What influences on their professional development do general practice trainees report from their hospital placements? A qualitative study

BACKGROUND

The clinical learning environment is important in GP specialty training and impacts professional development. Uniquely for GP trainees, about half of their training periods occur in a hospital environment, which is not their final workplace. There is still little understanding of how hospital-based training influences GP's professional development.

OBJECTIVES

To seek the views of GP trainees on how their hospital experience contributes to their professional development as a GP.

METHODS

This international and qualitative study seeks the views of GP trainees from Belgium, Ireland, Lithuania, and Slovenia. Semi-structured interviews were performed in the original languages. A joint thematic analysis in the English language resulted in key categories and themes.

RESULTS

From the four themes identified, GP trainees were found to experience additional challenges on top of the service provision/education tensions, which are common to all hospital trainees. Despite these, the hospital rotation component of GP training is valued by trainees. A strong finding of our study is the need to ensure that learning from the hospital placements is placed firmly in the context of general practice, e.g. GP placements prior or parallel with the hospital placements, educational activities resourced by GPs during their hospital experience, encouraging hospital teachers to have greater awareness of the educational needs of GPs, including an awareness of their training curriculum.

CONCLUSION

This novel study highlights how hospital placements for GP trainees could be enhanced. Further study could be broadened to recently qualified GPs, which may uncover new areas of interest.

Delirium occurrence in older Irish adults admitted to an acute medical hospital: a prospective cohort study

OBJECTIVES

Delirium, which is associated with adverse health outcomes, is poorly detected in hospital settings. This study aimed to determine delirium occurrence among older medical inpatients and to capture associated risk factors.

METHODS

This prospective cohort study was performed at an Irish University Hospital. Medical inpatients 70 years and over were included. Baseline assessments within 72 hours of admission included delirium status and severity as determined by the Revised Delirium Rating Scale (DRS-R-98), cognition, physical illness severity and physical functioning. Pre-existing cognitive impairment was determined with Short Informant Questionnaire on Cognitive Decline (IQCODE). Serial assessment of delirium status, cognition and the physical illness severity were undertaken every 3 (±1) days during participants' hospital admission.

RESULTS

Of 198 study participants, 92 (46.5%) were women and mean age was 80.6 years (s.d. 6.81; range 70-97). Using DRS-R-98, 17.7% (n = 35) had delirium on admission and 11.6% (n = 23) had new-onset delirium during admission. In regression analysis, older age, impaired cognition and lower functional ability at admission were associated with a significant likelihood of delirium.

CONCLUSIONS

In this study, almost one-third of older medical inpatients in an acute hospital had delirium during admission. Findings that increasing age, impaired cognition and lower functional ability at admission were associated with increased delirium risk suggest target groups for enhanced delirium detection and prevention strategies. This may improve clinical outcomes.

247 QUALITY IMPROVEMENT IN DEMENTIA CARE: STREAMLINING CARE PATHWAYS IN A PSYCHIATRY OF OLD AGE SERVICE

Background

Dementia is increasingly considered a public health priority worldwide in the context of predicted increased prevalence. In Ireland, there are an estimated 67,000 persons living with dementia and by 2041 it is expected to rise to 145,000 persons. Challenges in dementia care have been highlighted in health services across Europe and the ineffective structure of dementia care with fragmented non-person-centred pathways has been identified.

Methods

An initial review of the existing cognitive impairment diagnostic pathways in our specialised Psychiatry of Old Age (POA) Service was undertaken. This included surveying the multidisciplinary team to identify challenges, clinical chart review and audit of physical examination equipment. Diagnostic pathway was updated based on findings and informed by the developing national ‘Model of Care for Dementia in Ireland’ and best practice.

Results

Review findings included lack of standardisation of memory assessment, delays in accessing neuroimaging and laboratory results, gaps in staff training. A care pathway document was developed detailing requirements for care from the point of referral through to cognitive impairment diagnosis. Staff training was completed to accompany the introduction of standardised dementia assessment scales. Access to laboratory/radiology booking was enhanced. A cognitive remediation group was developed by Occupational Therapy as part of post-diagnostic supports for service users. Preliminary data indicates improvements in satisfaction of those attending the group. Physical examination equipment audit resulted in quality improvements.

