COVID-19 Stroke Apical Lung Examination Study 2: a national prospective CTA biomarker study of the lung apices, in patients presenting with suspected acute stroke (COVID SALES 2)

BACKGROUND

Apical ground-glass opacification (GGO) identified on CT angiography (CTA) performed for suspected acute stroke was developed in 2020 as a coronavirus-disease-2019 (COVID-19) diagnostic and prognostic biomarker in a retrospective study during the first wave of COVID-19.

OBJECTIVE

To prospectively validate whether GGO on CTA performed for suspected acute stroke is a reliable COVID-19 diagnostic and prognostic biomarker and whether it is reliable for COVID-19 vaccinated patients.

METHODS

In this prospective, pragmatic, national, multi-center validation study performed at 13 sites, we captured study data consecutively in patients undergoing CTA for suspected acute stroke from January-March 2021. Demographic and clinical features associated with stroke and COVID-19 were incorporated. The primary outcome was the likelihood of reverse-transcriptase-polymerase-chain-reaction swab-test-confirmed COVID-19 using the GGO biomarker. Secondary outcomes investigated were functional status at discharge and survival analyses at 30 and 90 days. Univariate and multivariable statistical analyses were employed.

RESULTS

CTAs from 1,111 patients were analyzed, with apical GGO identified in 8.5 % during a period of high COVID-19 prevalence. GGO showed good inter-rater reliability (Fleiss κ = 0.77); and high COVID-19 specificity (93.7 %, 91.8-95.2) and negative predictive value (NPV; 97.8 %, 96.5-98.6). In subgroup analysis of vaccinated patients, GGO remained a good diagnostic biomarker (specificity 93.1 %, 89.8-95.5; NPV 99.7 %, 98.3-100.0). Patients with COVID-19 were more likely to have higher stroke score (NIHSS (mean +/- SD) 6.9 +/- 6.9, COVID-19 negative, 9.7 +/- 9.0, COVID-19 positive; p = 0.01), carotid occlusions (6.2 % negative, 14.9 % positive; p = 0.02), and larger infarcts on presentation CT (ASPECTS 9.4 +/- 1.5, COVID-19 negative, 8.6 +/- 2.4, COVID-19 positive; p = 0.00). After multivariable logistic regression, GGO (odds ratio 15.7, 6.2-40.1), myalgia (8.9, 2.1-38.2) and higher core body temperature (1.9, 1.1-3.2) were independent COVID-19 predictors. GGO was associated with worse functional outcome on discharge and worse survival after univariate analysis. However, after adjustment for factors including stroke severity, GGO was not independently predictive of functional outcome or mortality.

CONCLUSION

Apical GGO on CTA performed for patients with suspected acute stroke is a reliable diagnostic biomarker for COVID-19, which in combination with clinical features may be useful in COVID-19 triage.

Charcot neuroarthropathy versus osteomyelitis: a case series

INTRODUCTION

Patients with diabetes and peripheral neuropathy have a 25% risk of developing a foot ulcer, and these can lead to soft tissue infections that worsen and result in osteomyelitis. While Charcot neuroarthropathy is not as common as osteomyelitis, it is often misdiagnosed as osteomyelitis.

CASE REPORTS

Three patients presented with diabetes, neuropathy, and foot ulcers. They underwent prophylactic surgery but later developed swelling at the surgical sites. Radiographs showed fragmentations that caused concern about osteomyelitis. The authors maintained diagnoses of Charcot neuroarthropathy and treated the patients with immobilization and offloading. All patients resolved the fragmentations without antibiotics or surgery.

CONCLUSION

While Charcot neuroarthropathy and osteomyelitis have similar signs and symptoms, understanding the similarities and differences between the conditions can aid providers in appropriate wound management.

Protection against invasive meningococcal disease and vaccination policy in the Netherlands

Background

A rise in serogroup C invasive meningococcal disease (IMD-C) led to introduction of MenC vaccination in 2002 in the Netherlands at 14 months of age, accompanied by a mass-campaign for all children between 1 and 18 years (coverage 94%). Due to an IMD-W outbreak in 2016-17, the MenC vaccine was replaced by a MenACWY vaccine and an adolescent booster at 14 years was introduced next to a mass campaign for 14-18 year-olds in 2018.

Aim/methods

We explored meningococcal antibody status in the Netherlands across the population in 2006-07, 2016-17 and 2020 in consecutive cross-sectional serosurveillance studies. Furthermore, we assessed the vaccine impact and effectiveness of the recent MenACWY vaccination campaign. We determined long-term protection in both adolescents and adults after a MenACWY vaccination and investigated sex-related differences in the vaccine response in adolescents.

Results

MenC antibody levels were low in 2016-17, except in recently vaccinated toddlers and individuals who were vaccinated as teenagers in 2002. We demonstrated waning of MenC immunity 15 years after the mass campaign and highlighted the lack of meningococcal AWY immunity across the population, which underlined the importance of the recently introduced MenACWY (booster) vaccination. The MenACWY vaccination program was effective in preventing IMD-W in the target population. Long-term protection was achieved for MenC, MenW, and MenY in 94-96% of adolescents five years postvaccination, but in adults only in 32%, 65% and 71% for MenC, W and Y. Adolescent antibody responses were higher in girls than in boys for all serogroups at most timepoints after MenACWY vaccination. The differences in average titers were however small and the percentage of participants with protective titers was very high for both sexes.

Conclusions

The current meningococcal vaccination policy in the Netherlands provides protection across the population against IMD-ACWY and seems sufficient on the long-term.

