Pulmonary artery angiomatoid fibrous histiocytoma mimicking pulmonary embolism

A young man presented to the emergency department with pleuritic chest pain and shortness of breath. Of note, he recently went on a long-distance flight of about 9 hours. Given his recent long-distance travel and clinical symptoms, a pulmonary embolism was suspected. However, pathological examination of the excised pulmonary artery intraluminal mass demonstrated an angiomatoid fibrous histiocytoma. This case describes the clinicopathological and immunohistochemical features and molecular profile of a rare type of pulmonary artery tumour, a pulmonary artery angiomatoid fibrous histiocytoma.

Barriers and facilitators to lung cancer screening and follow-up

Two randomized trials have shown that lung cancer screening (LCS) with low dose computed tomography (LDCT) reduces lung cancer mortality in patients at high-risk for lung malignancy by identifying early-stage cancers, when local cure and control is achievable. The implementation of LCS in the United States has revealed multiple barriers to preventive cancer care. Rates of LCS are disappointingly low with estimates between 5%-18% of eligible patients screened. Equally concerning, follow-up after baseline screening is far lower than that of clinical trials (44-66% v >90%). To optimize the benefits of LCS, programs must identify and address factors related to LCS participation and follow-up while concurrently recognizing and mitigating barriers. As a relatively new screening test, the most effective processes for LCS are uncertain. Therefore, LCS programs have adopted a wide range of approaches without clearly established best practices to guide them, particularly in rural and resource-limited settings. In this narrative review, we identify barriers and facilitators to LCS, focusing on those studies in non-clinical trial settings - reflecting "real world" challenges. Our goal is to identify effective and scalable LCS practices that will increase LCS participation, improve adherence to follow-up, inform strategies for quality improvement, and support new research approaches.

AB0413 HIGH-RESOLUTION COMPUTED TOMOGRAPHY FOR THE SCREENING, RE-SCREENING AND FOLLOW-UP OF SYSTEMIC SCLEROSIS RELATED INTERSTITIAL LUNG DISEASE: RESULTS OF A EUSTAR-SCTC SURVEY

Background:

High-resolution computed tomography (HRCT) is the gold standard diagnostic test for Interstitial lung disease (ILD), a significant cause of morbidity and mortality in systemic sclerosis (SSc). Different algorithms have been proposed for the screening of SSc-ILD, including the use of pulmonary function tests (Forced Vital Capacity - FVC, Lung Diffusion of Carbone Monoxyde - DLCO). A prior survey reported that 50-66% of general rheumatologists and SSc experts ordered HRCT for ILD screening in newly diagnosed SSc patients (1).

Objectives:

Given the recent availability of on-label treatment for SSc-ILD (2), the publication of consensus recommendations for the identification of SSc-ILD (3) and recent awareness programs for the use of HRCT to detect SSc-ILD, we aimed to re-evaluate the use of HRCT for screening, re-screening and follow-up of SSc-ILD.

Methods:

An invitation was sent to the European Scleroderma Trials and Research (EUSTAR) and Scleroderma Clinical Trials Consortium (SCTC) members, also advertised through social media. Answers were recorded between Nov 25th and Dec 31st 2020. Questions were asked on the use of chest HRCT at baseline, the re-screening of patients with a negative baseline HRCT and the follow-up of HRCT positive SSc-ILD patients. When HRCT was not routinely requested, additional details were collected about the parameters guiding its use. The results of the survey were tested for association with geographical origin, medical specialty, working environment, SSc referral institute and scientific group membership of the responders, using Chi-squared test.

Results:

205/630 (32.5%) physicians replied to the survey. Participants were widely distributed in terms of geographical origin (130 Europe, 23 Asia, 23 North America, 31 other continents), medical specialty (156 rheumatology, 21 internal medicine, 14 clinical immunology, 14 other), working environment (176 University Hospital, 12 community hospital, 17 other), SSc dedicated clinic (179 referral and 26 non-referral) and scientific group membership (98 EUSTAR, 42 SCTC, 42 EUSTAR and SCTC, 23 not declared).

At SSc diagnosis, 95.7% of responders would perform HRCT: 66.7% as routine screening for ILD (67,4% of SSc referral and 62% for non-referral physicians) and 29% for diagnostic purposes (among the latter, if crackles on auscultation – 92.5%, FVC<80% predicted - 86.6%, FVC±DLCO relative decline reaching the current definition of ILD progression, 86.6% or dyspnea at rest/exercise - 85.1/83.3%).

During follow-up, 78.8% of responders would repeat an HRCT in baseline negative cases: 20.3% as a yearly routine screening and 64.5% for diagnostic aims (decision on the latter group was more frequently driven by FVC±DLCO relative decline indicative of ILD progression– 90.6%, new onset or worsening of dyspnoea at rest/exercise – 80.5/86.6%, new onset or worsening of lung crackles on auscultation – 82.6%).

Finally, 94.5% of responders would repeat a chest HRCT after SSc-ILD diagnosis: 36.8% as a yearly routine and 56.7% according to clinical evaluation (driven by new FVC±DLCO relative decline based ILD progression – 90.8%, new onset or worsening of dyspnoea at rest/exercise – 83.2/81.7%; 5.2% to evaluate treatment effects). We found no difference in the distribution of answers among groups.