Conclusion

We demonstrate that a quality improvement approach can be implemented to enhance assessment, diagnosis and care provided to support diagnosis of cognitive impairment and dementia in POA service. The enhanced diagnostic care pathways will be assessed over time to assess impact on care of service users. Preliminary findings are positive and it is an approach that can be adopted in other services and inform development of national memory service developments.

329 ANTICHOLINERGIC BURDEN IN PEOPLE LIVING WITH DEMENTIA ATTENDING GERIATRIC MEDICINE AND PSYCHIATRY FOR OLDER PERSONS SERVICES

Background

Anticholinergic burden is associated with an increase in cognitive decline, delirium and confusion. We aimed to examine the Anticholinergic Cognitive Burden (ACB) of patients referred to local dementia services, and the prescribing of acetylcholinesterase inhibitors in patients with a significant anticholinergic burden. We also looked at frequency of prescribing of classes of some medications known to increase anticholinergic burden.

Methods

A retrospective chart review was carried out of new referrals attending local Geriatric Medicine and/or Psychiatry For Older Persons outpatient services with a diagnosis of dementia between 2017 and 2018. Medications in use at the time of patient review were obtained. ACB was calculated using ACB score. Results were analysed descriptively.

Results

163 patients over 65 years old were included in this study, 94 (57.6%) were female. 30% (N = 49) had a significant anticholinergic burden (ACB >3). The mean ACB was 1.69 (Range 0 – 8). 38% of all patients (N = 63) were prescribed an acetylcholinesterase inhibitor, and of those, 20% (N = 13) had a significant anticholinergic burden. Polypharmacy (use of 5 medications or more) was evident with 76% (N = 124) patients. Regarding groups of medications known to increase ACB, 35.5% (N = 58) were prescribed antipsychotics and 18.4% (30) were prescribed benzodiazepines.

Conclusion

There is a significant anticholinergic burden among people living with dementia attending the geriatric medicine and psychiatry of later life services. Some patients with a significant anticholinergic burden were being prescribed acetylcholinesterase inhibitors. This suggests acetylcholinesterase inhibitors may be prescribed without also discontinuing inappropriate medications that are contributing to the anticholinergic burden. We should look to further reduce the anticholinergic burden of patients attending the dementia services by avoiding these medications or using alternatives where available.

Electronic smart-hub based intervention during COVID-19 in a rural Psychiatry of Old Age service in North-West Ireland

Introduction

The COVID-19 pandemic caused significant disruptions in services and necessitated innovation to continue care provision to the vulnerable population of older adults with psychiatric needs.

Objectives

The objective of this study was to examine the experiences of staff and patients using a hands-free electronic smart-hub (eSMART hub) intervention to keep patients connected with psychiatry of old age following COVID-19 restrictions.

Methods

A risk stratification register was created of all patients known to the Psychiatry of Old Age service in the North-West of Ireland to identify those at highest risk of relapse. These patients were offered a smart-hub with remote communication and personal assistant technology to be installed into their homes. Smart-hubs were also installed in the team base to facilitate direct device to device communication. Semi-structured qualitative interviews were conducted with 10 staff members and 15 patients at 6-12 months following the installation of the smart-hubs.

Results

The smart-hubs were utilized by the POA team to offer remote interventions over video including clinician reviews, regular contact with key workers and day-hospital based therapeutic interventions such as anxiety management groups and OT led physical exercises. Patients also used the personal assistant aspect of the hub to attend to personal hobbies such as accessing music and radio. Positive feedback related to companionship during isolation and connectivity to services. Negative feedback was mainly related to technology, particularly internet access and narrow scope of communication abilities.

Conclusions

Electronic smart-hub devices may offer an acceptable avenue for remote intervention and communication for isolated high-risk older persons.