Key messages

Opening Cuboid Wedge Osteotomy (Zoom Osteotomy) for Triplanar Correction of Flexible Pes Planovalgus Deformities

Surgical correction of flexible pes planovalgus often involves reestablishing the length of the lateral column. This is a review of a cohort of patients who underwent an opening cuboid osteotomy with interpositional graft for triplanar correction of flexible pes planovalgus. The medical records of 35 patients involving 51 feet were reviewed. All patients were treated with an opening wedge osteotomy of the cuboid in combination with adjunctive procedures as needed for correction of the pes planovalgus deformity. Radiographs were obtained before and a minimum of 12 months after surgery. Preoperative and postoperative cuboid abduction and Meary's (lateral talometatarsal) angles were measured using the radiographs, and adjunctive procedures and complications were recorded. Mean follow-up was 46 (range, 12-85) months. The mean cuboid abduction angle improved from 20.3° (range, 8°-31°) to 6.6° (range, 0°-15°), and the mean Meary's angle improved from 10.5° (range, 0°-25°) to 2° (range, -3° to 15°). All patients also underwent adjunctive procedures at the time of cuboid osteotomy. In the 51 feet treated, there were 3 (6%) complications, including wound dehiscence, neuritis, and deep vein thrombosis. There were no recurrences. Triplanar correction of flexible pes planovalgus can be performed safely and successfully with an opening cuboid osteotomy as an alternative to the Evans Osteotomy.

0362 The Cost of In-Person versus Telehealth PAP Initiation for Patients with Sleep Apnea

Introduction

Telehealth has been widely integrated into healthcare systems during the COVID-19 pandemic and is likely to remain a part of routine clinical care. At the VA Greater Los Angeles Healthcare System (VAGLAHS), positive airway pressure (PAP) set-up visits transitioned from in person to telehealth for newly diagnosed sleep apnea patients during the pandemic. The telehealth pathway included mailing of PAP machines to patients with follow-up video/phone education by respiratory therapists (RTs). As part of a larger study examining the clinical outcomes resulting from telehealth versus in-person PAP initiation, we performed a cost analysis of these two treatment pathways within VAGLAHS.

Methods

We examined the total variable direct cost of telehealth versus in-person PAP initiation for patients newly diagnosed with sleep apnea at VAGLAHS between March and October 2021 (n = 2,662 PAP set-ups) using a bottom-up analysis. There was an average of 16 PAP set-ups per day with 11 set-ups (68.7%) via telehealth and 5 set-ups (31.3%) in person.

Results

The total variable direct cost of telehealth PAP initiation was $98.87 per patient. The total variable direct cost of in-person PAP initiation was $50.58 per patient. For telehealth, there was an additional cost of mailing the PAP machine and 31.2% more RT time spent on educating patients compared to the in-person pathway. After the initial PAP set-up visit, a larger subset of patients required additional troubleshooting help from RTs about proper PAP use after telehealth compared to in-person set-ups (5% versus 1%).

Conclusion

The telehealth PAP initiation pathway was nearly two times the cost of in-person PAP initiation. This resulted from the additional cost of mailing the PAP machine, more RT time spent on education, and a greater need for troubleshooting after the visit. Telehealth visits may need to be supplemented by written educational materials or web-based resources to reduce the need for additional support after the initial visit.

Support (If Any)

OCC study funding, VAGLAHS GRECC

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Ramucirumab and Paclitaxel Administered Every 2 Weeks (mRAINBOW Regimen) in Advanced Gastroesophageal Adenocarcinoma

BACKGROUND

The RAINBOW trial established ramucirumab combined with paclitaxel as a second-line option in metastatic gastric and gastroesophageal junction (GEJ) adenocarcinoma. Ramucirumab was given on days 1 and 15 with paclitaxel on days 1, 8, and 15 of a 28-day cycle. The median overall survival (OS) was significantly longer with ramuciru-mab plus paclitaxel (p = 0.017), and it led to 41% grade 3 or higher neutropenia. We review our experience with both ramucirumab plus paclitaxel given biweekly (mRAINBOW) to assess efficacy and safety.

OBJECTIVES

The primary objective was to assess OS. Secondary end points were progression-free survival (PFS), overall response, and safety.

METHODS

We identified 129 patients retrospectively from our database between November 2014 and May 2017. Patients were included if they were followed up at our institution.

RESULTS

Median doses given were ramucirumab 8 mg/kg i.v. plus paclitaxel 110 mg/m2 i.v. given once every 2 weeks. The median performance status was 1, and ∼60% had poorly differentiated histology; 55.8% had progression in < 6 months on first-line therapy, and the majority had measurable cancer. Median overall OS and PFS for the entire cohort was 9.4 months (95% CI: 8.05-10.74) and 3.68 months (95% CI: 2.73-4.5), respectively. Median OS was 9.46 months (95% CI: 8.05-14.95) and median PFS was 4.14 months (95% CI: 2.96-5.29) in those patients that received ramucirumab plus paclitaxel in the second-line setting.

CONCLUSION

Biweekly administration of ramucirumab plus paclitaxel did not compromise efficacy. Delays, adjustments, or doses held were similar to the RAINBOW trial, with 31% requiring a dose or schedule modification.

Collaborating With Sonographers and Vascular Technologists to Develop Ergonomics Interventions to Address Work-Related Musculoskeletal Disorders

For more than two decades, surveys of imaging technologists have consistently reported high prevalence of work-related musculoskeletal discomfort (WRMSD). Yet, workplace intervention research involving sonographers is limited. In this study, a transdisciplinary team of researchers used a participatory approach to work with diagnostic medical sonographers (DMS) and vascular technologists (VT) to identify needs and opportunities for developing new approaches to work that will reduce sonographers’ exposures to WRMSD risk factors. In this paper, we describe the approach and the resulting identified needs. We also describe the prototyping and testing of two work approaches that target specific needs of DMS and VT, respectively. We would like designers, manufacturers, engineers, and ergonomists, in collaboration with sonographers and their managers, to recognize this area of opportunity and come together to apply their knowledge of biomechanics and design in developing useful and usable workplace interventions (solutions) to reduce sonographers’ WRMSD risk factor exposure.