Conclusion:

The use of baseline HRCT for the screening of SSc-ILD has slightly increased in non-referral and remained stable in referral centers compared to previous surveys, indicating that the implementation of guidelines might be successful and awareness programs should be continued. In addition, we provide new data on use of HRCT in re-screening and follow-up. The development of validated algorithms to further support the appropriate application of HRCT at follow-up is highly needed.

References:

[1]Bernstein EJ et al. Arthritis Rheumatol. 2018 Jun;70(6):971-972.

[2]Distler O et al. N Engl J Med. 2019 Jun 27;380(26):2518-2528.

[3]Hoffmann-Vold AM et al. The Lancet Rheumatology, Volume 2, Issue 2, e71 - e83.

Disclosure of Interests:

Cosimo Bruni Speakers bureau: Actelion, Consultant of: Eli Lilly, Grant/research support from: Foundation for Research in Rheumatology (FOREUM), Gruppo Italiano Lotta alla Sclerodermia (GILS), Fondazione Italiana per la Ricerca sull’Artrite (FIRA), New Horizon Fellowship, European Sclerodermia Trial and Reserach (EUSTAR) Group., Lorinda Chung Consultant of: Boehringer Ingelheim, Eicos, Mitsubishi Tanabe, Reata., Anna-Maria Hoffmann-Vold Consultant of: Actelion, ARXX therapeutics, Bayer, Boehringer-Ingelheim, Medscape, MSD, Lilly, Roche, Shervin Assassi Speakers bureau: Integrity Continuing Education, Consultant of: Boehringer Ingelheim, Novartis, and Corbus, Armando Gabrielli: None declared, Dinesh Khanna Consultant of: Acceleron, Actelion, Abbvie, Amgen, Bayer, Boehringer Ingelheim, CSL Behring, Corbus, Gilead, Galapagos, Genentech/Roche, GSK, Horizon, Merck, Mitsubishi Tanabe Pharma, Sanofi-Aventis, and United Therapeutics Leadership, Grant/research support from: NIH, Immune Tolerance Network, Bayer, BMS, Horizon, Pfizer, Employee of: Equity position – Chief Medical Officer, Eicos Sciences, Inc., Elana Bernstein Consultant of: Boehringer Ingelheim, Oliver Distler Consultant of: Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Bayer, Boehringer Ingelheim, ChemomAb, Corbus Pharmaceuticals, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Italfarmaco, iQone, Kymera Therapeutics, Lilly, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB., Grant/research support from: Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Bayer, Boehringer Ingelheim, ChemomAb, Corbus Pharmaceuticals, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Italfarmaco, iQone, Kymera Therapeutics, Lilly, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143).

A Nationwide Survey of Educational Resource Utilization and Perception Among Internal Medicine Residents

BACKGROUND

New virtual resources ("novel resources") have been incorporated into medical education. No recent large studies about their use and perception among internal medicine (IM) residents exist.

OBJECTIVE

Characterize the use and perceived helpfulness of educational resources.

DESIGN

Nationwide survey from December 2019 to March 2020.

PARTICIPANTS

IM residents in the USA.

MAIN MEASURES

Residents were surveyed on their use and their perceived helpfulness of resources for both attaining general medical knowledge and for point-of-care (POC) learning. Traditional resources included board review resources, clinical experience, digital clinical resources (e.g., UpToDate), journal articles, pocket references, professional guidelines, textbooks, and residency curricula. Novel resources included Twitter, video streaming platforms (e.g., YouTube), online blogs, podcasts, and Wikipedia.

KEY RESULTS

We had 662 respondents from 55 residency programs across 26 states. On average, residents used 9 total resources (7 traditional and 2 novel). Digital clinical resources and clinical experience were used by all residents and found helpful by the highest percentage of residents (96% and 94%, respectively). Journal articles were next (used by 90%), followed by board review resources and residency curricula (both used by 85%). Their perceived helpfulness varied, from 90% for board review resources, to 66% for journal articles and 64% for residency curricula, the lowest perceived helpfulness of any traditional resource. Podcasts and video streaming platforms were used as frequently as textbooks (58-59%), but were rated as helpful more frequently (75% and 82% vs 66%, respectively).

CONCLUSIONS

Digital clinical resources, video streaming platforms, and podcasts were perceived as helpful, underscoring the importance of ensuring their integration into medical education to complement clinical experience and other traditional resources which remain highly valued by residents.

IMPORTANCE

Our findings can inform residency programs as they transition to virtual curricula in the wake of the COVID-19 pandemic.

Multifactorial Wrist Pain Treated with Tenotomy of Anomalous Flexor Carpi Radialis Brevis: A Case Report

CASE

We present a case of a 33-year-old left hand-dominant/right hand-involved active duty Navy sailor woman with volar radial wrist pain. She underwent scaphoid cyst excision and bone grafting as well as tenotomy. Intraoperatively, she was noted to have a flexor carpi radialis brevis (FCRB) tendon that was transected. After surgery, her 1-year outcomes demonstrated range of motion improved equivalent with her contralateral side, her visual analogue scale (VAS) pain score had decreased to 1, and her QuickDASH and Patient-Rated Wrist Evaluation improved.

