Development of a decision-support framework to support professionals and promote comfort among older hospital inpatients living with dementia

BACKGROUND

Acute hospital wards can be difficult places for many people living with dementia. Promoting comfort and wellbeing can be challenging in this environment. There is little evidence-based support for professionals working on acute care wards on how to respond to distress and maximise comfort and wellbeing among patients living with dementia.

OBJECTIVES

Our overall aim was to codesign an evidence-based easy-to-use heuristic decision-support framework, which was acceptable and practical but acknowledges the complex and acute nature of caring for patients with dementia in the hospital. This paper presents the development process and resulting framework.

METHODS

A codesign study was informed by data from (1) a literature review of the care and management of people living with dementia in acute hospitals; (2) a cohort study of comfort and discomfort in people with dementia in acute hospitals; and (3) interviews with family carers and health care professionals. We synthesised evidence from these data sources and presented to key stakeholders through codesign meetings and workshops to produce our decision-support framework.

RESULTS

The framework consists of a series of flowcharts and operates using a three-stage process of: (1) assess comfort/discomfort; (2) consider causes of discomfort; and (3) address patient needs to manage the discomfort.

CONCLUSION

Working with key stakeholders, synthesising diverse quantitative and qualitative evidence to build a clinical framework is a feasible approach to help address the needs of patients living with dementia in an acute hospital setting. The result is a framework which is now ready for evaluation and implementation.

PATIENT AND PUBLIC CONTRIBUTION

We worked closely with people living with dementia and family carers throughout this study, including the development of the study protocol with input on study development and design, through to inclusion in stakeholder workshops and codesign of the decision support framework.

T2 FLAIR Hyperintensity Volume Is Associated With Cognitive Function and Quality of Life in Clinically Stable Patients With Lower Grade Gliomas

Survival outcomes for patients with lower grade gliomas (LrGG) continue to improve. However, damage caused both by tumor growth and by the consequences of treatment often leads to significantly impaired cognitive function and quality of life (QoL). While neuropsychological testing is not routine, serial clinical MRIs are standard of care for patients with LrGG. Thus, having a greater understanding of MRI indicators of cognitive and QoL impairment risk could be beneficial to patients and clinicians. In this work we sought to test the hypothesis that in clinically stable LrGG patients, T2 FLAIR hyperintensity volumes at the time of cognitive assessment are associated with impairments of cognitive function and QoL and could be used to help identify patients for cognitive and QoL assessments and interventions. We performed anatomical MR imaging, cognitive testing and QoL assessments cross-sectionally in 30 clinically stable grade 2 and 3 glioma patients with subjective cognitive concerns who were 6 or more months post-treatment. Larger post-surgical T2 FLAIR volume at testing was significantly associated with lower cognitive performance, while pre-surgical tumor volume was not. Older patients had lower cognitive performance than younger patients, even after accounting for normal age-related declines in performance. Patients with Astrocytoma, IDH mutant LrGGs were more likely to show lower cognitive performance than patients with Oligodendroglioma, IDH mutant 1p19q co-deleted LrGGs. Previous treatment with combined radiation and chemotherapy was associated with poorer self-reported QoL, including self-reported cognitive function. This study demonstrates the importance of appreciating that LrGG patients may experience impairments in cognitive function and QoL over their disease course, including during periods of otherwise sustained clinical stability. Imaging factors can be helpful in identifying vulnerable patients who would benefit from cognitive assessment and rehabilitation.

Postacute Cognitive Rehabilitation for Adult Brain Tumor Patients

Intrinsic brain tumors often occur within functional neural networks, leading to neurological impairment and disability of varying degrees. Advances in our understanding of tumor-network integration, human cognition and language processing, and multiparametric imaging, combined with refined intraoperative tumor resection techniques, have enhanced surgical management of intrinsic brain tumors within eloquent areas. However, cognitive symptoms impacting health-related quality of life, particularly processing speed, attention, concentration, working memory, and executive function, often persist after the postoperative recovery period and treatment. Multidisciplinary cognitive rehabilitation is the standard of care for addressing cognitive impairments in many neurological diseases. There is promising research to support the use of cognitive rehabilitation in adult brain tumor patients. In this review, we summarize the history and usefulness of postacute cognitive rehabilitation for adult brain tumor patients.

Cognitive impact of lower-grade gliomas and strategies for rehabilitation

Outcomes for patients with lower-grade gliomas (LrGGs) continue to improve with advances in molecular characterization and treatment. However, cognitive sequela from the tumor and its treatment leave a significant impact on health-related quality of life for these patients. Several factors affect each patient's cognition, such as tumor location, treatment, medication, and comorbidities. However, impairments of processing speed, attention, concentration, working memory, and executive function are common across LrGG patients. Cognitive rehabilitation strategies, well established in traumatic brain injury and stroke populations, are based on neural plasticity and functional reorganization. Adapting these strategies for implementation in patients with brain tumors is an active area of research. This article provides an overview of cognitive domains commonly impaired in LrGG patients and evidence for the use of cognitive rehabilitation strategies to address these impairments with the goal of improving health-related quality of life in this patient population.

Prediction of intramuscular fat in lamb by visible and near-infrared spectroscopy in an abattoir environment

The study used visible and near-infrared spectroscopy (Vis-NIR) in a large commercial processing plant, to test a system for meat quality (intramuscular fat; IMF) data collection within a supply chain for UK lamb meat. Crossbred Texel x Scotch Mule lambs (n = 220), finished on grass on 4 farms and slaughtered across 2 months, were processed through the abattoir and cutting plant and recorded using electronic identification. Vis-NIR scanning of the cut surface of the M. longissimus lumborum produced spectral data that predicted laboratory-measured IMF% with moderate accuracy (R² 0.38-0.48). Validation of the Vis-NIR prediction equations on an independent sample of 30 lambs slaughtered later in the season, provided similar accuracy of IMF prediction (R² 0.54). Values of IMF from four different laboratory tests were highly correlated with each other (r 0.82-0.95) and with Vis-NIR predicted IMF (r 0.66-0.75). Results suggest scope to collect lamb loin IMF data from a commercial UK abattoir, to sort cuts for different customers or to feed back to breeding programmes to improve meat quality.