Conceptual frameworks for the workplace change adoption process: elements integration from decision making and learning cycle process

Sound workplace ergonomics and safety-related interventions may be resisted by employees, and this may be detrimental to multiple stakeholders. Understanding fundamental aspects of decision-making, behavioural change, and learning cycles may provide insights into pathways influencing employees' acceptance of interventions. This manuscript reviews published literature on thinking processes and other topics relevant to decision making and incorporates the findings into two new conceptual frameworks of the workplace change adoption process. Such frameworks are useful for thinking about adoption in different ways and testing changes to traditional intervention implementation processes. Moving forward, it is recommended that future research focuses on systematic exploration of implementation process activities that integrate principles from the research literature on sense-making, decision-making, and learning processes. Such exploration may provide the groundwork for development of specific implementation strategies that are theoretically grounded and provide a revised understanding of how successful intervention adoption processes work. Practitioner summary: Adoption and acceptance of workplace changes may be facilitated through sound implementation strategies. This manuscript explores several principles of sense-making and decision-making processes that can potentially be used by industrial practitioners to inform the design and development of implementation strategies for interventions that improve workplace ergonomics and safety.

ABBREVIATIONS

 Musculoskeletal Disorders (MSDs); National Institute for Occupational Safety and Health (NIOSH); National Occupational Research Agenda (NORA); Health and Safety Executive (HSE).

Queer Youth, Intoxication and Queer Drinking Spaces

Research on intoxicating substances and gender has developed considerably in the last 30 years, especially in the social sciences as feminist scholars highlighted the contradictory discourses about young women's intoxication. Nevertheless, there still remain significant gaps if we are to fully understand the role and meaning of intoxication for all young people and not merely for heterosexual, cisgender young people. As a way of exploring the possible limitations of this legacy, we will examine the qualitative data from 52 in-depth interviews with self-identified LGBTQ young people. Our analysis explores the relationships between meanings of intoxication and sexual and gender identities, drinking spaces, and the extent to which notions of masculinity and femininity influence alcohol consumption and drinking practices among LGBTQ youth. As gender expressions among young people, especially those who identify as LGBTQ, become increasingly nuanced and fluid, understanding the role of social and cultural practices of alcohol consumption in the performance of sexual and gender identities may increase our understanding of the ways in which sexuality and gender influence alcohol consumption.

The Impact of Written Emotional Disclosure on Cancer Caregivers' Perceptions of Burden, Stress, and Depression: A Randomized Controlled Trial

Spousal cancer caregivers' emotional and relational health can become compromised over time due to ongoing challenges related to the cancer experience. This warrants a call for the assessment of interventions aimed at improving aspects of caregiver well-being. The current study employed a randomized controlled trial to determine whether emotional disclosure via the use of expressive writing improved spousal cancer caregivers' perceived caregiver burden, stress, and depression. Participants (N = 64) were assigned to one of the two disclosure conditions: expressive disclosure or benefit finding-or to a time-management control condition. Participants completed three at-home writing sessions at one-week intervals. Results indicated that written forms of emotional disclosure might improve burden, stress, and depression contingent on writing condition. Specifically, both forms of emotional disclosure outperformed the control condition in reducing caregivers' depression. The control condition outperformed treatments in reducing caregiver stress. Finally, posttest caregiver burden was significantly lower than pretest burden across all writing conditions. This trial was registered with clinicaltrials.gov, ID: NCT02339870.

What Is the Impact of the Underserved Pathway Program on Graduates Entering an Underserved Family Medicine Residency? Five-Year Findings From the University of Washington School of Medicine

PURPOSE

More primary care physicians are needed in underserved areas of the United States. Prior research indicates that medical student experiences in underserved settings increase the likelihood that they will practice in underserved areas; few studies have controlled for selection bias. This study aimed to estimate the effect of the University of Washington School of Medicine's (UWSOM's) longitudinal extracurricular experience, the Underserved Pathway (UP), on graduates' choice in entering a family medicine residency with underserved training opportunities.

METHOD

The American Medical College Application Service application that all students submit to apply to UWSOM and a matriculation survey were used to collect demographic information for medical school graduates who subsequently entered family medicine residencies between 2010 and 2015. A given family medicine residency offered underserved training if it had a clinic or rotation at a federally qualified health center or if the admitting hospital was a critical access hospital. Multiple logistic regression was used to estimate the UP program's effect on graduates entering an underserved family medicine residency, adjusting for 26 covariates.

RESULTS

Participants were 158 UWSOM graduates; 39 (25%) completed the UP program. UP completion was associated with a 3.58 odds ratio increase to matching to an underserved family medicine residency, compared with non-UP graduates.

CONCLUSIONS

Completion of the UP was linked to a significant increase in program graduates matching to an underserved family medicine residency. Longitudinal extracurricular programs similar to the UP could be an important component in the pipeline to meeting the primary care needs of underserved populations.