Disclosure

The smart hub devices used in this study were donated by Amazon. However, the company was not involved in any other aspect of the study and the researchers have no significant financial interest, consultancy or other relationship with products, manufactur

Patient and staff satisfaction with remote psychiatry assessments using mobile tablets in long-stay facilities in rural north-west Ireland

Introduction

The COVID-19 pandemic has required services to evolve quickly to continue routine care and telemedicine has been rapidly implemented to facilitate this. Older persons are at high risk of serious complications of COVID-19 and it is essential that their exposure to COVID-19 is minimized.

Objectives

Our aim was to assess staff and patient satisfaction with remote psychiatric assessments using mobile tablets in long-stay facilities.

Methods

Remote clinics using Skype video on mobile tablets were conducted with patients in long-stay facilities attending psychiatry in rural North-West Ireland between April and July 2020. At each review, a satisfaction survey was administered to the patient, their keyworker and the clinician. The patient/keyworker survey instrument had four yes/no statements and the clinician survey had four statements with 5-point likert scale responses (1=very low to 5=very high). Open feedback was also obtained for thematic analysis. Descriptive analyses were completed using SPSS software.

Results

23 patients (mean age 80.9yrs) were assessed in 10 long-stay facilities. All patients were agreeable to participating in video consultation although only 13 patients were able to respond to survey due to cognitive impairment. There was a 92.3% positive patient response (12/13) and 95.7% positive keyworker response (N=22/23) for all statements. The mean score on the assessor response ranged from 3.43 to 4.04 with the lowest rate for quality of transmission. The main themes identified were related to the quality of connection and sensory difficulties.

Conclusions

Video consultations using mobile tablets offer an acceptable form of remote psychiatry assessment for older persons in long-stay facilities.

Brain complications of diabetes mellitus: a cross-sectional study of awareness among individuals with diabetes and the general population in Ireland

AIMS

To identify awareness of potential brain complications of diabetes among individuals with diabetes and the public.

METHODS

For this observational, cross-sectional survey study, we recruited consecutive adult attendees of a specialist diabetes clinic and two primary care practices. Primary care attendees represented members of the general population of Ireland. An interviewer-administered questionnaire was used to gather data on respondents' awareness of brain complications of diabetes and modifiable risk factors for dementia. Multivariable logistic regression was undertaken to identify variables independently associated with awareness.

RESULTS

Respondents included a total of 502 adults: 250 in the diabetes group (37% women, mean age 63 ± 14 years, 88% with Type 2 diabetes) and 252 in the general population group (51% women, mean age 47 ± 17 years, 7% with Type 2 diabetes). The diabetes group had significantly greater awareness of diabetes complications, except for depression, compared with the general population group. In the group as a whole, respondent awareness of dementia (35%) and memory problems (47%) as potential complications of diabetes was poor compared with awareness of kidney (84%) and eye damage (84%). Respondents were 1.5 times more likely to identify that individuals can modify their risk of developing Type 2 diabetes than their risk of dementia.

CONCLUSIONS

This study shows that there is poor awareness of brain complications of diabetes among individuals with diabetes and the general population in Ireland. The results suggest a need for expansion of public awareness campaigns and diabetes education programmes to promote awareness of the brain complications of diabetes and of the modifiable risk factors for dementia, as part of a life-course approach to dementia prevention.

A Delphi Study to Establish an Expert Consensus Opinion on Risk Factors for Type 2 Diabetes, and Potential Complications of Diabetes, Including Brain Health Associations

Introduction

Type 2 diabetes (T2DM) has a multifactorial aetiology, and wide-ranging potential health complications, including brain health associations.

Objectives

A number of diabetes risk factors and complications have a strong evidence base. This study will address ambiguity in the literature regarding others.

Aims

Results will inform development of a questionnaire for use among the public and individuals with diabetes, assessing knowledge of diabetes and brain health associations and the role of modifiable risk factors. Aiming to ultimately inform effective preventative strategies for both dementia and depression.

