a near-instantaneous radiation ∼5 million years ago, coincident with major geographical changes in southeast Asia that caused cycles of habitat compression and expansion. Finally, we identify signatures of positive selection in genes important for forelimb development (TBX5) and connective tissues (COL1A1) that may have been involved in the adaptation of gibbons to their arboreal habitat.

The genome of the gibbon, a tree-dwelling ape from Asia positioned between Old World monkeys and the great apes, is presented, providing insights into the evolutionary history of gibbon species and their accelerated karyotypes, as well as evidence for selection of genes such as those for forelimb development and connective tissue that may be important for locomotion through trees.

The many species of gibbons are small, tree-living apes from Southeast Asia, most of them listed as 'endangered' or 'critically endangered' on the IUCN list. In their presentation of the genome of the northern white-cheeked gibbon (Nomascus leucogenys) , Lucia Carbone and colleagues provide intriguing insights into the biology and evolutionary history of a group that straddles the divide between Old World monkeys and the great apes. The authors investigate how a novel gibbon-specific retrotransposon might be the source of gibbons' genome plasticity. Rapid karyotype evolution combined with multiple episodes of climate and environmental change might explain the almost instantaneous divergence of the four gibbon genera. Positive selection on genes involved in forelimb development and connective tissue might have been related to gibbons' unique mode of locomotion in the tropical canopy.

Effect of a cognitive behavioral self-help intervention on depression, anxiety, and coping self-efficacy in people with rheumatic disease

OBJECTIVE

The aim of this study was to investigate whether a new cognitive-behavioral self-help program with minimal coaching could improve psychological well-being (depression, anxiety, and coping self-efficacy) in people with rheumatic disease and depressive symptoms.

METHODS

In total, 82 persons with a rheumatic disease enrolled in a randomized controlled trial were allocated to either a group receiving the self-help program or a waiting list control condition group. For both groups, measurements were done at baseline, posttest, and followup. The outcome measures were the depression and anxiety scales of the Hospital Anxiety and Depression Scale and an adaptation of the Generalized Self-Efficacy Scale. Repeated-measures analyses of covariance were performed to evaluate changes in outcome measures from pretest to posttest and from posttest to followup.

RESULTS

The results showed that the self-help program was effective in reducing symptoms of depression and anxiety and in strengthening coping self-efficacy. The positive effects remained after a followup period of 2 months.

CONCLUSION

This cost-effective program could very well be used as a first step in a stepped care approach or as one of the treatment possibilities in a matched care approach.

Differences in seclusion rates between admission wards: does patient compilation explain?

Comparison of seclusion figures between wards in Dutch psychiatric hospitals showed substantial differences in number and duration of seclusions. In the opinion of nurses and ward managers, these differences may predominantly be explained by differences in patient characteristics, as these are expected to have a large impact on these seclusion rates. Nurses assume more admissions of severely ill patients are related to higher seclusion rates. In order to test this hypothesis, we investigated differences in patient and background characteristics of 718 secluded patients over 5,097 admissions on 29 different admission wards over seven Dutch psychiatric hospitals. We performed an extreme group analysis to explore the relationship between patient and ward characteristics and the wards' number of seclusion hours per 1,000 admission hours. In a multivariate and a multilevel analysis, various characteristics turned out to be related to the number of seclusion hours per 1,000 admission hours as well as to the likelihood of a patient being secluded, confirming the nurses assumptions. The extreme group analysis showed that seclusion rates depended on both patient and ward characteristics. A multivariate and multilevel analyses revealed that differences in seclusion hours between wards could partially be explained by ward size next to patient characteristics. However, the largest deal of the difference between wards in seclusion rates could not be explained by characteristics measured in this study. We concluded ward policy and adequate staffing may, in particular on smaller wards, be key issues in reduction of seclusion.

Methodological issues in monitoring the use of coercive measures

PURPOSE

In many European countries, initiatives have emerged to reduce the use of seclusion and restraint in psychiatric institutions. To study the effects of these initiatives at a national and international level, consensus on definitions of coercive measures, assessment methods and calculation procedures of these coercive measures are required. The aim of this article is to identify problems in defining and recording coercive measures. The study contributes to the development of consistent comparable measurements definitions and provides recommendations for meaningful data-analyses illustrating the relevance of the proposed framework.