A coupled-enzyme equilibrium method for measuring urea in serum: optimization and evaluation of the AACC study group on urea candidate reference method

We describe a coupled-enzyme equilibrium method for measuring urea in serum, which is performed on supernates prepared by treating each specimen with Ba(OH)2 and ZnSO4 (Somogyi reagent). Analytical recovery of [14C]urea added to a variety of matrices was essentially complete (mean, 100.6%) for the supernates after precipitation. Nine variables were univariately examined in arriving at the reaction conditions for the method: glutamate dehydrogenase, urease, 2-oxoglutarate, ADP, Tris . HCI, NADH, EDTA, pH, and temperature. The reagent is stable for at least 48 days at--20 degrees C and for 23 days at 4 degrees C. Mean analytical recovery of urea (14 mmol/L) added to seven different specimens (three different matrices) was 100.8%. The analytical linear range of the method extends to 30 mmol of urea per liter. Of 22 potential interferents, only bilirubin at 1 mmol/L (580 mg/L), hemoglobin at 10 g/L, and hydroxyurea at 6 mmol/L showed more than 2% interference. We discuss precision and effects of specimen dilution, and compare results for 100 human serum specimens with those measured for the same specimens with four other urea methods. We examined the effects of measuring a blank, consisting of sample and reagent without urease, with each specimen.

Quantum Spin Ice Dynamics in the Dipole-Octupole Pyrochlore Magnet Ce_{2}Zr_{2}O_{7}

Neutron scattering measurements on the pyrochlore magnet Ce_{2}Zr_{2}O_{7} reveal an unusual crystal field splitting of its lowest J=5/2 multiplet, such that its ground-state doublet is composed of m_{J}=±3/2, giving these doublets a dipole-octupole (DO) character with local Ising anisotropy. Its magnetic susceptibility shows weak antiferromagnetic correlations with θ_{CW}=-0.4(2)  K, leading to a naive expectation of an all-in, all-out ordered state at low temperatures. Instead, our low-energy inelastic neutron scattering measurements show a dynamic quantum spin ice state, with suppressed scattering near |Q|=0, and no long-range order at low temperatures. This is consistent with recent theory predicting symmetry-enriched U(1) quantum spin liquids for such DO doublets decorating the pyrochlore lattice. Finally, we show that disorder, especially oxidation of powder samples, is important in Ce_{2}Zr_{2}O_{7} and could play an important role in the low-temperature behavior of this material.

High-Dose Vitamin D3 Administration Is Associated With Increases in Hemoglobin Concentrations in Mechanically Ventilated Critically Ill Adults: A Pilot Double-Blind, Randomized, Placebo-Controlled Trial

BACKGROUND

Anemia and vitamin D deficiency are highly prevalent in critical illness, and vitamin D status has been associated with hemoglobin concentrations in epidemiologic studies. We examined the effect of high-dose vitamin D therapy on hemoglobin and hepcidin concentrations in critically ill adults.

MATERIALS AND METHODS

Mechanically ventilated critically ill adults (N = 30) enrolled in a pilot double-blind, randomized, placebo-controlled trial of high-dose vitamin D3 (D3 ) were included in this analysis. Participants were randomized to receive placebo, 50,000 IU D3 , or 100,000 IU D3 daily for 5 days (totaling 250,000 IU D3 and 500,000 IU D3 , respectively). Blood was drawn weekly throughout hospitalization for up to 4 weeks. Linear mixed-effects models were used to assess change in hemoglobin and hepcidin concentrations by treatment group over time.

RESULTS

At enrollment, >75% of participants in all groups had plasma 25-hydroxyvitamin D (25(OH)D) concentrations <30 ng/mL, and >85% of participants across groups were anemic. In the 500,000-IU D3 group, hemoglobin concentrations increased significantly over time (Pgroup × time = .01) compared with placebo but did not change in the 250,000-IU D3 group (Pgroup × time = 0.59). Hepcidin concentrations decreased acutely in the 500,000-IU D3 group relative to placebo after 1 week (P = .007). Hepcidin did not change significantly in the 250,000-IU D3 group.

CONCLUSION

In these critically ill adults, treatment with 500,000 IU D3 was associated with increased hemoglobin concentrations over time and acutely reduced serum hepcidin concentrations. These findings suggest that high-dose vitamin D may improve iron metabolism in critical illness and should be confirmed in larger studies.

The Vitamin D for Enhancing the Immune System in Cystic Fibrosis (DISC) trial: Rationale and design of a multi-center, double-blind, placebo-controlled trial of high dose bolus administration of vitamin D3 during acute pulmonary exacerbation of cystic fibrosis

Vitamin D deficiency is highly prevalent in children and adults with cystic fibrosis (CF). Recent studies have found an association between vitamin D status and risk of pulmonary exacerbations in children and adults with CF. The ongoing Vitamin D for enhancing the Immune System in Cystic fibrosis (DISC) study is a multi-center, double-blind, randomized, placebo-controlled trial that will test the hypothesis of whether high dose vitamin D given as a single oral bolus of 250,000 IU to adults with CF during a pulmonary exacerbation followed by a maintenance dose of vitamin D will improve time to next pulmonary exacerbation and re-hospitalization, improve survival and lung function compared to placebo and reduce the rates of pulmonary exacerbation,. Subjects will be randomized 1:1 at each clinical site to vitamin D or placebo within 72 hours of hospital admission for pulmonary exacerbation. Clinical follow-up visits will occur at 1, 2, 3, and 7 days, and 1, 3, 6 and 12 months after randomization. Blood and sputum will be collected and determination of clinical outcomes will be assessed at each visit. The primary endpoint will be the time to next pulmonary exacerbation requiring antibiotics, re-hospitalization or death. The secondary endpoints will include lung function assessed by forced expiratory volume in 1 second (FEV1), blood markers of inflammatory cytokines, anti-microbial peptide expression by peripheral blood mononuclear cells and circulating concentrations in blood. Other exploratory endpoints will examine the phenotype of neutrophils and monocyte/macrophages in sputum. Nutritional status will be assessed by 3 day food records and food frequency questionnaire.

Persistent HPV infection in postmenopausal age women

OBJECTIVE

Persistence of human papillomavirus (HPV) is associated with an increased risk of developing cervical SIL and cancer in young women. Because this association in older, postmenopausal age women has received little attention, we evaluated persistence of HPV among women in this age group.