Translating Interdisciplinary Research on Language Learning into Identifying Specific Learning Disabilities in Verbally Gifted and Average Children and Youth

The current research was grounded in prior interdisciplinary research that showed cognitive ability (verbal ability for translating cognitions into oral language) and multiple-working memory endophenotypes (behavioral markers of genetic or brain bases of language learning) predict reading and writing achievement in students with and without specific learning disabilities in written language (SLDs-WL). Results largely replicated prior findings that verbally gifted with dyslexia score higher on reading and writing achievement than those with average verbal ability but not on endophenotypes. The current study extended that research by comparing those with and without SLDs-WL with assessed verbal ability held constant. The verbally gifted without SLDs-WL (n = 14) scored higher than the verbally gifted with SLDs-WL (n = 27) on six language skills (oral sentence construction, best and fastest handwriting in copying, single real word oral reading accuracy, oral pseudoword reading accuracy and rate) and four endophenotypes (orthographic and morphological coding, orthographic loop, and switching attention). The verbally average without SLDs-WL (n = 6) scored higher than the verbally average with SLDs-WL (n = 22) on four language skills (best and fastest handwriting in copying, oral pseudoword reading accuracy and rate) and two endophenotypes (orthographic coding and orthographic loop). Implications of results for translating interdisciplinary research into flexible definitions for assessment and instruction to serve students with varying verbal abilities and language learning and endophenotype profiles are discussed along with directions for future research.

Collaborating with mammographers to address their work-related musculoskeletal discomfort

Mammographers are an understudied group of health care workers, yet the prevalence of musculoskeletal (MSK) symptoms in mammographers appears to be elevated, similar to many occupations in health care. In this study, we used a participatory approach to identify needs and opportunities for developing interventions to reduce mammographers' exposures to risk factors that lead to the development of MSK symptoms. In this paper, we present a number of those needs and several intervention concepts along with evaluations of those concepts from experienced mammographers. We include findings from a preliminary field test of a novel intervention concept to reduce the need to adopt awkward postures while positioning patients for a screening or diagnostic mammogram. Practitioner Summary: This paper discusses needs, opportunities and methods for working with mammographers in order to develop interventions to reduce their exposure to risk factors for work-related musculoskeletal discomfort. Results from a field test of a novel intervention to reduce mammographers' awkward work postures while positioning patients are presented.

Collaborating with cardiac sonographers to develop work-related musculoskeletal disorder interventions

For more than two decades, surveys of imaging technologists, including cardiac sonographers, diagnostic medical sonographers and vascular technologists, have consistently reported high prevalence of work-related musculoskeletal discomfort (WRMSD). Yet, intervention research involving sonographers is limited. In this study, we used a participatory approach to identifying needs and opportunities for developing interventions to reduce sonographers' exposures to WRMSD risk factors. In this paper, we present some of those needs. We include descriptions of two interventions, targeted for cardiac sonographers, that were developed, through an iterative process, into functional prototypes that were evaluated in pilot tests by practicing sonographers. One of these interventions is now in daily use. We would like other engineers and ergonomists to recognise this area of opportunity to apply their knowledge of biomechanics and design in order to begin to address the high prevalence of WRMSDs in sonographers, by working with sonographers to develop useful and usable interventions. Practitioner Summary: This paper discusses needs, opportunities and methods for working with sonographers in order to develop interventions to reduce their exposure to risk factors for work-related musculoskeletal discomfort. Results from field tests of two novel interventions targeting cardiac sonographers are also presented.

Novel Form of Curcumin Improves Endothelial Function in Young, Healthy Individuals: A Double-Blind Placebo Controlled Study

Curcumin, a turmeric extract, may protect against cardiovascular diseases by enhancing endothelial function. In this randomized controlled double-blind parallel prospective study, fifty-nine healthy adults were assigned to placebo, 50 mg (50 mg), or 200 mg (200 mg) curcumin, for 8 weeks. The higher curcumin (200 mg) supplementation produced a dose-mediated improvement in endothelial function measured by flow-mediated dilation (FMD). The outcome was a clinically substantial 3.0% increase (90% CI 0.7 to 5.3%, p = 0.032; benefit : harm odds ratio 546 : 1) with the 200 mg dose, relative to placebo. The 50 mg dose also increased FMD relative to placebo by 1.7% (-0.6 to 4.0%, p = 0.23; 25 : 1), but the outcome was not clinically decisive. In apparently healthy adults, 8 weeks of 200 mg oral curcumin supplementation resulted in a clinically meaningful improvement in endothelial function as measured by FMD. Oral curcumin supplementation may present a simple lifestyle strategy for decreasing the risk of cardiovascular diseases. This trial was registered at ISRCTN registry (ISRCTN90184217).

The influence of eating psychopathology on autobiographical memory specificity and social problem-solving

The primary aim was to examine the influence of subclinical disordered eating on autobiographical memory specificity (AMS) and social problem solving (SPS). A further aim was to establish if AMS mediated the relationship between eating psychopathology and SPS. A non-clinical sample of 52 females completed the autobiographical memory test (AMT), where they were asked to retrieve specific memories of events from their past in response to cue words, and the means-end problem-solving task (MEPS), where they were asked to generate means of solving a series of social problems. Participants also completed the Eating Disorders Inventory (EDI) and Hospital Anxiety and Depression Scale. After controlling for mood, high scores on the EDI subscales, particularly Drive-for-Thinness, were associated with the retrieval of fewer specific and a greater proportion of categorical memories on the AMT and with the generation of fewer and less effective means on the MEPS. Memory specificity fully mediated the relationship between eating psychopathology and SPS. These findings have implications for individuals exhibiting high levels of disordered eating, as poor AMS and SPS are likely to impact negatively on their psychological wellbeing and everyday social functioning and could represent a risk factor for the development of clinically significant eating disorders.