METHODS

Relevant literature was reviewed to identify various definitions and calculation modalities used to measure coercive measures in psychiatric inpatient care. Figures on the coercive measures and epidemiological ratios were calculated in a standardized way. To illustrate how research in clinical practice on coercive measures can be conducted, data from a large multicenter study on seclusion patterns in the Netherlands were used.

RESULTS

Twelve Dutch mental health institutes serving a population of 6.57 million inhabitants provided their comprehensive coercion measure data sets. In total 37 hospitals and 227 wards containing 6812 beds were included in the study. Overall seclusion and restraint data in a sample of 31,594 admissions in 20,934 patients were analyzed. Considerable variation in ward and patient characteristics was identified in this study. The chance to be exposed to seclusion per capita inhabitants of the institute's catchment areas varied between 0.31 and 1.6 per 100.000. Between mental health institutions, the duration in seclusion hours per 1000 inpatient hours varied from less than 1 up to 18h. The number of seclusion incidents per 1000 admissions varied between 79 up to 745. The mean duration of seclusion incidents of nearly 184h may be seen as high in an international perspective.

CONCLUSION

Coercive measures can be reliably assessed in a standardized and comparable way under the condition of using clear joint definitions. Methodological consensus between researchers and mental health professionals on these definitions is necessary to allow comparisons of seclusion and restraint rates. The study contributes to the development of international standards on gathering coercion related data and the consistent calculation of relevant outcome parameters.

Skin autofluorescence is increased in systemic lupus erythematosus but is not reflected by elevated plasma levels of advanced glycation endproducts

OBJECTIVES

To examine whether skin advanced glycation endproducts (AGEs) accumulation, plasma levels of AGEs-N(epsilon)-carboxymethyllysine (CML) and N(epsilon)-carboxyethyllysine (CEL)-and serum levels of soluble receptor for AGEs (sRAGE) are elevated in SLE patients compared with controls, and whether these parameters are related to disease activity and endothelial cell (EC) activation.

METHODS

Ten SLE patients (9 women, age 34 +/- 13 yrs, mean +/- s.d.) and 10 age- and sex-matched controls were included. Patients were analysed during inactive as well as active disease. Skin AGE accumulation was estimated using ultraviolet-A (UV-A) light for measurement of autofluorescence obtained by Excitation-Emission matrix Scanner (AF-EEMS). Levels of CML and CEL were determined by tandem mass spectrometry. Levels of sRAGE and of soluble vascular cell adhesion molecule-1 (sVCAM-1) were determined by ELISAs.

RESULTS

Skin AF-EEMS was increased in SLE patients compared with controls (P < 0.05). Levels of CML and CEL were comparable between patients and controls and were not influenced by disease activity. sRAGE and sVCAM-1 levels were higher in quiescent SLE patients compared with controls (P < 0.05) and increased further during active disease (P < 0.05). In patients with quiescent disease and controls, sRAGE levels correlated to sVCAM-1 levels (r = 0.579, P = 0.007).

CONCLUSIONS

Skin AGEs and levels of sRAGE and sVCAM-1 were elevated in SLE patients, whereas levels of CML and CEL were comparable with controls. As sRAGE even further increased during endothelial activation, it might be hypothesized that sRAGE acts as a decoy receptor. Why this proposed mechanism is insufficient to prevent increased AGE accumulation in the skin of SLE patients has to be established.

DupMasker: a tool for annotating primate segmental duplications

Segmental duplications (SDs) play an important role in genome rearrangement, evolution, and the copy-number variation (CNV) of primate genomes. Such sequences are difficult to detect, a priori, because they share no defining sequence features that distinguish them from unique portions of the genome. Current sequence annotation of segmental duplications requires computationally intensive, genome-wide self-comparisons that cannot be easily implemented on new data sets. Based on the successful implementation of RepeatMasker, we developed a new genome annotation tool, DupMasker. The program uses a library of nonredundant consensus sequences of human segmental duplications, wherein a majority of the ancestral origins have been determined based on comparisons to mammalian outgroup genomes. Using DupMasker, new human and nonhuman primate (NHP) sequences may be readily queried to provide details on the origin and degree of sequence identity of each duplicon. This program can be applied to delineate the order and orientation of duplicons within complex duplication blocks and used to characterize structural variation differences between sequenced human haplotypes. We predict this tool will be valuable in the annotation of large-insert sequence clones, allowing putative unique and duplicated regions of the genomes to be annotated prior to whole genome assembly comparisons.