CONCLUSIONS

Our case represents 1-year outcome after surgical release of a FCRB. Our patient's pain and functional scores exceeded the minimal clinically important difference.

Incorporation of Whipstitch Suture in Tibial Interference Fixation Improves Pullout in Anterior Cruciate Ligament Soft Tissue Grafts

INTRODUCTION

Interference screw fixation of soft tissue grafts is commonly used in anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to determine whether including suture material at the graft-screw interface affects ultimate fixation strength of soft tissue grafts using a tibialis anterior tendon allograft model.

MATERIALS AND METHODS

Forty fresh-frozen human tibialis anterior tendon allografts were fixed to rigid polyurethane foam simulating the tibial tunnel. Twenty grafts underwent fixation with interference screws and 20 with interference bolts. Within each group, 10 grafts had suture in contact with either the screw or bolt. A load-to-failure test was then performed at a rate of 200 mm/min.

RESULTS

The group of allografts with sutures in the tibial tunnel had significantly higher load to failure than the group without sutures. Using interference screw fixation, failure load of the grafts without sutures in the tunnel (535.2 ± 73.40 N) was significantly lower (P = .001) than with sutures in the tunnel (696.3 ± 110.0 N). Using interference bolt fixation, failure load of the grafts without sutures in the tunnel (613.0 ± 83.46 N) was significantly lower (P <.0001) than with sutures in the tunnel (845.8 ± 87.23 N).

CONCLUSIONS

In a biomechanical model, suture within the tibial tunnel enhances fixation strength with both interference screw and bolt fixation for soft tissue tibialis anterior allografts. Additionally, there was no difference in load to failure when comparing failure of a screw with suture in the tunnel with an interference bolt without suture. Due to improved biomechanical properties, incorporation of suture in the bone-graft interface should be considered when performing soft tissue ACL allograft reconstructions. Failure at the tibial bone-graft interface is a known complication of ACL reconstruction, and incorporation of suture within the interface should be considered for improved biomechanical properties.

Improved Functional Outcomes Following Operative Treatment of Midshaft Clavicle Fractures in an Active Duty Population

Clavicle fractures are common orthopedic injuries that occur in a young active population and are even more common in the military. Military fitness test data presents the unique opportunity to analyze functional ability with regard to military-specific activities. The primary goal of this study was to compare functional outcomes using military fitness test data between operative and non-operative treatment of midshaft clavicle fractures.  We performed a retrospective review of active-duty U.S. Navy and Marine patients with midshaft clavicle fractures treated at our institution over a seven-year period. There were 94 and 153 patients in our operative and non-operative cohorts, respectively. Average follow-up time from the date of injury or surgery was 28 months. The rate of infection in the operative group (4%) was significantly greater than in the non-operative group (0%, p = 0.023). The rate of non-union in the operative group (3%) was significantly lower than in the non-operative group (14.5%, p = 0.004). The rate of symptomatic malunion in the operative group (0%) was significantly different from that in the non-operative group (4.6%, p = 0.036). There was no significant difference in the rate of revision surgery between the operative (9.2%) and non-operative (13.2%) groups (p = 0.105). A total of 51 marines met inclusion criteria for our functional outcome analysis using Marine Corps Physical Fitness Test (PFT) data. Of those who underwent operative fixation, 68% were able to meet or surpass their pre-injury average amount of pull-ups in their first PFT after surgery and 88% by the next PFT at least one year after surgery. While 69% of non-operative patients met their pre-injury average in their first PFT, only 57% maintained this level at least one year after surgery. This difference was statistically significant. In our functional outcome subgroup analysis, we found improved outcomes for pull-ups at least one year out when midshaft clavicle fractures are treated operatively compared to non-operatively. While similar findings in the literature are based on functional outcome questionnaires, physical fitness performance data has not been reported on to our knowledge.

Client and provider factors associated with integration of family planning services among maternal and reproductive health clients in Kigoma Region, Tanzania: a cross-sectional study, April-July 2016

BACKGROUND

Integration of family planning (FP) services into non-FP care visits is an essential strategy for reducing maternal and neonatal mortality through reduction of short birth intervals and unplanned pregnancies.

METHODS

Cross-sectional surveys were conducted across 61 facilities in Kigoma Region, Tanzania, April-July 2016. Multilevel, mixed effects logistic regression analyses were conducted on matched data from providers (n = 330) and clients seeking delivery (n = 935), well-baby (n = 272), pregnancy loss (PL; n = 229), and other routine (postnatal, HIV/STI, other; n = 69) services. Outcomes of interest included receipt of FP information and a modern FP method (significance level p < 0.05).