Modes of Alphabet Letter Production during Middle Childhood and Adolescence: Interrelationships with Each Other and Other Writing Skills

Although handwriting is typically taught during early childhood and keyboarding may not be taught explicitly, both may be relevant to writing development in the later grades. Thus, Study 1 investigated automatic production of the ordered alphabet from memory for manuscript (unjoined), cursive (joined), and keyboard letter modes (alphabet 15 sec) and their relationships with each other and spelling and composing in typically developing writers in grades 4 to 7 (N = 113). Study 2 compared students with dysgraphia (impaired handwriting, n=27), dyslexia (impaired word spelling, n=40), or oral and written language learning disability (OWL LD) (impaired syntax composing, n=11) or controls without specific writing disabilities (n=10) in grades 4 to 9 (N=88) on the same alphabet 15 modes, manner of copying (best or fast), spelling, and sentence composing. In Study 1, sequential multilevel model regressions of predictor alphabet 15 letter production/selection modes on spelling and composition outcomes, measured annually from grade 4 to grade 7 (ages 9 to 13 years), showed that only the cursive mode uniquely, positively, and consistently predicted both spelling and composing in each grade. For composing, in grade 4 manuscript mode was positively predictive and in grades 5-7 keyboard selection was. In Study 2 all letter production modes correlated with each other and one's best and fast sentence copying, spelling, and timed sentence composing. The groups with specific writing disabilities differed from control group on alphabet 15 manuscript mode, copy fast, and timed sentence composing. The dysgraphia and dyslexia groups differed on copying sentences in one's best handwriting, with the dysgraphia group scoring lower. The educational and theoretical significance of the findings are discussed for multiple modes and manners of letter production/selection of the alphabet that support spelling and composing beyond the early grades in students with and without specific writing disabilities.

N-cadherin is required for cytodifferentiation during zebrafish odontogenesis

N-cadherin is a well-studied classic cadherin involved in multiple developmental processes and is also known to have a signaling function. Using the zebrafish (Danio rerio) as a model, we tested the hypothesis that tooth morphogenesis is accompanied by dynamic changes in N-cadherin distribution and that absence of N-cadherin disturbs tooth development. N-cadherin, encoded by the gene cdh2, is absent during the initiation and morphogenesis stages of both primary (first-generation) and replacement teeth, as demonstrated by immunohistochemistry. However, N-cadherin is up-regulated at the onset of differentiation of cells of the inner dental epithelium and the dental papilla, i.e., the ameloblasts and odontoblasts, respectively. In the inner dental epithelium, N-cadherin is co-expressed with E-cadherin, excluding the occurrence of cadherin switching such as observed during human tooth development. While early lethality of N-cadherin knockout mice prevents any functional study of N-cadherin in mouse odontogenesis, zebrafish parachute (pac) mutants, deficient for N-cadherin, survive beyond the age when primary teeth normally start to form. In these mutants, the first tooth forms, but its development stops at the early cytodifferentiation stage. N-cadherin deficiency also completely inhibits the development of the other first-generation teeth, possibly due to the absence of N-cadherin signaling once the first tooth has differentiated.

The results of two multicenter, open-label studies assessing efficacy, tolerability and safety of protiramer, a high molecular weight synthetic copolymeric mixture, in patients with relapsing–remitting multiple sclerosis

Objective

Two pilot studies were conducted to evaluate safety, tolerability, and efficacy of two doses of Protiramer (TV-5010) in patients with relapsing–remitting multiple sclerosis.

Background

Both glatiramer acetate and TV-5010 are synthetic copolymers comprised the same four amino acids in a defined molar ratio. TV-5010 has higher average molecular weight than Glatiramer acetate and might be hypothesized that glatiramoids with higher molecular weight might be more immunoreactive than lower molecular weight peptides, thus increasing therapeutic potential and allowing for less frequent dosing.

Methods

In the two separate studies, after a 10 week pretreatment period, TV-5010 was given subcutaneously once weekly at 15 mg and 30 mg for 36 weeks. The primary end point was a reduction in the number of magnetic resonance imaging active lesions (i.e., T1-weigthed gadolinium-enhancing and new T2-weighted lesions) between the pretreatment period and the end of study.

Results

Both TV-5010 doses were generally well tolerated. The treatment with TV-5010 at a dose of 15 mg/wk did not show any significant effect. In contrast, in patients treated with at a dose of 30 mg/wk, a significant reduction in the mean number of gadolinium-enhancing (−58.8%; P = 0.0013) and new T2-W (−50%; P = 0.0002) lesions was observed. However, a large decrease in the mean number of both gadolinium-enhancing (−55%) and new T2-W (−40%) lesions during the pretreatment period made difficult the interpretation of the efficacy assessments.

Conclusions

Further studies are needed to confirm these preliminary data on safety and efficacy of TV-5010 at a weekly dose of 30 mg.

Development of research capability in Ethiopia: the Ethio-Netherlands HIV/AIDS Research Project (ENARP), 1994-2002

History of the Ethio-Netherlands HIV/AIDS Research Project (ENARP), 1994-2002 and Ethiopia's HIV/AIDS Prevention and Control Council.

Calibration of a proton beam energy monitora)

Delivery of therapeutic proton beams requires an absolute energy accuracy of +/-0.64 to 0.27 MeV for patch fields and a relative energy accuracy of +/-0.10 to 0.25 MeV for tailoring the depth dose distribution using the energy stacking technique. Achromatic switchyard tunes, which lead to better stability of the beam incident onto the patient, unfortunately limit the ability of switchyard magnet tesla meters to verify the correct beam energy within the tolerances listed above. A new monitor to measure the proton energy before each pulse is transported through the switchyard has been installed into a proton synchrotron. The purpose of this monitor is to correct and/or inhibit beam delivery when the measured beam energy is outside of the tolerances for treatment. The monitor calculates the beam energy using data from two frequency and eight beam position monitors that measure the revolution frequency of the proton bunches and the effective offset of the orbit from the nominal radius of the synchrotron. The new energy monitor has been calibrated by measuring the range of the beam through water and comparing with published range-energy tables for various energies. A relationship between depth dose curves and range-energy tables was first determined using Monte Carlo simulations of particle transport and energy deposition. To reduce the uncertainties associated with typical scanning water phantoms, a new technique was devised in which the beam energy was scanned while fixed thickness water tanks were sandwiched between two fixed parallel plate ionization chambers. Using a multitude of tank sizes, several energies were tested to determine the nominal accelerator orbit radius. After calibration, the energy reported by the control system matched the energy derived by range measurements to better than 0.72 MeV for all nine energies tested between 40 and 255 MeV with an average difference of -0.33 MeV. A study of different combinations of revolution frequency and radial offsets to test the envelope of algorithm accuracy demonstrated a relative accuracy of +/-0.11 MeV for small energy changes between 126 and 250 MeV. These new measurements may serve as a data set for benchmarking range-energy relationships.