The Thr505 and Ser557 residues of the AGT1-encoded alpha-glucoside transporter are critical for maltotriose transport in Saccharomyces cerevisiae

AIMS

The main objective of this study was to identify amino acid residues in the AGT1-encoded alpha-glucoside transporter (Agt1p) that are critical for efficient transport of maltotriose in the yeast Saccharomyces cerevisiae.

METHODS AND RESULTS

The sequences of two AGT1-encoded alpha-glucoside transporters with different efficiencies of maltotriose transport in two Saccharomyces strains (WH310 and WH314) were compared. The sequence variations and discrepancies between these two proteins (Agt1p(WH310) and Agt1p(WH314)) were investigated for potential effects on the functionality and maltotriose transport efficiency of these two AGT1-encoded alpha-glucoside transporters. A 23-amino-acid C-terminal truncation proved not to be critical for maltotriose affinity. The identification of three amino acid differences, which potentially could have been instrumental in the transportation of maltotriose, were further investigated. Single mutations were created to restore the point mutations I505T, V549A and T557S one by one. The single site mutant V549A showed a decrease in maltotriose transport ability, and the I505T and T557S mutants showed complete reduction in maltotriose transport.

CONCLUSIONS

The amino acids Thr(505) and Ser(557), which are respectively located in the transmembrane (TM) segment TM(11) and on the intracellular segment after TM(12) of the AGT1-encoded alpha-glucoside transporters, are critical for efficient transport of maltotriose in S. cerevisiae.

SIGNIFICANCE AND IMPACT OF THE STUDY

Improved fermentation of starch and its dextrin products, such as maltotriose and maltose, would benefit the brewing and whisky industries. This study could facilitate the development of engineered maltotriose transporters adapted to starch-efficient fermentation systems, and offers prospects for the development of yeast strains with improved maltose and maltotriose uptake capabilities that, in turn, could increase the overall fermentation efficiencies in the beer and whisky industries.

A cost-efficiency analysis of a mobile dental clinic in the public services

During 1997, the Gauteng Oral Health Services implemented a Mobile Oral Health Care System (MOHCS) in the province. For the first year (1997/98) one mobile dental clinic was utilised in the West Rand region of the province and services were provided by dentists, dental therapists and oral hygienists. The purpose of the MOHCS is to provide an accessible and affordable comprehensive oral health care service of high quality and standard. The aim of this study was to determine the cost-efficiency of the mobile dental clinic utilised in the West Rand region over the first year of implementation. After consultation with all stakeholders, an operational plan was finalised. The plan included a traveling schedule, clinicians available for service delivery, and a management information system (MIS). Statistics on dental materials, consumables, treatment provided, etc. were collected and analysed. During the study period 2072 patients received dental treatment at 38 different sites in the region. At an average cost of R56.50 (+/- US$11) per patient, services to the value of R92.45 (+/- US$18) per patient were delivered during 104 working days. Of the 1477 patients treated by a dentist or dental therapist, 53% were treated by extracting 1026 teeth, and 27% by restoring 570 teeth. For oral hygiene patients, 67% received an oral hygiene procedure and 13% received fissure sealants. With a net margin ratio of 0,39 and a breakeven point of 1173,46 patients and 58,90 days, an accessible and cost-efficient service was provided to health districts in the West Rand region.

Short-term effects of enhanced treatment for depression in primary care: results from a randomized controlled trial

BACKGROUND

Depression is a highly prevalent, often recurring or persistent disorder. The majority of patients are initially seen and treated in primary care. Effective treatments are available, but possibilities for providing adequate follow-up care are often limited in this setting. This study assesses the effectiveness of primary-care-based enhanced treatment modalities on short-term patient outcomes.