RESULTS

Clients had significantly greater odds of receiving FP information if the primary reason for seeking care was for PL versus (vs) any other types of care (aOR 1.97), had four or more pregnancies vs fewer (aOR 1.78), and had had a FP discussion with their partner vs no FP discussion (aOR 1.73). Clients had lower odds of receiving FP information if they were aged 40-49 vs 15-19 (aOR 0.50) and reported attending religious services at least weekly vs less frequently (aOR 0.61). Clients of providers who perceived that in-service training had helped vs had not helped job performance (aOR 2.27), and clients of providers having high vs low recent FP training index scores (aOR 1.58) had greater odds of receiving FP information. Clients had greater odds of receiving a modern method when they received information on two or more vs fewer methods (aOR 7.13), had had a FP discussion with their partner vs no discussion (aOR 5.87), if the primary reason for seeking care was for PL vs any other types of care (aOR 4.08), had zero vs one or more live births (aOR 3.92), made their own FP decisions vs not made own FP decisions (aOR 3.17), received FP information from two or more vs fewer sources (aOR 3.12), and were in the middle or high vs the low wealth tercile (aOR 1.99 and 2.30, respectively). Well-baby care clients, Other routine services clients, and married clients had significantly lower odds of receiving a method (aOR 0.14; aOR 0.08; and aOR 0.41, respectively) compared to their counterparts.

CONCLUSIONS

Strategies that better integrate FP into routine care visits, encourage women to have FP discussions with their partners and providers, increase FP training among providers, and expand FP options and sources of information may help reduce the unmet need for FP, and ultimately lower maternal and neonatal mortality.

Hip Arthroscopy for Femoroacetabular Impingement in a Military Population

BACKGROUND

Femoroacetabular impingement (FAI) can lead to hip pain and early joint degeneration. There have been few reports to date on the outcomes of hip arthroscopy for the treatment of FAI in the military population. Purpose/Hypothesis: The purpose of this study was to compare patient demographics with postoperative outcomes after hip arthroscopy for symptomatic FAI and to identify preoperative risk factors for poor outcomes. The hypothesis was that certain preoperative patient characteristics will be predictive of poorer outcomes and that lower outcomes scores will be associated with a higher likelihood of medical separation from the military.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Retrospective chart review of active-duty and dependent patients older than 18 years who underwent hip arthroscopy for symptomatic FAI from 2009 to 2014 at a single institution.

RESULTS

A total of 469 (309 males and 160 females) surgeries were performed on 456 active-duty personnel and 13 dependent civilians, with a mean 2.5-year follow-up. Overall, 39% (n = 179) were able to return to duty (RTD), 18% (n = 82) were medically cleared to return to normal daily activities but did not remain on active duty, and 43% (n = 195) required referral to the Disability Evaluation System (DES). Increasing rank and male sex were positive predictors and Axis 1 psychiatric diagnosis, revision surgery, concomitant psoas tenotomy, multiple medical comorbidities, and complaints of generalized pelvic pain were negative predictors for returning to duty. US Marine Infantry and Special Forces showed improved RTD rates (50%-86%) compared with administrative, more sedentary, occupations (22%). On average, Single Alpha Numeric Evaluation (SANE) and visual analog scale (VAS) scores improved after surgery, with SANE scores improving 37 ± 28 points and VAS scores improving 2.6 ± 2.5 points. The mean postoperative SANE and VAS scores differed significantly between the RTD group and those not returning to duty; 87 and 1.2 points compared with 69 and 3.6 points, respectively ( P < .0001).

CONCLUSION

Hip arthroscopy for the treatment of symptomatic FAI effectively improves pain symptoms and self-reported overall function but shows a much lower than expected return to full, unrestricted active duty in the general active-duty military population. Underlying psychiatric diagnoses, female sex, and more sedentary occupations are associated with lower RTD rates. Furthermore, lower postoperative SANE and VAS scores are associated with lower RTD rates. Only the more active and elite components of the military study population showed RTD rates consistent with previously reported outcomes of return to competitive sports after hip arthroscopy for FAI.

Blood Culture in Evaluation of Pediatric Community-Acquired Pneumonia: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

Current guidelines strongly recommend collection of blood cultures (BCs) in children requiring hospitalization for presumed moderate to severe bacterial community-acquired pneumonia (CAP). Our objective was to systematically review the international pediatric literature to evaluate how often BCs are positive in hospitalized children with CAP, identify the most commonly isolated pathogens, and determine the impact of positive BCs on clinical management.

METHODS

We identified articles in PubMed and Scopus published from January 1970 through December 2013 that addressed BCs in children with CAP. We extracted total number of BCs collected and prevalence of positive BCs and used meta-regression to evaluate whether subgroups had any impact on prevalence.

RESULTS

Meta-analysis showed that the overall prevalence of positive BCs was 5.14% (95% confidence interval 3.61-7.28). Studies focusing on severe CAP had a significant effect on prevalence (P=.008), at 9.89% (95% CI 6.79-14.19) compared with 4.17% (95% confidence interval 2.79-6.18) for studies not focusing on severe CAP. The most commonly isolated organisms were Streptococcus pneumoniae (76.7%) followed by Haemophilus influenzae (3.1%) and Staphylococcus aureus (2.1%). Contaminants accounted for 14.7%. Only 3 studies reported on BC-driven change in management, with contrasting findings.

CONCLUSIONS

BCs in pediatric CAP identified organisms in only a small percentage of patients, predominantly S. pneumoniae. False-positive BC rates can be substantial. The 3 studies that examined BC-driven changes in management had conflicting results. This systematic review was limited by heterogeneous case definitions, which may overestimate the true prevalence of positive BCs in hospitalized children.