Drug susceptibility of Mycobacterium tuberculosis in HIV-infected and -uninfected Ethiopians and its impact on outcome after 24 months of follow-up

From a prospective cohort study on tuberculosis/human immunodeficiency virus (TB/HIV) interaction in Addis Ababa, Ethiopia, drug susceptibility results were available for 94 TB patients (46% HIV-infected). Resistance to one or more drug(s) was detected in 21 (22.3%) and multidrug resistance in five (5.3%) patients. Occurrence of resistance was not related to HIV status or outcome after 24 months of follow-up. However, among HIV-infected TB patients who died during follow-up, survival time in those with a resistant Mycobacterium tuberculosis strain was significantly shorter compared to those with a sensitive strain (6 vs. 13 months). Early detection of drug resistance and timely treatment change can therefore have a positive impact on survival in HIV-infected TB patients.

Performance of routine syphilis serology in the Ethiopian cohort on HIV/AIDS

OBJECTIVES

To assess the performance of routine syphilis screening during 5 year follow up of Ethiopian factory workers, participating in a cohort study on HIV/AIDS.

METHODS

Syphilis serology test results of factory workers, who each donated at least six blood samples were evaluated. Screening in 1997-8 had been performed by the Treponema pallidum particle agglutination (TPPA) assay and in 1999-2001 by the rapid plasma reagin (RPR) test. TPPA had been followed by RPR or RPR by TPPA, in case of a positive screening result. Samples of study subjects showing inconsistent sequential TPPA and/or RPR results were retested independently by three laboratory technicians.

RESULTS

A total of 540 cohort participants (8.3% HIV positive at enrollment) donated 4,376 blood samples (mean 8.3 per subject). From 93 of the 176 participants with at least one positive TPPA result during follow up, 152 samples were retested by RPR and/or TPPA. Based on the revised syphilis test results, the 540 cohort participants were classified as having no (70.5%), past (20.6%), prevalent (6.9%), or incident (2.0%) syphilis. The RPR screening test was difficult to interpret and yielded 8.2% biological false positive (BFP) RPR results, or 3.2% if weak positive results were excluded. There was no correlation between HIV infection and BFP RPR reactions. Sample mix-ups were detected in 1.2%.

CONCLUSION

Evaluation of routine syphilis screening as performed in a long term cohort study on HIV/AIDS in Ethiopia showed difficulties encountered in syphilis screening programmes such as a high percentage of BFP RPR, inconsistencies in interpretation of the RPR test, and sample mix ups. The findings stress the need to develop a syphilis screening assay that is easy to perform and interpret and to implement quality assurance programmes.

CD44 isoform expression on colonic epithelium mediates lamina propria lymphocyte adhesion and is controlled by Th1 and Th2 cytokines

BACKGROUND AND AIMS

CD44v6 and CD44v3 are expressed on the surface of colonic epithelial cells in ulcerative colitis to a much greater extent than in Crohn's disease. We investigated mediators that induce CD44v6 and CD44v3 expression on colonic epithelium and the potential role of CD44 in mediating leucocyte-epithelial adhesion.

DESIGN AND METHODS

HT-29 cells were exposed to a range of T-helper 1 and T-helper 2 cytokines. Flow cytometry was used to determine their effect on CD44 isoform expression. The adhesion of peripheral blood and lamina propria lymphocytes to HT-29 monolayers was assessed and the effect of induction and blocking of CD44 isoforms was investigated.

RESULTS

Treatment of HT-29 cells with IL-4 and IL-13 resulted in a two- to three-fold increase in membrane expression of CD44v6 and CD44v3 isoforms. This was inhibited by T-helper 1 cytokines and hydrocortisone (P < 0.001). IL-4 increased lymphocyte adhesion to HT-29 monolayers approximately two-fold (P < 0.01). This increased adhesion of both lamina propria leucocytes and peripheral blood lymphocytes was abolished by anti-CD44v6 monoclonal antibodies (P < 0.01 and P < 0.05, respectively).

CONCLUSION

IL-4 and IL-13 are potent inducers of CD44v6 and CD44v3 expression on colon epithelial cells. The reciprocal effects of T-helper 2 and T-helper 1 cytokines on CD44 isoform expression may explain the observed differences between ulcerative colitis and colonic Crohn's disease. We have identified increased adhesion between lymphocytes and colon epithelial cells caused by IL-4-induced CD44v6 expression. This may contribute to epithelial targeting of inflammation in ulcerative colitis.

Low CD4+ T-cell count and high HIV viral load precede the development of tuberculosis disease in a cohort of HIV-positive Ethiopians

SETTING

Prospective cohort study, Ethiopia.

OBJECTIVE

To study changes in biological markers of HIV infection progression before and after development of TB disease.

DESIGN

A longitudinal study of 804 adult factory workers (95 HIV-positive, 709 HIV-negative), who were followed every 6 months for a median of 3.8 years.