METHODS

Women (n=105) ages 45-64 were examined annually for 7 years to evaluate HPV in cervical cytologic specimens. PCR, dot blot hybridization and DNA sequencing were used to detect HPV types.

RESULTS

The cumulative prevalence of HPV was 34%, and 24% had HPV high-risk oncogenic types which are associated with genital cancers. The most common oncogenic types were HPV-16 (72%) and HPV-31 (16%). The persistence rate of HPV infection was 16%. No specific risk factors were associated with repeat viral positivity.

CONCLUSION

Postmenopausal women are infected with persistent oncogenic HPV at a substantial rate, supporting the need for continued screening in postmenopausal women to detect preneoplastic genital lesions.

Pot1 OB-fold mutations unleash telomere instability to initiate tumorigenesis

Chromosomal aberrations are a hallmark of human cancers, with complex cytogenetic rearrangements leading to genetic changes permissive for cancer initiation and progression. Protection of Telomere 1 (POT1) is an essential component of the shelterin complex and functions to maintain chromosome stability by repressing the activation of aberrant DNA damage and repair responses at telomeres. Sporadic and familial mutations in the oligosaccharide-oligonucleotide (OB) folds of POT1 have been identified in many human cancers, but the mechanism underlying how hPOT1 mutations initiate tumorigenesis has remained unclear. Here we show that the human POT1’s OB-folds are essential for the protection of newly replicated telomeres. Oncogenic mutations in hPOT1 OB-fold fail to bind to ss telomeric DNA, eliciting a DNA damage response at telomeres that promote inappropriate chromosome fusions via the mutagenic alternative non-homologous end joining (A-NHEJ) pathway. hPOT1 mutations also result in telomere elongation and the formation of transplantable hematopoietic malignancies. Strikingly, conditional deletion of both mPot1a and p53 in mouse mammary epithelium resulted in development of highly invasive breast carcinomas and the formation of whole chromosomes containing massive arrays of telomeric fusions reminiscent of chromothripsis. Our results reveal that hPOT1 OB-folds are required to protect and prevent newly replicated telomeres from engaging in A-NHEJ mediated fusions that would otherwise promote genome instability to fuel tumorigenesis.

High-dose vitamin D3 reduces circulating hepcidin concentrations: A pilot, randomized, double-blind, placebo-controlled trial in healthy adults

BACKGROUND & AIMS

In vitro studies suggest that vitamin D may reduce hepcidin expression and pro-inflammatory cytokine release from monocytes. However, data assessing the vitamin D-mediated effects on iron recycling in healthy individuals are lacking. We aimed to examine the effect of high-dose vitamin D₃ on plasma hepcidin, inflammatory cytokine, and ferritin concentrations in healthy adults.

METHODS

This was a pilot, double-blind, placebo-controlled trial in healthy adults (N = 28) randomized to receive a one-time oral dose of 250,000 IU of vitamin D₃ or placebo. Between- and within-group differences in plasma hepcidin, pro-inflammatory cytokine [interleukin (IL)-1β, IL-6, IL-8, monocyte chemoattractant protein-1 (MCP-1)], and ferritin concentrations at baseline and 1 week were determined using two-sample and paired t-tests, respectively.

RESULTS

At baseline, plasma 25-hydroxyvitamin D [25(OH)D], hepcidin, pro-inflammatory cytokine, and ferritin concentrations did not differ between the two groups, and greater than 70% of subjects in both groups were vitamin D deficient (25(OH)D < 20 ng/mL). After 1 week, plasma hepcidin concentrations decreased by 73% from baseline in those who received vitamin D₃ (geometric mean ratio [GMR] = 0.27 (95% CI: 0.11-0.62); P = 0.005); there was no significant change in the placebo group (GMR = 0.73 (95% CI: 0.49-1.09); P = 0.11). Plasma cytokine and ferritin concentrations did not change significantly in either group.

CONCLUSIONS

High-dose vitamin D₃ significantly reduced plasma hepcidin concentrations in healthy adults 1 week post-dosing, without a change in plasma pro-inflammatory cytokine or ferritin concentrations. These data suggest that vitamin D may have a role in regulating iron recycling by acting independently of changes in pro-inflammatory markers.

Vitamin D and anemia: insights into an emerging association

PURPOSE OF REVIEW

The current review highlights recent findings in the emerging association between vitamin D and anemia through discussion of mechanistic studies, epidemiologic studies, and clinical trials.

RECENT FINDINGS

Vitamin D has previously been found to be associated with anemia in various healthy and diseased populations. Recent studies indicate that the association may differ between race and ethnic groups and is likely specific to anemia of inflammation. The mechanism underlying this association involves the reduction of proinflammatory cytokines by vitamin D and the direct suppression of hepcidin mRNA transcription. There is also evidence that vitamin D may be protective against anemia by supporting erythropoiesis. Other calciotropic hormones including fibroblast growth factor 23, and parathyroid hormone have also been found to be associated with iron homeostasis and erythropoiesis.

SUMMARY

Recent advances in our understanding of the association between vitamin D and anemia suggest that maintenance of sufficient vitamin D status may be important in preventing anemia, particularly in diseases characterized by inflammation. Early clinical trials have been promising, but further research is needed to define the efficacy of vitamin D as a future approach for the treatment of anemia.

Changes in Mineral Micronutrient Status During and After Pulmonary Exacerbation in Adults With Cystic Fibrosis

BACKGROUND

Patients with cystic fibrosis (CF) may be at risk for micronutrient depletion, particularly during periods of illness and infection. The purpose of this study was to investigate serum micronutrient status over time in adults with CF initially hospitalized with a pulmonary exacerbation.

MATERIALS AND METHODS

This was an ancillary study of a multicenter trial investigating the role of high-dose vitamin D supplementation in 24 adults with CF (mean age, 29.6 ± 7.3 years). We measured serum concentrations of copper (Cu), iron (Fe), calcium (Ca), magnesium (Mg), potassium (K), and sulfur (S) in subjects at the beginning of a pulmonary exacerbation and again at 3 months.