Microblog use and student engagement in the large-classroom setting

BACKGROUND AND OBJECTIVES

Encouraging student engagement in the large-classroom setting can be difficult. Challenges include the depersonalized nature of the environment and the fact that students frequently find asking questions and participating in class discussion intimidating. Social media has the potential to address these barriers, but this has not yet been formally evaluated. Our study analyzed the impact of microblog use on students' question-asking behaviors (an indicator of student engagement) in a large-classroom setting.

METHODS

Formative evaluation of a large-classroom medical humanities course identified microblog use as a potential tool to facilitate greater student engagement. A microblog was thereafter incorporated into the course. Student engagement was operationalized as question-asking behaviors before and after microblog incorporation.

RESULTS

Paired t tests showed that the total number of questions asked was significantly greater in the microblog-available classes, t (2)=12.12. In addition, significantly more individual students asked questions in the microblog-available classes, t (2)=17.39.

CONCLUSIONS

Our study, demonstrating an increase in question-asking behavior after incorporation of a microblog, has important implications for educators who seek to enhance student engagement and learning in the large-classroom setting. In addition, innovative use of emerging technologies (such as microblogs) as educational tools requires continuous assessment and iterative change to maximize benefit. More research is needed to evaluate what specific barriers to engagement are overcome by microblog use and whether microblog use can similarly benefit other courses.

The transparency trap

To promote accountability, productivity, and shared learning, many organizations create open work environments and gather reams of data on how individuals spend their time. A few years ago, HBS professor Ethan Bernstein set out to find empirical evidence that such approaches improve organizational performance. What he discovered is that this kind of transparency often has an unintended consequence: It can leave employees feeling vulnerable and exposed. When that happens, they conceal any conduct that deviates from the norm so that they won't have to explain it. Unrehearsed, experimental behaviors sometimes stop altogether. But Bernstein also discovered organizations that had established zones of privacy within open environments by setting four types of boundaries: around teams, between feedback and evaluation, between decision rights and improvement rights, and around periods of experimentation. Moreover, across several studies, the companies that had done all this were the ones that consistently got the most creative, efficient, and thoughtful work from their employees. Bernstein's conclusion? By balancing transparency and privacy, organizations can capture the benefits of both, and encourage just the right amount of "positive deviance" needed to increase innovation and productivity.

Structural transition in rare earth oxide clusters

Size effects, such as structure transition, have been reported in small clusters of alkali halide compounds. We extend the study to rare earth sesquioxide (Gd(2)O(3)) clusters which are as ionic as the alkali halide compounds, but have a more complicated structure. In a clean and controlled environment (ultra high vacuum), such particles are well crystallized, facetted and tend to adopt a rhombic dodecahedron shape. This indicates the major role of highly ionic bonds in preserving the crystal lattice even at small sizes (a few lattice parameter). Based on both cathodo-luminescence and transmission electron microscopy, we report the existence of a structural transition from bcc to monoclinic at small sizes.

Synthesis and properties of europium-based phosphors on the nanometer scale: Eu2O3, Gd2O3:Eu, and Y2O3:Eu

Nanocrystals of oxides containing europium as the main constituent or as a doping element in RE2O3 ( RE=Y, Gd) have been prepared by direct oxide precipitation in high-boiling polyalcohol solutions and characterized by high-resolution TEM, absorption spectroscopy, and luminescence spectroscopy. The samples obtained consisted of concentrated and colloidally stable suspensions of luminescent oxide nanoparticles with an average grain diameter in the range 2-5 nm. The nanoparticles were found to be highly crystalline despite their ultrasmall size and the low temperature of 180 degrees C applied during the synthesis. Upon UV excitation, the red luminescence relative to the 5D0-->7Fn transition within the cubic form of RE2O3 exhibits some important differences from that usually found in bulk materials.

Synthesis and biological characterization of .alpha.-(4-fluorophenyl)-4-(5-fluoro-2-pyrimidinyl)-1-piperazinebutanol and analogs as potential atypical antipsychotic agents

A series of 1-(pyrimidin-2-yl)piperazine derivatives were prepared and evaluated in receptor binding assays and in in vivo behavioral paradigms as potential atypical antipsychotic agents. Compound 16 (BMS 181100 (formerly BMY 14802)) emerged as the lead compound from within the series on the basis of its good activity and duration of action in the inhibition of both conditioned avoidance responding and apomorphine-induced stereotopy in the rat. Compound 16 not only failed to induce catalepsy in the rat but was quite effective in reversing the cataleptic effect of neuroleptic agents, thus indicating a low propensity for causing extrapyramidal side effects. In comparison to reference antipsychotic agents, 16 appeared to be less sedating and was relatively weaker in causing muscle incoordination. The compound was essentially inactive in binding to dopamine D2 receptors and its chronic administration to rats did not result in dopamine receptor supersensitivity. It exhibited modest to weak affinity for 5-HT1A and alpha 1 receptors but was found to be a fairly potent ligand for sigma binding sites (IC50 vs (+)-[3H]-3-PPP = 112 nM). Although the resolved enantiomers of racemic 16 did not show dramatic differences from racemate or from each other in most tests, the R(+) enantiomer was up to 11-fold more potent than its antipode in binding to sigma sites. Several studies have indicated that 16 may be a limbic-selective agent which may modulate dopaminergic activity by an indirect mechanism. The compound has been selected for clinical evaluation in the treatment of psychosis.