METHOD

In a randomized controlled trial we evaluated a psycho-educational self-management intervention. We included 267 adult patients meeting criteria for a DSM-IV diagnosis of major depressive disorder, assessed by a structured psychiatric interview. Patients were randomly assigned to: the Depression Recurrence Prevention (DRP) program (n=112); a combination of the DRP program with psychiatric consultation (PC+DRP, n=39); a combination with brief cognitive behavior therapy (CBT+DRP, n=44); and care as usual (CAU, n=72). Follow-up assessments were made at 3 months (response 90%) and 6 months (85%).

RESULTS

Patient acceptance of enhanced care was good. The mean duration of the index episode was 11 weeks (S.D.=9.78) and similar in CAU and enhanced care. Recovery rate after 6 months was 67% overall; 17% of all participants remained depressed for the entire 6-month period.

CONCLUSION

Enhanced care did not result in better short-term outcomes. We found no evidence that the DRP program was more effective than CAU and no indications for added beneficial effects of either the psychiatric evaluation or the CBT treatment to the basic format of the DRP program. Observed depression treatment rates in CAU were high.

Molecular evolution and tempo of amplification of human LINE-1 retrotransposons since the origin of primates

We investigated the evolution of the families of LINE-1 (L1) retrotransposons that have amplified in the human lineage since the origin of primates. We identified two phases in the evolution of L1. From approximately 70 million years ago (Mya) until approximately 40 Mya, three distinct L1 lineages were simultaneously active in the genome of ancestral primates. In contrast, during the last 40 million years (Myr), i.e., during the evolution of anthropoid primates, a single lineage of families has evolved and amplified. We found that novel (i.e., unrelated) regulatory regions (5'UTR) have been frequently recruited during the evolution of L1, whereas the two open-reading frames (ORF1 and ORF2) have remained relatively conserved. We found that L1 families coexisted and formed independently evolving L1 lineages only when they had different 5'UTRs. We propose that L1 families with different 5'UTR can coexist because they don't rely on the same host-encoded factors for their transcription and therefore do not compete with each other. The most prolific L1 families (families L1PA8 to L1PA3) amplified between 40 and 12 Mya. This period of high activity corresponds to an episode of adaptive evolution in a segment of ORF1. The correlation between the high activity of L1 families and adaptive evolution could result from the coevolution of L1 and a host-encoded repressor of L1 activity.

Elective hand surgery in patients taking warfarin

We reviewed 22 patients who had undergone either carpal tunnel decompression or release of Dupuytren's contractures while anticoagulated with warfarin. All patients continued with their usual anticoagulant regime over the period of operation, provided that the international normalized ratio (INR) was 3 or less. There was no abnormal intraoperative or postoperative bleeding in any patient. Journal of Hand Surgery (British and European volume, 2004).

Accelerated atherosclerosis in patients with Wegener's granulomatosis

BACKGROUND

Several autoimmune disorders are complicated by excess cardiovascular disease. In addition to traditional risk factors, non-traditional risk factors such as endothelial activation and excessive vascular remodelling might be determinants of the progression of atherosclerosis in patients with an autoimmune disease.

OBJECTIVE

To evaluate whether patients with Wegener's granulomatosis (WG) have an increased prevalence of atherosclerosis and to determine predisposing factors.

METHODS

29 WG patients (19 men; mean (SD) age, 53 (14) years) with inactive disease and 26 controls (16 men; age 53 (15) years) were studied. Common carotid intima-media thickness (IMT) was measured by ultrasound. In all individuals traditional risk factors for cardiovascular disease were determined. High sensitivity C reactive protein (hsCRP) was measured. Endothelial activation was assessed by measuring thrombomodulin, vascular cell adhesion molecule-1, and von Willebrand factor. As a marker of vascular remodelling matrix metalloproteinases (MMP-3 and MMP-9) and TIMP-1 were measured.

RESULTS

IMT was increased in WG patients compared with controls (p<0.05). No differences in traditional risk factors and endothelial activation markers between patients and controls were found. Levels of hsCRP, MMPs, and TIMP-1 were increased in WG patients (p<0.05).