Methods

A systematic literature review preceded this two-round modified Delphi study. Respondents rated their agreement with risk factors for T2DM, and potential complications of diabetes on an e-questionnaire.

Results

Of 46 international experts invited to participate in round-one; 14 responded (30.4%). Thirteen respondents (92.9%) completed round-two questionnaire. Consensus was pre-defined as 70% or more agreement between respondents on questionnaire items. On completion, 11/18 risk factor items for T2DM met consensus criteria however ‘depression’ did not. Of diabetes complication items, 13/16 met consensus criteria (see Table 1).

Conclusions

Study results indicate that international experts consider a number of brain health complications to be associated with diabetes. Results will be incorporated in a diabetes and brain health knowledge questionnaire for use among vulnerable populations.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Synthesis, tailoring and characterization of silica nanoparticles containing a highly stable ruthenium complex

This paper describes the synthesis and characterization of sol-gel silica nanoparticles (NPs) derived from tetraethoxysilane (TEOS) and from tetraethoxysilane and methyltriethoxysilane (TEOS-MTEOS) in which is encapsulated, an in-house synthesized, stable oxygen-sensitive ruthenium complex, ruthenium (II) (bis-2,2-bipyridyl)-2(4-carboxylphenyl) imidazo[4,5-f][1,10]phenanthroline. These NPs were characterized using dynamic light scattering, transmission electron microscopy, scanning electron microscopy, Fourier transform infrared spectroscopy and Brunauer-Emmett-Teller analysis. The spherical, stable and monodispersed NPs have been prepared using the Stöber method. It was found that the addition of prehydrolyzed MTEOS-based sol prepared in an acidic environment to the reaction mixture containing TEOS NPs synthesized for 6 h produced material with increased porosity when compared to pure silica NPs. Oxygen sensitivity, stability, photobleaching and leaching have been characterized. The hybrid NPs exhibit enhanced O₂ sensitivity but a high degree of leaching when compared to pure silica NPs, which have minimum O₂ sensitivity and no leaching.

The long-term longitudinal course of oppositional defiant disorder and conduct disorder in ADHD boys: findings from a controlled 10-year prospective longitudinal follow-up study

BACKGROUND

A better understanding of the long-term scope and impact of the co-morbidity with oppositional defiant disorder (ODD) and conduct disorder (CD) in attention deficit hyperactivity disorder (ADHD) youth has important clinical and public health implications.

METHOD

Subjects were assessed blindly at baseline (mean age=10.7 years), 1-year (mean age=11.9 years), 4-year (mean age=14.7 years) and 10-year follow-up (mean age=21.7 years). The subjects' lifetime diagnostic status of ADHD, ODD and CD by the 4-year follow-up were used to define four groups (Controls, ADHD, ADHD plus ODD, and ADHD plus ODD and CD). Diagnostic outcomes at the 10-year follow-up were considered positive if full criteria were met any time after the 4-year assessment (interval diagnosis). Outcomes were examined using a Kaplan-Meier survival function (persistence of ODD), logistic regression (for binary outcomes) and negative binomial regression (for count outcomes) controlling for age.

RESULTS

ODD persisted in a substantial minority of subjects at the 10-year follow-up. Independent of co-morbid CD, ODD was associated with major depression in the interval between the 4-year and the 10-year follow-up. Although ODD significantly increased the risk for CD and antisocial personality disorder, CD conferred a much larger risk for these outcomes. Furthermore, only CD was associated with significantly increased risk for psychoactive substance use disorders, smoking, and bipolar disorder.

CONCLUSIONS

These longitudinal findings support and extend previously reported findings from this sample at the 4-year follow-up indicating that ODD and CD follow a divergent course. They also support previous findings that ODD heralds a compromised outcome for ADHD youth grown up independently of the co-morbidity with CD.