The rest is silence

Over the past several years, RNAi and its related phenomena have emerged not only as a powerful experimental tool but also as a new mode of gene regulation. Through a combination of genetic and biochemical approaches we have learned much about the mechanisms underlying dsRNA responses. However, many of the most intriguing aspects of dsRNA-induced gene silencing have yet to be illuminated. What has become abundantly clear is that the complex and highly conserved biology underlying RNA interference is critical both for genome maintenance and for the development of complex organisms. However, it seems probable that we have only begun to reveal the diversity of biological roles played by RNAi-related processes.

Dicer functions in RNA interference and in synthesis of small RNA involved in developmental timing in C. elegans

Double-stranded RNAs can suppress expression of homologous genes through an evolutionarily conserved process named RNA interference (RNAi) or post-transcriptional gene silencing (PTGS). One mechanism underlying silencing is degradation of target mRNAs by an RNP complex, which contains approximately 22 nt of siRNAs as guides to substrate selection. A bidentate nuclease called Dicer has been implicated as the protein responsible for siRNA production. Here we characterize the Caenorhabditis elegans ortholog of Dicer (K12H4.8; dcr-1) in vivo and in vitro. dcr-1 mutants show a defect in RNAi. Furthermore, a combination of phenotypic abnormalities and RNA analysis suggests a role for dcr-1 in a regulatory pathway comprised of small temporal RNA (let-7) and its target (e.g., lin-41).

Role for a bidentate ribonuclease in the initiation step of RNA interference

RNA interference (RNAi) is the mechanism through which double-stranded RNAs silence cognate genes. In plants, this can occur at both the transcriptional and the post-transcriptional levels; however, in animals, only post-transcriptional RNAi has been reported to date. In both plants and animals, RNAi is characterized by the presence of RNAs of about 22 nucleotides in length that are homologous to the gene that is being suppressed. These 22-nucleotide sequences serve as guide sequences that instruct a multicomponent nuclease, RISC, to destroy specific messenger RNAs. Here we identify an enzyme, Dicer, which can produce putative guide RNAs. Dicer is a member of the RNase III family of nucleases that specifically cleave double-stranded RNAs, and is evolutionarily conserved in worms, flies, plants, fungi and mammals. The enzyme has a distinctive structure, which includes a helicase domain and dual RNase III motifs. Dicer also contains a region of homology to the RDE1/QDE2/ARGONAUTE family that has been genetically linked to RNAi.

Keeping mammography referral appointments: motivation, health beliefs, and access barriers experienced by older minority women

Older women of color tend to have much lower rates of regular mammography screening for breast cancer than younger Caucasian women; yet, they have higher rates of mortality. This study was designed to increase mammography rates among inner-city women aged 50 years or older. Another goal was to investigate differences in mammography utilization related to race/ethnicity and language after barriers associated with cost and the difficulty of making an appointment are removed. A peer delivered intervention, which consisted of interview, mammography referral, and the scheduling of a next-day appointment, was conducted among a convenience sample of 151 culturally and racially diverse older women through a primary care referral project operating within an urban emergency department (ED). A brief motivational interview and mammography referral at the time of an ED visit, including scheduling of a next-day no cost appointment, was followed by a cross-sectional telephone survey of utilization and motivating and hindering factors. Follow-up was achieved with 96 women (66%). Fifty-eight women (60%) had a post-intervention mammogram; of those, 69% were first time users. More than 90% planned a repeat mammogram the following year. Of the 27 who did not receive a mammogram, 21 (77%) requested a "second try" appointment. These findings demonstrate that an interactive intervention among older women of color has the potential to dramatically increase mammography rates.

An RNA-directed nuclease mediates post-transcriptional gene silencing in Drosophila cells

In a diverse group of organisms that includes Caenorhabditis elegans, Drosophila, planaria, hydra, trypanosomes, fungi and plants, the introduction of double-stranded RNAs inhibits gene expression in a sequence-specific manner. These responses, called RNA interference or post-transcriptional gene silencing, may provide anti-viral defence, modulate transposition or regulate gene expression. We have taken a biochemical approach towards elucidating the mechanisms underlying this genetic phenomenon. Here we show that 'loss-of-function' phenotypes can be created in cultured Drosophila cells by transfection with specific double-stranded RNAs. This coincides with a marked reduction in the level of cognate cellular messenger RNAs. Extracts of transfected cells contain a nuclease activity that specifically degrades exogenous transcripts homologous to transfected double-stranded RNA. This enzyme contains an essential RNA component. After partial purification, the sequence-specific nuclease co-fractionates with a discrete, approximately 25-nucleotide RNA species which may confer specificity to the enzyme through homology to the substrate mRNAs.

Pulsed dye laser therapy for sun damaged skin

OBJECTIVE

The objective of this study was to evaluate the effectiveness of the pulsed dye laser (585 nm, 450 ms) in the treatment of sun induced wrinkles.

DESIGN

Patients had one pulsed dye laser (585 nm) treatment. The treated areas were assessed by the following methods: grading of skin wrinkles at 6 weeks, 12 weeks, and 6-14 months after treatment by blinded observers and by light and electron microscopy.

SETTING

An ambulatory care center at Abbott Northwestern Hospital (ANH) and the Laser & Skin Surgery Center of Northern California (LSSCNC).