RESULTS

Serum concentrations of Cu, Fe, and Ca were significantly lower at baseline compared with 3 months following the pulmonary exacerbation (Cu: baseline, 1.5 ± 0.6 vs 3 months, 1.6 ± 0.6 µg/mL, P = .027; Fe: 0.8 ± 0.3 vs 1.3 ± 1.1 µg/mL, P = .026; Ca: 9.7 ± 0.8 vs 10.8 ± 2.0 mg/dL, P = .024). Serum concentrations of K, Mg, and S did not change over time (K: baseline, 4.9 ± 0.3 vs 3 months, 5.1 ± 0.5 mEq/L; Mg: 1.8 ± 0.2 vs 2.0 ± 0.3 mg/dL; S: 1288.6 ± 343 vs 1309.9 ± 290 µg/mL; P > .05 for all).

CONCLUSION

Serum concentrations of Cu, Fe, and Ca increased significantly several months following recovery from acute pulmonary exacerbation in adults with CF. This may reflect decreased inflammation, improved food intake, and/or increased absorption following recovery.

Vitamin D deficiency in critically ill children

OBJECTIVE

Vitamin D influences cardiovascular and immune function. We aimed to establish the prevalence of vitamin D deficiency in critically ill children and identify factors influencing admission 25-hydroxy vitamin D (25(OH)D) levels. We hypothesized that levels would be lower with increased illness severity and in children with serious infections.

METHODS

Participants were 511 severely or critically ill children admitted to the PICU from November 2009 to November 2010. Blood was collected near PICU admission and analyzed for 25(OH)D concentration by using Diasorin radioimmunoassay.

RESULTS

We enrolled 511 of 818 (62.5%) eligible children. The median 25(OH)D level was 22.5 ng/mL; 40.1% were 25(OH)D deficient (level <20 ng/mL). In multivariate analysis, age and race were associated with 25(OH)D deficiency; summer season, vitamin D supplementation, and formula intake were protective; 25(OH)D levels were not lower in the 238 children (46.6%) admitted with a life-threatening infection, unless they had septic shock (n = 51, 10.0%) (median 25(OH)D level 19.2 ng/mL; P = .0008). After adjusting for factors associated with deficiency, lower levels were associated with higher admission day illness severity (odds ratio 1.19 for a 1-quartile increase in Pediatric Risk of Mortality III score per 5 ng/mL decrease in 25(OH)D, 95% confidence interval 1.10-1.28; P < .0001).

CONCLUSIONS

We found a high rate of vitamin D deficiency in critically ill children. Given the roles of vitamin D in bone development and immunity, we recommend screening of those critically ill children with risk factors for vitamin D deficiency and implementation of effective repletion strategies.

Serotonin (5-HT) receptor 5A sequence variants affect human plasma triglyceride levels

Neurotransmitters such as serotonin (5-hydroxytryptamine, 5-HT) work closely with leptin and insulin to fine-tune the metabolic and neuroendocrine responses to dietary intake. Losing the sensitivity to excess food intake can lead to obesity, diabetes, and a multitude of behavioral disorders. It is largely unclear how different serotonin receptor subtypes respond to and integrate metabolic signals and which genetic variations in these receptor genes lead to individual differences in susceptibility to metabolic disorders. In an obese cohort of families of Northern European descent (n = 2,209), the serotonin type 5A receptor gene, HTR5A, was identified as a prominent factor affecting plasma levels of triglycerides (TG), supported by our data from both genome-wide linkage and targeted association analyses using 28 publicly available and 12 newly discovered single nucleotide polymorphisms (SNPs), of which 3 were strongly associated with plasma TG levels (P < 0.00125). Bayesian quantitative trait nucleotide (BQTN) analysis identified a putative causal promoter SNP (rs3734967) with substantial posterior probability (P = 0.59). Functional analysis of rs3734967 by electrophoretic mobility shift assay (EMSA) showed distinct binding patterns of the two alleles of this SNP with nuclear proteins from glioma cell lines. In conclusion, sequence variants in HTR5A are strongly associated with high plasma levels of TG in a Northern European population, suggesting a novel role of the serotonin receptor system in humans. This suggests a potential brain-specific regulation of plasma TG levels, possibly by alteration of the expression of HTR5A.

INSIG1 influences obesity-related hypertriglyceridemia in humans

In our analysis of a quantitative trait locus (QTL) for plasma triglyceride (TG) levels [logarithm of odds (LOD) = 3.7] on human chromosome 7q36, we examined 29 single nucleotide polymorphisms (SNPs) across INSIG1, a biological candidate gene in the region. Insulin-induced genes (INSIGs) are feedback mediators of cholesterol and fatty acid synthesis in animals, but their role in human lipid regulation is unclear. In our cohort, the INSIG1 promoter SNP rs2721 was associated with TG levels (P = 2 x 10(-3) in 1,560 individuals of the original linkage cohort, P = 8 x 10(-4) in 920 unrelated individuals of the replication cohort, combined P = 9.9 x 10(-6)). Individuals homozygous for the T allele had 9% higher TG levels and 2-fold lower expression of INSIG1 in surgical liver biopsy samples when compared with individuals homozygous for the G allele. Also, the T allele showed additional binding of nuclear proteins from HepG2 liver cells in gel shift assays. Finally, the variant rs7566605 in INSIG2, the only homolog of INSIG1, enhances the effect of rs2721 (P = 0.00117). The variant rs2721 alone explains 5.4% of the observed linkage in our cohort, suggesting that additional, yet-undiscovered genes and sequence variants in the QTL interval also contribute to alterations in TG levels in humans.

Human Experience Modeler: context-driven cognitive retraining to facilitate transfer of learning

We describe a cognitive rehabilitation mixed-reality system that allows therapists to explore natural cuing, contextualization, and theoretical aspects of cognitive retraining, including transfer of training. The Human Experience Modeler (HEM) mixed-reality environment allows for a contextualized learning experience with the advantages of controlled stimuli, experience capture and feedback that would not be feasible in a traditional rehabilitation setting. A pilot study for testing the integrated components of the HEM is discussed where the participant presents with working memory impairments due to an aneurysm.