Cyclooxygenase-1 haplotype modulates platelet response to aspirin

BACKGROUND

Aspirin (acetylsalicylic acid) irreversibly inhibits platelet cyclooxygenase (COX)-1, the enzyme that converts arachidonic acid (AA) to the potent platelet agonist thromboxane (TX) A2. Despite clear benefit from aspirin in patients with cardiovascular disease (CAD), evidence of heterogeneity in the way individuals respond has given rise to the concept of 'aspirin resistance.'

AIMS

To evaluate the hypothesis that incomplete suppression of platelet COX as a consequence of variation in the COX-1 gene may affect aspirin response and thus contribute to aspirin resistance.

PATIENTS AND METHODS

Aspirin response, determined by serum TXB2 levels and AA-induced platelet aggregation, was prospectively studied in patients (n = 144) with stable CAD taking aspirin (75-300 mg). Patients were genotyped for five single nucleotide polymorphisms in COX-1 [A-842G, C22T (R8W), G128A (Q41Q), C644A (G213G) and C714A (L237M)]. Haplotype frequencies and effect of haplotype on two platelet phenotypes were estimated by maximum likelihood. The four most common haplotypes were considered separately and less common haplotypes pooled.

RESULTS

COX-1 haplotype was significantly associated with aspirin response determined by AA-induced platelet aggregation (P = 0.004; 4 d.f.). Serum TXB2 generation was also related to genotype (P = 0.02; 4 d.f.).

CONCLUSION

Genetic variability in COX-1 appears to modulate both AA-induced platelet aggregation and thromboxane generation. Heterogeneity in the way patients respond to aspirin may in part reflect variation in COX-1 genotype.

Ultrasound-enhanced thrombolysis at 20 kHz with air-filled and perfluorocarbon-filled contrast bispheres

BACKGROUND

Ultrasound (US) at low frequencies has been shown to enhance clot lysis by itself and in the presence of urokinase (UK). The comparative effects of air-filled versus perfluorocarbon-filled polymer bispheres in enhancing this effect have not been previously demonstrated.

METHODS

Freshly drawn human blood was incubated at 37 degrees C for 2 hours, and the subsequent formed clot was dried and weighed. It was then exposed to saline control, saline + UK (10,000 IU), saline + UK + US, saline + UK + US + low shell-strength polymer bispheres (PB1), saline + UK + US + high shell-strength polymer bispheres (PB2), and perfluorocarbon-filled high shell-strength polymer bipsheres (PB3) for a total of 6 minutes. Clots were removed and weighed to determine the percentage of thrombolysis.

RESULTS

The percentage of clot lysis for each study group was as follows: saline 18.5% +/- 4%, US alone 22.2% +/- 5%, UK alone 21.9% +/- 4%, US+UK 32.2% +/- 8% (P <.05 compared with UK alone), US+UK+PB1 36.9% +/- 8%, US+UK+PB2 34.3% +/- 8%, and US+UK+PB3 45.0% +/- 11% (P <.05 compared with US+UK, P <.05 compared with US+UK+PB2).

CONCLUSION

Ultrasound at 20 kHz significantly enhances clot lysis. The addition of perfluorocarbon-filled bispheres increased this effect more significantly than did the addition of air-filled polymer bispheres.

Characterization of surfactant liquid crystal phases suitable for molecular alignment and measurement of dipolar couplings

Media employed for imparting partial alignment onto solute molecules have recently attracted considerable attention, since they permit the measurement of NMR parameters for solute biomolecules commonly associated with solid state NMR. Here we characterize a medium which is based on a quasi-ternary surfactant system comprising cetylpyridinium bromide/hexanol/sodium bromide. We demonstrate that dilute solutions of this system can exist in liquid crystalline phases which orient in the magnetic field and allow the measurement of residual dipolar couplings under a variety of conditions. The present system is extremely versatile and robust, tolerating different buffer conditions, temperature ranges and concentrations.