CONCLUSIONS

Increased IMT found in WG patients cannot be explained by an increased prevalence of traditional risk factors. Although endothelial activation markers in WG patients with inactive disease were not increased, the raised levels of hsCRP, MMPs, and TIMP-1 suggest that enhanced inflammation and excessive vascular remodelling are contributing factors in the development of accelerated atherosclerosis in WG.

Genome sequence of the Brown Norway rat yields insights into mammalian evolution

The laboratory rat (Rattus norvegicus) is an indispensable tool in experimental medicine and drug development, having made inestimable contributions to human health. We report here the genome sequence of the Brown Norway (BN) rat strain. The sequence represents a high-quality 'draft' covering over 90% of the genome. The BN rat sequence is the third complete mammalian genome to be deciphered, and three-way comparisons with the human and mouse genomes resolve details of mammalian evolution. This first comprehensive analysis includes genes and proteins and their relation to human disease, repeated sequences, comparative genome-wide studies of mammalian orthologous chromosomal regions and rearrangement breakpoints, reconstruction of ancestral karyotypes and the events leading to existing species, rates of variation, and lineage-specific and lineage-independent evolutionary events such as expansion of gene families, orthology relations and protein evolution.

MultiPipMaker and supporting tools: Alignments and analysis of multiple genomic DNA sequences

Analysis of multiple sequence alignments can generate important, testable hypotheses about the phylogenetic history and cellular function of genomic sequences. We describe the MultiPipMaker server, which aligns multiple, long genomic DNA sequences quickly and with good sensitivity (available at http://bio.cse.psu.edu/ since May 2001). Alignments are computed between a contiguous reference sequence and one or more secondary sequences, which can be finished or draft sequence. The outputs include a stacked set of percent identity plots, called a MultiPip, comparing the reference sequence with subsequent sequences, and a nucleotide-level multiple alignment. New tools are provided to search MultiPipMaker output for conserved matches to a user-specified pattern and for conserved matches to position weight matrices that describe transcription factor binding sites (singly and in clusters). We illustrate the use of MultiPipMaker to identify candidate regulatory regions in WNT2 and then demonstrate by transfection assays that they are functional. Analysis of the alignments also confirms the phylogenetic inference that horses are more closely related to cats than to cows.

Covariation in frequencies of substitution, deletion, transposition, and recombination during eutherian evolution

Six measures of evolutionary change in the human genome were studied, three derived from the aligned human and mouse genomes in conjunction with the Mouse Genome Sequencing Consortium, consisting of (1) nucleotide substitution per fourfold degenerate site in coding regions, (2) nucleotide substitution per site in relics of transposable elements active only before the human-mouse speciation, and (3) the nonaligning fraction of human DNA that is nonrepetitive or in ancestral repeats; and three derived from human genome data alone, consisting of (4) SNP density, (5) frequency of insertion of transposable elements, and (6) rate of recombination. Features 1 and 2 are measures of nucleotide substitutions at two classes of "neutral" sites, whereas 4 is a measure of recent mutations. Feature 3 is a measure dominated by deletions in mouse, whereas 5 represents insertions in human. It was found that all six vary significantly in megabase-sized regions genome-wide, and many vary together. This indicates that some regions of a genome change slowly by all processes that alter DNA, and others change faster. Regional variation in all processes is correlated with, but not completely accounted for, by GC content in human and the difference between GC content in human and mouse.

Human-mouse alignments with BLASTZ

The Mouse Genome Analysis Consortium aligned the human and mouse genome sequences for a variety of purposes, using alignment programs that suited the various needs. For investigating issues regarding genome evolution, a particularly sensitive method was needed to permit alignment of a large proportion of the neutrally evolving regions. We selected a program called BLASTZ, an independent implementation of the Gapped BLAST algorithm specifically designed for aligning two long genomic sequences. BLASTZ was subsequently modified, both to attain efficiency adequate for aligning entire mammalian genomes and to increase its sensitivity. This work describes BLASTZ, its modifications, the hardware environment on which we run it, and several empirical studies to validate its results.