Aip1 and cofilin promote rapid turnover of yeast actin patches and cables: a coordinated mechanism for severing and capping filaments

Rapid turnover of actin structures is required for dynamic remodeling of the cytoskeleton and cell morphogenesis, but the mechanisms driving actin disassembly are poorly defined. Cofilin plays a central role in promoting actin turnover by severing/depolymerizing filaments. Here, we analyze the in vivo function of a ubiquitous actin-interacting protein, Aip1, suggested to work with cofilin. We provide the first demonstration that Aip1 promotes actin turnover in living cells. Further, we reveal an unanticipated role for Aip1 and cofilin in promoting rapid turnover of yeast actin cables, dynamic structures that are decorated and stabilized by tropomyosin. Through systematic mutagenesis of Aip1 surfaces, we identify two well-separated F-actin-binding sites, one of which contributes to actin filament binding and disassembly specifically in the presence of cofilin. We also observe a close correlation between mutations disrupting capping of severed filaments in vitro and reducing rates of actin turnover in vivo. We propose a model for balanced regulation of actin cable turnover, in which Aip1 and cofilin function together to "prune" tropomyosin-decorated cables along their lengths. Consistent with this model, deletion of AIP1 rescues the temperature-sensitive growth and loss of actin cable defects of tpm1Delta mutants.

Multilocus sequence typing of intercontinental bovine Staphylococcus aureus isolates

A total of 258 bovine-associated Staphylococcus aureus isolates from the United States, Chile, and the United Kingdom, plus the reference isolate S. aureus Newbould 305 (NCIMB 702892), were analyzed by multilocus sequence typing (MLST). A collection of previously characterized United Kingdom isolates were also included in the analysis. The results demonstrated that MLST is suitable for the differentiation of bovine S. aureus isolates from various sites (milk, teat skin, milking machine unit liners, hands, and bedding) and countries. The theory of the host specificity of S. aureus is supported by the detection of a previously undescribed clonal complex that comprised 87.4% of the isolates studied, with representatives from all geographic locations investigated. This suggests that a single clonal group has achieved a widespread distribution and is responsible for the majority of infections. Some sequence types (STs; ST25, ST115, ST124, and ST126) demonstrated site specificity, as they were significantly (P < 0.05) associated with milk or teat skin.

Multilocus sequence typing of Staphylococcus aureus isolated from high-somatic-cell-count cows and the environment of an organic dairy farm in the United Kingdom

An outbreak of Staphylococcus aureus intramammary infections on an organic dairy farm was monitored for 10 months. Environmental and milk samples were collected from a total of 26 cows and a group of 21 purchased heifers about to be introduced into the milking herd. There was variation in the rate of isolation of S. aureus (9.5 to 43.8%) from individual mammary quarters, although no S. aureus isolates were detected in the milk samples collected from the heifers. One hundred ninety-one S. aureus isolates were detected from cow milk samples (n = 182), milking machine clusters (n = 4), farm personnel (n = 4), and the environment (n = 1). Multilocus sequence typing (MLST) had a typeability of 100% when it was applied to the 191 isolates. Among the 191 isolates there was limited strain diversity, with seven sequence types (STs) dominated by two strains with closely related STs that differed at a single locus. Within individual mammary quarters there were naturally occurring dual infections, although this was identified in only 0.4% of milk samples. Different strains were associated with variable persistence within quarters. MLST is clearly a very suitable tool for the differentiation and analysis of S. aureus populations detected on dairy cattle farms.

HPV prevalence and concordance in the cervix and oral cavity of pregnant women

OBJECTIVES

This investigation examined human papillomavirus (HPV) in pregnant women in order to characterize viral prevalence, types and concordance between infection in the cervix and in the oral cavity.

METHODS

A total of 577 pregnant women seeking routine obstetric care were evaluated for HPV infection in their cervix during gestation and immediately before delivery, and in the oral cavity during gestation. Male partners present during the gestational clinic visit also provided a specimen from their oral cavity. HPV assessment was performed by PCR, dot blot hybridization and DNA sequencing. A sexual and health questionnaire was completed by the pregnant women.

RESULTS

HPV prevalence in women was 29% in the cervix and 2.4% in the oral cavity. Among those with both gestational and delivery specimens, 35% were infected at least once and 20% had infection at both intervals. At delivery, 68% of infected women had an oncogenic HPV type in the cervix. There was no type-specific HPV concordance between the two cervical specimens, nor cervical and oral results in women, nor with cervical and oral findings between partners.

CONCLUSION

The lack of association in HPV positivity and types between the cervix and oral cavity in these women suggests that self-inoculation is uncommon. This source of infection does not appear to be from oral contact with a current male partner, since there also was no concordance between partners. These results suggest either other modes of HPV transmission or differences in susceptibility to HPV infection or its clearance in the oral cavity and genital mucosa.

Assessing the independent contribution to quality of life from anxiety and depression in patients with advanced cancer

BACKGROUND

The aim of palliative care services is to ensure the best quality of life for patients and their carers. Depression is common amongst palliative care patients and has been shown to adversely affect quality of life. This study aimed to examine the independent contribution of depression to quality of life.

OBJECTIVE

To investigate the hypothesis that a) illness severity, pain, anxiety and depression are all associated with impaired health-related quality of life and b) once the effects of illness severity have been adjusted for, there is further independent contribution to quality of life from anxiety and depression.

METHOD

Consecutive patients with advanced cancer under the care of palliative care services were screened. Sixty-eight patients were evaluated for levels of anxiety and depression, severity of illness, pain severity and health-related quality of life.

RESULTS

Thirty-three males and 35 females were recruited and had an age range of 41-93 years (median 71). Seventeen (25%) of patients were anxious [anxiety score > or = 11 on the Hospital Anxiety and Depression Scale (HADS)], 15 (22%) were depressed (HADS depression score > or = 11). After controlling for the effects of pain and illness severity, anxiety and depression were independently associated with global health status, emotional and cognitive functioning, and fatigue. Anxiety further contributed significantly towards social functioning, nausea and vomiting.

CONCLUSIONS

This study has confirmed that pain, anxiety and depression were associated with impaired quality of life. Anxiety and depression contributed independently towards various dimensions of quality of life. Longitudinal studies are required to examine the direction of the causal association between pain and depression in patients receiving palliative care.

The current and future management of malignant ascites

Malignant ascites occurs in association with a variety of neoplasms. It is a frequent cause of morbidity and presents significant problems for which there are no clear management guidelines. In this article we discuss various modalities which are available including diuretic therapy, paracentesis, peritoneovenous shunts and intraperitoneal chemotherapy. There are no randomized trials of diuretic drugs to assess their efficacy in malignant ascites. Phase II data suggest that they are effective in approximately one-third of patients with malignancy, and their efficacy may be determined by plasma renin/aldosterone concentrations. Paracentesis provides relief in up to 90% of patients; because of varying reports of hypovolaemia, some advocate simultaneous intravenous fluid infusion. Permanent percutaneous drains may prevent the need for repeated paracentesis, although there is potential for infection. A peritoneovenous shunt also prevents the need for repeated paracenteses, whilst maintaining normal serum albumin concentrations. Blockage occurs in 25% of shunts, which are contraindicated in the presence of heavily bloodstained ascites because of the risk of occlusion. The preclinical and clinical experience with anti-angiogenic agents such as the matrix metalloproteinase inhibitors and the VEGF antagonists suggests that these agents may have a role in the treatment of malignant ascites.