PATIENTS

Twenty patients were treated, half with mild to moderate and half with moderate to severe sun induced skin wrinkles.

RESULTS

At last follow up 90% (9/10) of the mild to moderate wrinkles and 40% (4/10) of the treated patients with moderate to severe wrinkles had clinically observable improvement in their sun induced skin wrinkles. Histologic examinations of the treated areas showed a superficial dermal band of well organized elastin and collagen fibers replacing pre-treatment elastic tissue. Increased cellularity and mucin deposition was consistent with dermal collagen remodeling.

Sabbatical programs and the status of academic emergency medicine: a survey

OBJECTIVES

The Society for Academic Emergency Medicine (SAEM) commissioned a survey in 1998 to describe sabbatical programs, academic rank, and tenure, and to shed light on factors affecting the continuum of faculty development, as a context for evaluating the potential importance of emergency medicine (EM) sabbatical programs.

METHODS

The chairs of 120 EM residency programs were surveyed.

RESULTS

The response rate was 90%. Of 108 responses, 44 were academic EM departments (AEMDs); ten were their affiliates. The setting was urban for 82%; 37% were publicly funded and 58% privately. AEMDs were more likely to have a tenure track and eligibility for a sabbatical program, but not more likely to use a sabbatical program. Among 2,042 ranked EM faculty, there were 121 professors and 346 associate professors. Mean sabbatical length was six months, provided at full pay requiring a mean of 5.7 years of employment. Among 39 programs reporting eligibility for an EM sabbatical, requirements included: tenure (43%), academic rank of associate professor (78%), an application with multiple approval levels (92%), and a formal report (75%). Thirteen EM programs used sabbaticals; only 40 faculty members altogether (9% of senior faculty) have taken sabbaticals. The mean value of sabbaticals (rated by users on a scale of 1 to 10) was 6.8. Reduced funding, lack of departmental status, difficulty retaining faculty, Health Care Financing Administration (HCFA) regulations, graduate medical education (GME) cutbacks, and no release time were identified as challenges for emergency physicians (EPs) wishing to participate in sabbaticals. Strategies proposed to overcome these obstacles include quality customer service, streamlined operations, outside contracts, computerization, hiring individuals with PhDs, collaboration, political activity, and faculty development.

CONCLUSIONS

A sabbatical can be beneficial for individuals and their institutions, but presently EPs have not been able to maximize use of available opportunities. Some obstacles to successful participation of EM in sabbatical programs might be overcome with creative strategies and the active support of professional academic organizations.

Immune response to influenza vaccination in a large healthy elderly population

Elderly individuals not only demonstrate a greater risk of morbidity and mortality from influenza than the young, but also have greater difficulty mounting a protective response to influenza vaccine. The mechanism of the decreased efficacy of influenza vaccination in the elderly is not well understood. The present study was designed to assess the interaction between cell-mediated and humoral immune responses to influenza vaccine in a large population (n = 233) of healthy elderly individuals (mean age = 80.7) living in six continuing care retirement communities (CCRCs). While influenza vaccination resulted in significant increases in the mean anti-influenza antibody titres and mean proliferative responses of peripheral blood mononuclear cells to purified subvirion trivalent influenza vaccine one month after vaccination, only 48.9% and 30.0% of subjects had intact humoral and cell-mediated immune responses, respectively. No association was observed between intact cell-mediated and humoral responses: 14.7% of subjects had an intact cell-mediated, but not humoral response, and 32.6% of subjects had an intact humoral, but not cell-mediated response. However, IFNgamma production was significantly correlated with both antibody and cell-mediated responses to influenza vaccination, a finding not previously reported in the elderly. These results indicate that there is considerable heterogeneity among immune responses of the elderly to influenza vaccination. This heterogeneity needs to be a major consideration in evaluation of new vaccine preparations.

Patients with alcohol problems in the emergency department, part 1: improving detection. SAEM Substance Abuse Task Force. Society for Academic Emergency Medicine

Medical and social problems related to alcohol use are frequently seen in the ED. Often, the tempo of emergency medicine practice seems to preclude assessment beyond that required by the acute complaint. However, detection of ED patients with alcohol problems can occur using brief screening tools. This article was developed by members of the SAEM Substance Abuse Task Force, and describes screening tools that have been used successfully to identify at-risk and dependent drinkers. Their brevity, reproducibility, and accuracy vary somewhat, but screening can be realistically performed in the busy ED setting. The early detection of patients with alcohol problems would provide the opportunity for early intervention, and may reduce subsequent morbidity and mortality in this patient population.

Patients with alcohol problems in the emergency department, part 2: intervention and referral. SAEM Substance Abuse Task Force. Society for Academic Emergency Medicine

Early intervention and appropriate referral of patients with alcohol problems have the potential to reduce alcohol-related morbidity and mortality. Part 1 of this series introduced screening tools that can be applied in the ED to allow early detection of at-risk drinkers. This article was developed by members of the SAEM Substance Abuse Task Force and describes assessment and intervention techniques once the at-risk or dependent drinkers has been identified. Appropriate aftercare and referral of patients found to have alcohol problems are also discussed.

Behavioral risk factors in emergency department patients: a multisite survey

BACKGROUND

Many people rely on EDs for routine health care. Often, however, screening and counseling for health risks are not provided.