Initial sequencing and comparative analysis of the mouse genome

The sequence of the mouse genome is a key informational tool for understanding the contents of the human genome and a key experimental tool for biomedical research. Here, we report the results of an international collaboration to produce a high-quality draft sequence of the mouse genome. We also present an initial comparative analysis of the mouse and human genomes, describing some of the insights that can be gleaned from the two sequences. We discuss topics including the analysis of the evolutionary forces shaping the size, structure and sequence of the genomes; the conservation of large-scale synteny across most of the genomes; the much lower extent of sequence orthology covering less than half of the genomes; the proportions of the genomes under selection; the number of protein-coding genes; the expansion of gene families related to reproduction and immunity; the evolution of proteins; and the identification of intraspecies polymorphism.

Whole-genome shotgun assembly and analysis of the genome of Fugu rubripes

The compact genome of Fugu rubripes has been sequenced to over 95% coverage, and more than 80% of the assembly is in multigene-sized scaffolds. In this 365-megabase vertebrate genome, repetitive DNA accounts for less than one-sixth of the sequence, and gene loci occupy about one-third of the genome. As with the human genome, gene loci are not evenly distributed, but are clustered into sparse and dense regions. Some "giant" genes were observed that had average coding sequence sizes but were spread over genomic lengths significantly larger than those of their human orthologs. Although three-quarters of predicted human proteins have a strong match to Fugu, approximately a quarter of the human proteins had highly diverged from or had no pufferfish homologs, highlighting the extent of protein evolution in the 450 million years since teleosts and mammals diverged. Conserved linkages between Fugu and human genes indicate the preservation of chromosomal segments from the common vertebrate ancestor, but with considerable scrambling of gene order.

Genomic analysis of the olfactory receptor region of the mouse and human T-cell receptor alpha/delta loci

We have conducted a comparative genomic analysis of several olfactory receptor (OR) genes that lie immediately 5' to the V-alpha gene segments at the mouse and human T-cell receptor (TCR) alpha/delta loci. Five OR genes are identified in the human cluster. The murine cluster has at least six OR genes; the first five are orthologous to the human genes. The sixth mouse gene has arisen since mouse-human divergence by a duplication of a approximately 10-kb block. One pair of OR paralogs found at the mouse and human loci are more similar to each other than to their corresponding orthologs. This paralogous "twinning" appears to be under selection, perhaps to increase sensitivity to particular odorants or to resolve structurally-similar odorants. The promoter regions of the mouse OR genes were identified by RACE-PCR. Orthologs share extensive 5' UTR homology, but we find no significant similarity among paralogs. These findings extend previous observations that suggest that OR genes do not share local significant regulatory homology despite having a common regulatory agenda. We also identified a diverged TCR-alpha gene segment that uses a divergent recombination signal sequence (RSS) to initiate recombination in T-cells from within the OR region. We explored the hypothesis that OR genes may use DNA recombination in expressing neurons, e.g., to recombine ORs into a transcriptionally active locus. We searched the mouse sequence for OR-flanking RSS motifs, but did not find evidence to suggest that these OR genes use TCR-like recombination target sequences.

Comparison of immulite with vidas for detection of infection in a low-prevalence population of pregnant women in The Netherlands

A comparative evaluation of the Vidas system (bioMérieux, Marcy l'Etoile, France) and the Immulite System (Diagnostic Products Corporation) was performed using 500 prospectively collected serum samples. As part of a routine antenatal screening program, these samples were tested for hepatitis B surface antigen, and immunoglobulin G (IgG) and IgM antibodies to Toxoplasma gondii and rubella virus. The overall agreement between the two assay systems ranged from 98.0 to 99.8%. After discrepancy analysis the outcome in terms of relative sensitivity and specificity varied from 97.5 to 100%.

Pseudolikelihood estimation of the Rasch model

An estimation method is proposed for the Rasch model on the basis of the pseudolikelihood theory of Arnold and Strauss (1988). A simulation study was conducted to compare the proposed maximum pseudolikelihood estimates with the well known conditional maximum likelihood and unconditional maximum likelihood estimates for the item parameters of the Rasch model. The results show great similarity between the methods.