Is use of hormone replacement therapy associated with increased detection of human papillomavirus and potential risk of HPV-related genital cancers?

Oral contraceptives (OC) are a risk factor for female genital cancers and in vivo studies have shown that progestins stimulate human papillomavirus (HPV) gene expression. A similar role for hormone replacement therapy (HRT) has received little evaluation. Cervical/vaginal specimens were obtained to detect HPV from postmenopausal women (n = 429) seeking annual gynaecologic care. HPV was detected in 14% of women and 4.4% had high-risk, oncogenic types. HPV prevalence was similar across current, past and never HRT users. After adjustment for HPV-related risk factors, current and past user status showed no increased viral detection compared with never users. HRT duration also did not elevate risk among current users. However, longer duration (adj. OR 1.5/year, 95% CI 1.0-2.3) and longer latency (adj. OR 1.2/year, 95% CI 0.9-1.7) among past users of oestrogen/progestin regimens were associated with greater risk. Overall use of HRTs was not associated with HPV detection or disease. However, past users of combination HRTs had significantly greater risk of HPV detection with longer HRT duration and latency, similar to OC-HPV findings. The recommendation that postmenopausal women continue HRTs long term may lead to an increased development of HPV-related diseases, of particular concern among those who discontinue HRTs and subsequent gynaecologic care for early cancer detection.

Beta (CC)-chemokines as modulators of sleep: implications for HIV-induced alterations in arousal state

Sleep is altered early in the course of HIV infection, before the onset of AIDS, indicating effects of the virus on neural processes. Previous observations suggest HIV envelope glycoproteins are possible mediators of these responses. Because some beta (CC)-chemokine receptors serve as co-receptors for HIV and bind HIV envelope glycoproteins, we determined in this study whether selected CC chemokine ligands alter sleep and whether their mRNAs are detectable in brain regions important for sleep. CCL4/MIP-1beta, but not CCL5/RANTES, injected centrally into rats prior to dark onset increased non-rapid eye movements sleep, fragmented sleep, and induced fever. mRNA for the chemokine receptor CCR3 was detectable under basal conditions in multiple brain regions. These data suggest some CC chemokines may also be involved in processes by which HIV alters sleep.

A prospective study of coping after exposure to a mass murder episode

In a study of 136 survivors of a mass murder spree, multidimensional scaling identified clusters of responses mapping from 75 coping behaviors described by victims. This powerful method identified three coping dimensions: (a) Active Outreach versus Passive Isolation, (b) Informed Pragmatism versus Abandonment of Control, and (c) Reconciliation/Acceptance versus Evading the Status Quo. These coping dimensions were used to predict change in psychiatric status prospectively assessed with structured diagnostic interviews at index 3-4 months after the event and follow-up assessments 1 and 3 years later. Statistically significant changes in the positive direction on each of the three dimensions in this study were associated with reductions of 47-79% of the odds for acute postdisaster major depression, posttraumatic stress disorder (PTSD), and any non-PTSD disorder. These findings suggest mechanisms for development of therapeutic techniques capitalizing on encouraging active outreach, informed focus and pragmatism, and reconciliation and acceptance, and reduction of passive and isolative behaviors, resignation of control, and avoidance of realities of the postdisaster situation.

Planning for a multi-imaging center picture archiving and communications system

There are fundamental differences in planning and configuring a picture archiving and communications system (PACS) for a multisite imaging practice as compared to a hospital-based radiology department. In the for-profit, multi-imaging center environment, return on investment is more critical and the distributed nature of radiology operations presents complex communications, infrastructure, archiving, workflow, and distribution requirements. This article discusses desired outcomes for a multi-imaging center PACS and the planning, functional, technical, and support requirements necessary to achieve those outcomes.

ACTH receptor distribution and modulation among murine mononuclear leukocyte populations

Murine mononuclear leukocytes express adrenocorticotropin (ACTH) receptors that were recognized by a monospecific antiserum to the ACTH receptor on Y-1 adrenal cells. The antiserum was utilized in an immunofluorescence (IF) assay to characterize the distribution of ACTH receptors on resting murine mononuclear leukocyte populations. Forty-seven percent of spleen cells, 32% of lymph node cells, and 1% of thymocytes constitutively expressed ACTH receptors. Separation of lymphocytes into purified B cell and T cell populations, followed by IF analysis revealed that 47% of B cells and 23% of T cells possessed ACTH receptors. Helper T cells (CD4+ T cells) constituted the majority of ACTH receptor-positive T lymphocytes. Furthermore, 47% of resident peritoneal macrophages, purified by adherence to plastic, expressed ACTH receptors. The T-lymphocyte mitogen, concanavalin A, interferon gamma, and ACTH enhanced ACTH receptor expression. The differential distribution of ACTH receptor-positive cells among specific leukocyte populations explains in part why differential cellular responses are observed and implies important regulatory functions for these receptors in the generation or regulation of immune responses.