RESULTS

Overall, the incidence rate of TB was 10/222 = 45.1 (95%CI 24.3-83.9) per 1000 person-years of observation (PYO) among HIV-1-positive participants, compared to 14/2054 = 6.8 (95%CI 4.0-11.5) per 1000 PYO among HIV-1-negative participants (incidence rate ratio 6.62, 95%CI 2.94-14.9). Among the 10 HIV-positive participants who subsequently developed TB disease, the CD4 count was low (median 201/microliter, range 45-419), and viral load high (median 4.97 log copies/ml, range 3.70-5.58), at the routine follow-up visit prior to TB diagnosis. Following TB treatment, plasma viral load remained persistently elevated despite clinical resolution of TB disease, and seven of the 10 patients died within a median time of 8 months.

CONCLUSION

In this cohort, HIV-infected Ethiopians who developed TB disease already had low CD4 counts and high viral load prior to the diagnosis of TB. Viral load did not decrease following TB treatment, leading to a poor overall prognosis in these patients.

Low CD4+ T-cell count and high HIV viral load precede the development of tuberculosis disease in a cohort of HIV-positive ethiopians

SETTING

Prospective cohort study, Ethiopia.

OBJECTIVE

To study changes in biological markers of HIV infection progression before and after development of TB disease.

DESIGN

A longitudinal study of 804 adult factory workers (95 HIV-positive, 709 HIV-negative), who were followed every 6 months for a median of 3.8 years.

RESULTS

Overall, the incidence rate of TB was 10/ 222 = 45.1 (95%CI 24.3-83.9) per 1000 person-years of observation (PYO) among HIV-1-positive participants, compared to 14/2,054 = 6.8 (95%CI 4.0-11.5) per 1,000 PYO among HIV-1-negative participants (incidence rate ratio 6.62, 95%CI 2.94-14.9). Among the 10 HIV-positive participants who subsequently developed TB disease, the CD4 count was low (median 201/microl, range 45-419), and viral load high (median 4.97 log copies/ml, range 3.70-5.58), at the routine follow-up visit prior to TB diagnosis. Following TB treatment, plasma viral load remained persistently elevated despite clinical resolution of TB disease, and seven of the 10 patients died within a median time of 8 months.

CONCLUSION

In this cohort, HIV-infected Ethiopians who developed TB disease already had low CD4 counts and high viral load prior to the diagnosis of TB. Viral load did not decrease following TB treatment, leading to a poor overall prognosis in these patients.

Right aortic arch symptomatic in adulthood

We present a patient with progressive dysphagia and shortness of breath due to a right aortic arch with aberrant left subclavian artery that became symptomatic in adulthood. Diagnosis was made after a delay because the possibility of a congenital anomaly was not considered when the patient presented with dysphagia. A review is given of the incidence, embryology, aetiology, diagnostic evaluation and management, as well as a discussion of other congenital aortic arch anomalies.

Quantitative and functional differences in CD8+ lymphocyte responses in resolved acute and chronic hepatitis C virus infection

CD8+ T lymphocyte responses are important in the clearance of viral infections. In chronic infections they may contribute to pathogenesis. To investigate the role of CD8+ T lymphocyte responses in viral clearance and chronic hepatitis C we have compared hepatitis C virus (HCV) specific cytotoxicity and interferon-gamma (IFN-gamma) production in patients with resolved-acute, and chronic HCV infection. CD8+ T cell responses to a panel of 13 HCV T cell peptide epitopes were studied using Elispot assays of IFN-gamma production and chromium release cytotoxicity assays. Responses of seven patients with resolved acute HCV infection were compared with those of 14 chronically infected patients. HCV-specific cytotoxicity differentiated the two populations of patients. The majority (71%) of patients with resolved acute infection tested positive to 42% of relevant peptides compared with the minority (28%) of patients with chronic hepatitis C (P=0.03) who responded to only 8% of relevant peptides (P=0.0009). In contrast, HCV-specific IFN-gamma production was detected in 86% of patients with either resolved or chronic infection in response to 42% and 35%, respectively, of relevant peptides tested (not significant). In patients with chronic infection the magnitude of the HCV-specific IFN-gamma production was inversely correlated to viral load (R2=0.52; P=0.042). Failure to clear HCV infection may be attributable to the presence of noncytolytic IFN-gamma producing CD8+ T lymphocytes in chronically infected patients. However these CD8+ T cells may play a beneficial role in contributing to the control of viral load in chronic hepatitis C.

Effects of pubovaginal sling procedure on patients with urethral hypermobility and intrinsic sphincteric deficiency: would they do it again?

OBJECTIVE

This study was undertaken to assess the cure rate of stress urinary incontinence, long-term effects on other lower urinary tract symptoms, and quality of life in a cohort of patients who underwent pubovaginal sling procedures for treatment of incontinence related to intrinsic sphincteric deficiency and urethral hypermobility.

STUDY DESIGN

This was a retrospective analysis of 57 patients with 90% follow-up who underwent pubovaginal autologous fascial sling procedures for stress urinary incontinence related to urethral hypermobility and intrinsic sphincteric deficiency. Objective postoperative urodynamic evaluation was performed in 34 (60%) of the cases. Telephone interviews to assess quality-of-life parameters were performed in all cases.

RESULTS

The mean follow-up period was 42 months and the median follow-up period was 34 months, with a range of 0.5 to 134 months. The age at the time of the sling procedure ranged from 18 to 84 years, with a median parity of 3.0 (range, 0-6). Preoperative body mass index ranged from 19.5 to 39.1 kg/m(2). Five percent of patients had detrusor instability before the operation. Forty-one percent (41%) of the patients who underwent postoperative urodynamic evaluation had voiding dysfunction. The postoperative objective cure rate for stress urinary incontinence was 97%. Of all patients 88% indicated that the sling had improved the quality of life, 84% indicated that the sling relieved the incontinence in the long-term, and 82% would choose to undergo the procedure again.