Improving management of atrial fibrillation and anticoagulation in a community hospital

BACKGROUND

Clinical trials have established the safety and efficacy of warfarin anticoagulation for stroke prevention in patients with atrial fibrillation. Other studies have documented patterns of underutilization and suboptimal warfarin therapy; physician underuse of warfarin may reflect the demands associated with monitoring the drug's effects. BASELINE STUDY: At Carney Hospital, a 230-bed acute care community teaching hospital in Boston, a retrospective chart review indicated that between July 1, 1995, and June 30, 1996, of 465 patients admitted with atrial fibrillation, 209 (45%) patients were discharged with warfarin therapy: 198 were receiving warfarin at admission, and 11 began therapy during hospitalization. Analysis of the admission international normalized ratios (INRs) indicated that a minority of patients on warfarin were safely anticoagulated at the time of admission. DESIGNING THE INTERVENTION: An anticoagulation clinic was established in fall 1997 to increase utilization of warfarin, standardize anticoagulation practices, and minimize physician time and effort needed to ensure safe anticoagulation. In early 1998 monitoring of hospitalized patients with chronic atrial fibrillation began.

RESULTS

The proportion of patients receiving warfarin therapy at admission increased from 46% in February-May 1998 to 63% in April-June 1999. Between October 1997 and July 1998, 49.1% of the 2,738 patient visits to the anticoagulation clinic showed an INR in the desired range. For the 2,238 visits during January through August 1999, 53.7% of the INRs were in the desired range.

DISCUSSION

Establishment of a clinic to oversee warfarin therapy and dissemination of indications for anticoagulation in patients with atrial fibrillation were followed by increases in the frequency of warfarin use in hospital patients and the incidence of safe therapy in ambulatory patients.

A clinical trial of retroviral-mediated transfer of a rev-responsive element decoy gene into CD34(+) cells from the bone marrow of human immunodeficiency virus-1-infected children

Genetic modification of hematopoietic stem cells with genes that inhibit replication of human immunodeficiency virus-1 (HIV-1) could lead to development of T lymphocytes and monocytic cells resistant to HIV-1 infection after transplantation. We performed a clinical trial to evaluate the safety and feasibility of this procedure, using bone marrow from four HIV-1-infected pediatric subjects (ages 8 to 17 years). We obtained bone marrow, isolated CD34(+) cells, performed in vitro transduction with a retroviral vector carrying a rev-responsive element (RRE) decoy gene, and reinfused the cells into these subjects with no evidence of adverse effects. The levels of gene-containing leukocytes in peripheral blood samples in the 1 year after gene transfer/cell infusion have been extremely low. These observations support the potential of performing gene therapy for HIV-1 using hematopoietic cells, but emphasize the need for improved gene transfer techniques.

Long-term effects of childhood sexual abuse: objective and subjective characteristics of the abuse and psychopathology in later life

This study investigates the association between objective and subjective characteristics of childhood sexual abuse and psychopathology in later life. The sample consists of 404 Dutch female adults who had been sexually abused in their childhood or adolescence. The participants were recruited by means of articles about childhood sexual abuse in major Dutch newspapers. The characteristics and severity of the sexual abuse were assessed with the Questionnaire Unwanted Sexual Experiences in the Past (QUSEP). General psychopathology was measured with the Symptom Checklist (SCL-90), the degree of dissociation was measured with the Dissociation Questionnaire (DIS-Q). Stepwise multiple regression analyses showed a moderate association between psychopathology and objective characteristics of the abuse, such as number of different types of abusive events and the duration of the abuse. However, more strongly associated with later psychopathology were variables reflecting coping style, such as the degree of self-blame, and circumstantial factors, such as the emotional atmosphere in the family of origin and the reactions after disclosure. Whether or not the abuse was incestuous did not explain additional variance in later psychopathology.

Community rehabilitation workers: do they offer hope to disabled people in South Africa's rural areas?

This article outlines the thinking behind the Wits/Tintswalo community rehabilitation worker training programme which is located in South Africa's eastern Transvaal Lowveld. Drawing on a combination of qualitative and quantitative evidence collected during the first eighteen months in which the CRWs were working full-time (January 1993 - June 1994) it suggests that the two year training programme has been successful in providing therapeutic skills. Key issues raised are whether the coverage of disability is adequate in terms of numbers treated or in terms of categories of disability treated.