Inhibition of angiogenesis and tumor growth by SCH221153, a dual alpha(v)beta3 and alpha(v)beta5 integrin receptor antagonist

New blood vessel formation is essential for tumor growth and metastatic spread. Integrins alpha(v)beta3 and alpha(v)beta5 are arginine-glycine-aspartic acid-dependent adhesion receptors that play a critical role in angiogenesis. Hence, selective dual alpha(v)beta3 and alpha(v)beta5 antagonists may represent a novel class of angiogenesis and tumor-growth inhibitors. Here, an arginine-glycine-aspartic acid-based peptidomimetic library was screened to identify alpha(v)beta3 antagonists. Selected compounds were then modified to generate potent and selective dual inhibitors of alpha(v)beta3 and alpha(v)beta5 receptors. One of these compounds, SCH 221153, inhibited the binding of echistatin to alpha(v)beta3 (IC50 = 3.2 nM) and alpha(v)beta5 (IC50 = 1.7 nM) with similar potency. Its IC50 values for related alpha(IIb)beta3 and alpha5beta1 receptors were 1294 nM and 421 nM, respectively, indicating that SCH 221153 is highly selective for alpha(v)beta3 and alpha(v)beta5 receptors. In cell-based assays, SCH 221153 inhibited the binding of echistatin to alpha(v)beta3- and alpha(v)beta5-expressing 293 cells and blocked the adhesion of endothelial cells to immobilized vitronectin and fibroblast growth factor 2 (FGF2). SCH 221153, but not the inactive analogue SCH 216687, was effective in inhibiting FGF2 and vascular endothelial growth factor-induced endothelial cell proliferation in vitro with an IC50 equal to 3-10 microM. Angiogenesis induced by FGF2 in the chick chorioallantoic membrane assay was also inhibited by SCH 221153. Finally, SCH 221153 exerted a significant inhibition on tumor growth induced by intradermal or s.c. injection of human melanoma LOX cells in severe combined immunodeficient mice.

DNA separations in microfabricated devices with automated capillary sample introduction

A novel method is presented for automated injection of DNA samples into microfabricated separation devices via capillary electrophoresis. A single capillary is used to electrokinetically inject discrete plugs of DNA into an array of separation lanes on a glass chip. A computer-controlled micromanipulator is used to automate this injection process and to repeat injections into five parallel lanes several times over the course of the experiment. After separation, labeled DNA samples are detected by laser-induced fluorescence. Five serial separations of 6-carboxyfluorescein (FAM)-labeled oligonucleotides in five parallel lanes are shown, resulting in the analysis of 25 samples in 25 min. It is estimated that approximately 550 separations of these same oligonucleotides could be performed in one hour by increasing the number of lanes to 37 and optimizing the rate of the manipulator movement. Capillary sample introduction into chips allows parallel separations to be continuously performed in serial, yielding high throughput and minimal need for operator intervention.

Human papillomavirus in the oral cavities of children and adolescents

OBJECTIVE

The purpose of this pilot study was to determine the frequency of human papillomavirus (HPV) in the oral cavities of children and adolescents and to identify potential risk factors for HPV infection.

STUDY DESIGN

Sociodemographic information was obtained on 268 healthy infants, children, and adolescents who were < or = 20 years old. Oral squamous cells were collected from swabs with young children and from oral saline solution rinses with older children and adolescents. Extracted DNA was evaluated for HPV by polymerase chain reaction, dot blot hybridization, and DNA sequencing. Factors associated with the presence of HPV were tested by using chi(2), Fisher's exact test, and logistic regression tests.

RESULTS

HPV was detected in 6.0% of the participants. HPV frequency among young children (<7 years old) was 8.7% (11/127), and among adolescents (13-20 years old) it was 5.2% (5/97). HPV was not detected in children aged 7 to 12 years old (0/44). Fifty-four percent (6/11) of HPV-positive children were 1 year of age or less; 3 of the HPV-positive children (<7 years old) were delivered by cesarean section. No statistically significant association was found between the detection of HPV in the oral cavity and method of delivery or gender; parent's race, education, HPV-related conditions, smoking history, or number of sex partners; or adolescent's smoking history or history of sexual activity.

CONCLUSIONS

This study suggests that HPV is present in the oral cavity primarily in children 2 years old and younger and in adolescents 13 years and older. Cesarean delivery was not protective against oral HPV infection; in fact, half of the HPV-positive infants were born by cesarean delivery.

Human papillomavirus and risk of laryngeal cancer

We determined the relationship between human papillomavirus (HPV) infection and the HPV types detected in 44 patients with squamous cell carcinoma, 10 laryngeal leukoplakia patients, and 12 patients evaluated for benign laryngeal conditions (controls). The sources of HPV DNA were from brushings from the upper respiratory tract and lesion (benign or malignant), oral rinses, and biopsies of patient lesions. Polymerase chain reaction (PCR) and DNA sequencing were used to identify and type HPV. We detected HPV in 25.0% (11/44) of patients with laryngeal cancer, in 30.0% (3/10) of patients with laryngeal leukoplakia, and in 16.7% (2/12) of noncancer controls. Patients with cancer were not more likely to be identified with oncogenic HPV types ( 18.2%) than either the leukoplakia group (20%) or the control group (16.7%). An increased risk of disease was associated with current tobacco use and former alcohol drinking in cancer patients versus controls and in leukoplakia patients versus controls (all p < .05). After we controlled for tobacco and alcohol effects on the risk of disease, exposure to oncogenic HPV types was associated with an increased risk of laryngeal cancer (odds ratio = 3.0) and of laryngeal leukoplakia (odds ratio = 6.0) compared to controls, although the results were not statistically significant. This study suggests that although HPV infection and HPV oncogenic types are not found at a higher frequency in laryngeal cancer or laryngeal leukoplakia as compared to controls, infection is associated with an increased risk of disease after controlling for the effects of alcohol and tobacco use.

p53 polymorphism, human papillomavirus infection in the oral cavity, and oral cancer

OBJECTIVES

Human papillomavirus (HPV) infection has emerged as a risk factor in oral carcinogenesis. An arginine-coding polymorphism of the tumor suppressor protein p53 at codon 72 is more readily degraded by the HPV oncoprotein E6. Our objective was to evaluate the association between p53 polymorphism at codon 72 and HPV infection in the oral cavity, as well as its association with oral cancer.

STUDY DESIGN

Oral squamous cells from 202 patients with oral cancer and 333 age-sex frequency matched controls were evaluated by polymerase chain reaction for the presence and type of HPV and for alleles of codon 72 in p53. Fisher exact test and chi(2) tests were used to evaluate the data.

RESULTS

The p53 codon 72 polymorphism is not associated with HPV infection, whether comparing HPV-negative controls with HPV-positive controls or comparing HPV-negative cases with HPV-positive cases. Additionally, we found no association with the codon 72 polymorphism and oral cancer, whether comparing HPV-negative controls with HPV-negative cases or comparing HPV-positive controls with HPV-positive cases.

CONCLUSIONS

There is no association between p53 codon 72 polymorphism and HPV infection or between the p53 polymorphism and the risk of oral cancer.