CONCLUSION

Construction of a pubovaginal sling is an effective technique for relief of severe stress urinary incontinence. Voiding dysfunction is a common side effect. Despite this problem, a significant number of patients would elect to undergo the procedure again.

The HIV epidemic and the state of its surveillance in Ethiopia

A review of the information on the HIV epidemic in Ethiopia is important to guide policy and action. Published and unpublished reports and surveillance data from records of governmental and non-governmental institutions were examined to assess the extent of the epidemic. It appears that the HIV/AIDS epidemic has affected a large segment of the urban population. Surveillance data from pregnant women attending antenatal clinics indicate a decreasing trend in the prevalence of HIV in Addis Ababa. Similarly, data from blood donors from the majority of transfusion centres in the country indicate a decrease in prevalence. However, further studies will be required to establish the validity of these findings. Currently available data are not adequate to accurately measure the level of infection in rural areas where 85% of the population live. Outside of Addis Ababa, in places where ANC-based sentinel surveillance are operational, the systems are not fully supported by quality control. Thus, there are concerns regarding the validity of reported results. The impact of HIV/AIDS epidemic in Ethiopia needs to be further quantified both in its burden of diseases and its impact on the urban and rural economy and society. It is, therefore, important that effort and adequate resources are put into strengthening surveillance systems.

Development of capillary electrophoresis as an alternative to high resolution agarose electrophoresis for the diagnosis of multiple sclerosis

The presence of oligoclonal bands in cerebrospinal fluid (CSF) is used as a diagnostic indicator of multiple sclerosis (MS). These bands, gamma-globulins thought to result from a restricted antibody response directed against autoantigens or viral antigens, are consistent with CSF-specific immunoglobulin synthesis when observed in the spinal fluid and not in the serum. Current methodology commonly involves electrophoresing concentrated CSF with high-resolution agarose gel electrophoresis (HRAGE) followed by protein staining in order to visualize the oligoclonal bands. Capillary zone electrophoresis (CZE) was evaluated as an alternative method. Separation of CSF and serum proteins from 54 patients in a bare silica capillary containing a high pH borate buffer allowed for resolution of the five major zones including the gamma-region and showed a 90% concordance with the results from HRAGE banding studies. Since a simple borate buffer did not provide adequate resolution of the oligoclonal bands in the gamma-region, the separation buffer was augmented with polyethylene glycol (PEG) which provided a significant enhancement in resolution of proteins in this region (24 patient study). In addition to obtaining banding information from electropherograms obtained with these separation conditions, it was feasible to calculate a CSF Index which compared favorably with the results from nephelometry. Finally, we show that zwitterionic additives such as O-phosphorylethanolamine may further enhance resolution and that capallary electrophoresis (CE) may allow oligoclonal banding information to be obtained directly from CSF without concentration.

Prospective study of serum protein capillary zone electrophoresis and immunotyping of monoclonal proteins by immunosubtraction

Capillary zone electrophoresis and immune adsorption were evaluated for identification of serum protein abnormalities and immunotyping of monoclonal proteins. A 7-capillary, electrophoresis instrument and solid phase immunosubtraction reagents were used in a prospective study of 1,518 patients. Serum protein electrophoresis was performed by agarose gel electrophoresis and capillary electrophoresis and interpreted with regard to identification of abnormalities consistent with monoclonal gammopathies. The agarose gel electrophoresis had a sensitivity and specificity of 91% and 99%, respectively, whereas capillary electrophoresis gave results of 95% and 99%. Immunotyping of the monoclonal proteins was performed by immunofixation and immunosubtraction. Capillary electrophoresis was more sensitive than agarose gel electrophoresis for the identification of monoclonal proteins in serum. In addition, the immunosubtraction method seems technically simpler and more automated than immunofixation and represents a useful additional approach for immunotyping monoclonal proteins.

Seroprevalence of hepatitis markers; HAV, HBV, HCV and HEV amongst primary school children in Freetown, Sierra Leone

The prevalence of hepatitis markers (Hepatitis A, B, C and E) in primary school children in Freetown, Sierra Leone was investigated in a government school, representative of the urban middle class. The children were aged between 6-12 years old. A sub-sample (n = 120) of the 450 pupils were invited to participate. Of the 66 volunteers (mean 8.32 years) 12 were positive for HBsAg (males 9, females 3) and 11 were confirmed. Six of these were HBeAg positive, anti-HBe negative, (male 5, female 1). Whilst 6 were HBeAg negative, anti-HBe positive (male 4, female 2). HBcAb was present in 47 children (71%). Hepatitis A, C and E antibodies were detected in 64 (97%), 1 (2%) and 5 (8%) of children respectively.

Identification of monoclonal proteins in serum: a quantitative comparison of acetate, agarose gel, and capillary electrophoresis

A selected group of 308 sera were analyzed by capillary electrophoresis (CE), agarose gel electrophoresis (AGE), and cellulose acetate electrophoresis (CAE) and evaluated for abnormalities that would suggest the presence of a monoclonal protein. The sensitivity (an electrophoretic abnormality in sera that contained a monoclonal protein) and specificity (a normal electrophoretic pattern in sera that did not contain a monoclonal protein) was determined for each electrophoretic procedure. CAE was the most specific procedure and CE was the most sensitive. The increase in sensitivity of CE was primarily due to increased detection of cryoglobulins and free light chains. The quantitation of the gamma region and/or monoclonal antibody peaks by CE was similar to results obtained by AGE. Quantitation of very large monoclonal protein peaks (> 3.0 g/dL) by on-line absorption detection (CE) yielded higher results than quantitation by dye-binding (AGE).