Glomerular disease and urinary Sézary cells in cutaneous T-cell lymphomas

We report three cases of biopsy-documented renal glomerular disease occurring in patients with cutaneous T-cell lymphomas. One patient had immunoglobulin A (IgA) nephropathy and another had membranous nephropathy. The remaining patient had an immune complex glomerulonephritis without immunofluorescent evidence of IgA, but with mesangial deposits and a clinical course notable for stable renal function, minimal proteinuria, and episodic gross hematuria of renal origin. These three cases, along with IgA nephropathy in two of the four previously reported cases, suggest a possible association between cutaneous T-cell lymphoma and this glomerular lesion. In addition, Sézary cells were observed in the urine of two patients, one without evidence of glomerular disease. The prognostic value of this new observation is unknown.

Loss of chromosome 17p13 sequences and mutation of p53 in human breast carcinomas

DNAs from ninety seven primary breast carcinoma biopsies have been examined for loss of sequences on 17p13. In addition, immunohistochemical analysis has been carried out on the majority of these cases to determine whether p53 gene expression can be detected. Detection of p53 expression is taken to indicate mutation of p53 leading to stabilisation of the protein and thus detectable levels of p53 in the cell. In 86% of breast carcinoma samples where both allele loss and expression data were available, loss of sequences on 17p13 and/or expression of p53 was detected. Alterations to p53, whether loss of one allele or mutation, are therefore by far the most common changes so far detected in primary human breast tumours. In three cases where expression of p53 could be detected by immunohistochemistry, the precise mutation to p53 was identified. All three mutations fall within the regions which are highly conserved in p53, encoded by exons 5 to 8. Two are single base changes leading to misense mutations, and the third is a single base-pair deletion. The expression of the latter gene would result in production of a truncated protein which should lack normal biological activities.

Overuse Syndromes of the Lower Extremity

In brief: Overuse injuries of the lower extremity represent a frequent, significant problem. This article discusses management of the most common overuse disorders: anterior tibialis strain, medial tibial stress syndrome, compartment syndrome, stress fractures, and Achilles tendinitis. These injuries often are the culmination of a process (repetitive stress) rather than the result of a single event. Grading injuries on a scale of 1 to 4 according to severity can help determine the correct treatment. The primary treatment goal is to reduce inflammation through icing, rest, and appropriate use of nonsteroidal anti-inflammatory agents. For a safe return to pain-free activity, additional measures are required to correct biomechanical problems, educate the athlete on training techniques, and begin a gradual reconditioning program.

The subclass profile and complement activating potential of anti-alpha-gliadin antibodies in coeliac disease

In a randomly selected group of coeliac patients, alpha-gliadin antibodies (AGA) of subclasses IgG1 and IgG3 were significantly elevated (p less than 0.01) in comparison to both normal and disease control groups. This result was, however, influenced by increased total AGA levels in the coeliac patients. AGA subclass profiles of cohorts of coeliac and normal controls matched for total IgG AGA were therefore compared. It was found that IgG3 AGA levels were higher in the coeliac group (p = 0.006) while IgG4 titres were higher in the control group (p = 0.005). Titres of IgG1 and IgG2 AGA did not differ between the two groups. Because of the marked differences between the ability of IgG3 and IgG4 to activate complement, alpha-gliadin-specific complement fixation was measured. Using randomly selected coeliac and normal sera, the patient group activated highly significantly greater quantities of complement than controls (p less than 0.01). Furthermore, when samples matched for total IgG AGA were compared, sera from coeliac patients were again found to activate greater amounts of complement than sera from controls (p = 0.024). Thus AGA in coeliac sera are both structurally and functionally distinguishable from AGA in normal control sera.