Human immunodeficiency virus glycoprotein 160 induces cytokine mRNA expression in the rat central nervous system

1. Elevated proinflammatory cytokines within the central nervous system (CNS) of individuals infected with human immunodeficiency virus (HIV) may contribute to altered CNS processes prior to the onset of AIDS. Most studies of HIV-induced alterations in cytokine expression within the CNS have focused on interleukin (IL)-1 and tumor necrosis factor (TNF). 2. We used a ribonuclease protection assay (RPA) to elucidate further the pattern of cytokine mRNA expression in the rat CNS in response to HIV envelope glycoprotein 160 (gp160). Male Sprague-Dawley rats were surgically implanted with a guide cannula directed into a lateral cerebral ventricle. HIV gp160 was injected intracerebroventricularly and rats were sacrificed immediately (time = 0) or at 1, 2, or 4 hr postinjection. Discrete brain regions were dissected, and peripheral glands removed. All tissues were frozen in liquid nitrogen until RNA extraction and assay. 3. IL-1beta IL-1alpha, TNF-alpha, and TNFbeta mRNAs were constitutively expressed in brain tissues. Central administration of gp160 dramatically increased mRNA expression for IL-1beta and TNFalpha in the hypothalamus, hippocampus, brainstem, and cerebellum. Furthermore, although mRNA expression for IL-5, IL-6, and IL-10 was never detected under basal conditions, these mRNAs were increased in brain tissue after administration of gp160. Peak expression in each brain region was detected 2 hr after administration. Multiple cytokine mRNAs were detected in peripheral tissues, but their expression was not altered by central administration of gp160. 4. Our results indicate that gp160 induces mRNA expression in brain for cytokines other than IL-1 and TNF. Screening for multiple cytokine mRNA in this manner provides extensive information concerning the particular cytokines that may be involved in HIV-induced pathologies and alterations in CNS processes.

Risk factors for radial artery harvest site infection following coronary artery bypass graft surgery

Radial arteries increasingly are used during coronary artery bypass graft (CABG) surgery. Although risk factors for saphenous vein harvest site infection (HSI) have been reported, rates of and risk factors for radial artery HSI are not well established. We compared rates of radial artery HSI that were detected by 2 surveillance methods, regular and heightened. Risk factors were determined by a case-control study. We identified 35 radial artery HSIs ("case sites") in 26 case patients. The radial artery HSI rate was significantly higher during heightened surveillance than during routine surveillance (12.3% vs. 3.1%, respectively; P=.002). Multivariate analysis showed that diabetes mellitus with a preoperative glucose level >/=200 mg/dL (odds ratio [OR], 4.4; P=. 01) and duration of surgery >/=5 h (OR, 3.1; P=.02) were independent risk factors for radial artery HSI. Infection is a common complication of radial artery harvesting for CABG surgery, and infection rates are dependent on the intensity of surveillance. We identified preoperative hyperglycemia and surgery duration as independent risk factors for radial artery HSI.

What parts of PTSD are normal: intrusion, avoidance, or arousal? Data from the Northridge, California, earthquake

The incidence and comorbidity of posttraumatic stress disorder (PTSD) are addressed in a study of 130 Northridge, California, earthquake survivors interviewed 3 months post-disaster. Only 13% of the sample met full PTSD criteria, but 48% met both the re-experiencing and the arousal symptom criteria, without meeting the avoidance and numbing symptom criterion. Psychiatric comorbidity was associated mostly with avoidance and numbing symptoms. For moderately severe traumatic events, re-experiencing and arousal symptoms may be the most "normal," and survivors with a history of psychiatric problems may be those most likely to develop full PTSD. A system that considers people who meet all three symptom criteria to have a psychiatric disorder yet recognizes the distress of other symptomatic survivors may best serve traumatized populations.

Modifiable risk factors associated with deep sternal site infection after coronary artery bypass grafting

OBJECTIVE

Our objective was to identify risk factors for deep sternal site infection after coronary artery bypass grafting at a community hospital.

METHODS

We compared the prevalence of deep sternal site infection among patients having coronary artery bypass grafting during the study (January 1995-March 1998) and pre-study (January 1992-December 1994) periods. We compared any patient having a deep sternal site infection after coronary artery bypass graft surgery during the study period (case-patients) with randomly selected patients who had coronary artery bypass graft surgery but no deep sternal site infection during the same period (control-patients).

RESULTS

Deep sternal site infections were significantly more common during the study than during the pre-study period (30/1796 [1.7%] vs 9/1232 [0.7%]; P =.04). Among 30 case-patients, 29 (97%) returned to the operating room for sternal debridement or rewiring, and 2 (7%) died. In multivariable analyses, cefuroxime receipt 2 hours or more before incision (odds ratio = 5.0), diabetes mellitus with a preoperative blood glucose level of 200 mg/dL or more (odds ratio = 10.2), and staple use for skin closure (odds ratio = 4.0) were independent risk factors for deep sternal site infection. Staple use was a risk factor only for patients with a normal body mass index.

CONCLUSIONS

Appropriate timing of antimicrobial prophylaxis, control of preoperative blood glucose levels, and avoidance of staple use in patients with a normal body mass index should prevent deep sternal site infection after coronary artery bypass graft operations.

IL-10 as a mediator in the HPA axis and brain

Certain functional interactions between the nervous, endocrine, and immune systems are mediated by cytokines. The pro-inflammatory cytokines, interleukin-1 (IL-1) and tumor necrosis factor (TNF) were among the first to be recognized in this regard. A modulator of these cytokines, IL-10, has been shown to have a wide range of activities in the immune system; in this review, we describe its production and actions in the hypothalamic-pituitary-adrenal (HPA) axis. IL-10 is produced in pituitary, hypothalamic, and neural tissues in addition to lymphocytes. IL-10 enhances corticotropin releasing factor (CRF) and corticotropin (ACTH) production in hypothalamic and pituitary tissues, respectively. Further downstream in the HPA axis endogenous IL-10 has the potential to contribute to regulation of glucocorticosteroid production both tonically and following stressors. Our studies and those of others reviewed here indicate that IL-10 may be an important endogenous regulator in HPA axis activity and in CNS pathologies such as multiple sclerosis. Thus, in addition to its more widely recognized role in immunity, IL-10's neuroendocrine activities described here point to its role as an important regulator in communication between the immune and neuroendocrine systems.