Altered gastrointestinal immune response in sarcoidosis

Because of the possible clinical association between coeliac disease and sarcoidosis, the incidence of humoral sensitivity to dietary proteins was examined in patients with sarcoidosis. Raised concentrations of circulating IgG antibodies to alpha gliadin were found in 41/99 sarcoid patients whereas antibody levels to casein, beta lactoglobulin and ovalbumin were similar to normal controls. Subsequently, a group of 26 sarcoid patients were selected for small intestinal biopsy; 11 had raised and 15 normal alpha gliadin antibody (AGA) levels. One AGA positive patient had villous atrophy consistent with coeliac disease. Intraepithelial lymphocyte (IEL) counts were raised in AGA positive (median 30; 95% confidence limits 22-46) and AGA negative (median 24; 95% confidence limits 19-32) sarcoid patients when compared with a control group (median 13.5; 95% confidence limits 10-18) p less than 0.01. Serum IgG concentrations were raised in 11/52 patients tested but there was no correlation between IgG levels and the presence of IgG antigliadin antibodies. HLA Dr typing was done in 21 of the 26 biopsied patients. The coeliac disease associated antigen Dr3 was present in eight of 21 (38%) which is very similar to the prevalence in unselected blood donors (34%). There was no significant difference in IEL counts between Dr3 positive and Dr3 negative sarcoid patients. These findings suggest that in patients with sarcoidosis, there is an altered gastrointestinal mucosal immune response, accompanied in about 40% of patients by specific sensitisation to wheat protein.

Gliadin antibody detection in gluten enteropathy

Circulating antigliadin antibody has been described in patients with gluten enteropathy although the prevalence varies in different studies. It has been suggested that the investigation for antigliadin antibody might be useful as a screening test. The object of the present study was to evaluate two different techniques for assaying these antibodies - an indirect immunofluorescent method and an enzyme-linked immunosorbent assay (ELISA). Antibodies were assayed in the sera of 102 patients in whom jejunal biopsies were also obtained. The specificity of both tests was greater than 95%, and the correlation between the presence of antibody and histology was significant (p < 0.005), though the sensitivity of each test was less than 70%.

Accuracy and reproducibility of the AutoMicrobic System Gram-Negative General Susceptibility-Plus Card for testing selected challenge organisms

A total of 180 selected strains of gram-negative bacilli were tested for susceptibility to nine antibiotics by the prototype General Susceptibility Card and reference broth microdilution MIC method, and 112 of 180 were tested by the modified Gram-Negative General Susceptibility-Plus Card (Vitek Systems, Inc., Hazelwood, Mo.). When category calls--susceptible, intermediate, and resistant for the prototype card and very susceptible, moderately susceptible, and resistant for the modified card--were identical or compatible (very susceptible by one method and moderately susceptible by the other), the methods were considered in qualitative or categorical agreement. The overall categorical agreement improved from 83% for the prototype card to 91.5% for the modified card, and the frequency of major and very major disagreements was reduced from 7.5 to 1%, respectively. Overall agreement between the modified card and reference method for both category calls and MICs (+/- 2 dilutions) was 90%. Of the results, 67% were identical, 22% were more susceptible with the modified card, and 11% were more resistant. Reproducibility of identical or compatible category calls and MICs obtained from three trials was 94.5%. The poorest accuracy and reproducibility were observed when testing Pseudomonas aeruginosa. The study suggests that the modified card can rapidly and efficiently perform susceptibility tests with an acceptable level of accuracy and reproducibility provided that the system is appropriately used for testing strains of the family Enterobacteriaceae with preset criteria for excluding organism-antibiotic combinations. The evaluation also indicates dramatic improvement in the technical performance of the modified card compared with its earlier prototype.

Brucella suis: an unusual cause of suppurative lymphadenitis in an outpatient

A routine aerobic culture of purulent material from a draining sinus tract of a patient with chronic lymphadenitis yielded growth of a fastidious gram-negative coccobacillus later identified as Brucella suis biotype 1. The patient responded to administration of antibacterial drugs and surgical drainage.