OBJECTIVE

To determine prevalence rates of chronic disease and injury risk factors and access to routine health care in a random sample of ED patients in 3 cities.

METHODS

A prospective survey was conducted at 3 hospital EDs in Akron, OH, Boston, MA, and Denver, CO. A modified version of the national Behavioral Risk Factor Surveillance Survey was administered by trained researchers to a convenience sample of non-critically ill patients during randomly selected shifts.

RESULTS

Of 1,143 eligible patients, 923 (81%) agreed to participate. Their mean age was 39 (range = 17-96) years. Most were female (58%), white (60%), and unmarried (68%). Thirty-eight percent had no access to primary care. Injury-prone behaviors were prevalent: 53% of the respondents did not wear seat belts regularly; 15% had no working smoke detector; 3% kept loaded, unlocked handguns in their homes; 11% had attempted suicide; 23% had a positive CAGE screen for alcoholism; 3% had operated a motor vehicle in the preceding month while alcohol-intoxicated; and 11% had ridden in an automobile with an intoxicated driver. Cancer and chronic disease risks were also common: 48% smoked; 16% had not received a blood pressure check in the preceding year; and 4% reported unsafe sexual practices. Among women aged > 50 years, 42% had not received a Pap test in the prior 2 years and 14% had never had mammography. Many prevalence rates and access to care varied among the 3 sites. However, for most risk factors, prevalence rates did not differ in patients with and without access to primary health care.

CONCLUSIONS

ED patients have high rates of injury and chronic disease risks, and many have no other source of routine health care. Research is needed to determine whether ED-based programs, designed to reduce injury and chronic disease risks, are feasible and cost-effective.

Project ASSERT: an ED-based intervention to increase access to primary care, preventive services, and the substance abuse treatment system

STUDY OBJECTIVE

To test the feasibility and effectiveness of Project ASSERT, an innovative program developed by us to facilitate access to the substance abuse treatment system and to primary care and preventive services for emergency department patients with drug- and alcohol-related health problems.

METHOD

Multicultural health promotion advocates (HPAs) were trained by ED personnel to screen patients using a health needs history, to administer a brief negotiated interview based on readiness-to-change principles, and to use an active referral process to capture the marginal capacity of the substance abuse treatment system. Outcome measures included (1) number of referrals to the substance abuse treatment system, (2) patient self-report of satisfaction with services received from Project ASSERT and utilization of treatment resources, and (3) changes in self-reported frequency of drug and alcohol use and in Drug Abuse Screening Test scores between enrollment and follow-up at 60 to 90 days.

RESULTS

Between March 1, 1995, and February 29, 1996, 7,118 adult ED patients were screened. Substance abuse was detected among 2,931 patients (41%), and 1,096 (37% of detected patients) were enrolled. A total of 8,848 referrals were made: 3,189 to primary care, 2,018 to a variety of substance abuse treatment services, 2,253 for smoking cessation, 339 for mammography, and 689 to other support services (eg, psychiatric nurse, social worker, battered women's advocate or shelter). Comparison of enrollment and follow-up scores for the 245 enrollees who kept a follow-up appointment demonstrated significant reductions, including a 45% reduction in severity of drug problem, a 56% reduction in alcohol use, and a 64% reduction in the frequency of drinking six or more drinks at one sitting. At follow-up, patients expressed satisfaction with Project ASSERT: 91% were satisfied with their referrals; 93% thought the HPAs explained things well; and 99% thought the HPAs respected them as individuals. Among the follow-up group, 50% self-reported that they had kept an appointment for treatment.

CONCLUSION

Project ASSERT is an innovative approach to link ED patients with the substance abuse treatment system and with primary care and other preventive services. Its success is further demonstrated by its adoption by Boston Medical Center as a funded ED value-added service.

An emergency medicine approach to violence throughout the life cycle. SAEM Public Health and Education Committee

This document by the SAEM Public Health and Education Committee outlines the public health impact of interpersonal violence as it pertains to acute emergency care. This paper provides an overview of violence through the life cycle (i.e., child abuse, youth violence, intimate violence, and elderly abuse). It also makes specific recommendations regarding the role emergency physicians can play in reducing violence through medical education, research, surveillance, public education, advocacy, and clinical practice.

[On the need for spiritual help to patients with mental disorders]

The article presents a psychotherapeutic and spiritual approach to psychotic patients. Theoretical assumptions and a practical application (implementation and results) are described on the basis of ten years' experience with an open religious group at the Psychiatric Department of Warsaw Medical School.

Multicenter study of case finding in elderly emergency department patients

OBJECTIVES

To assess the feasibility of a brief comprehensive case-finding program for detecting functional, cognitive, and social impairments among elderly ED patients and to estimate the prevalence of unknown, undetected, or untreated impairments elderly patients may have.

METHODS

A multicenter prospective study conducted at five private and public hospital EDs in five different communities across the country. Patients aged 60 years and older released to their homes during 52 randomly selected evening and weekend shifts between February 1 and April 30, 1993, were eligible for the case-finding program. They were evaluated by medical students who received special training (instructional videotape, supervised examinations, and conference calls) in the administration of a standardized 17-item protocol that included an interview and simple tests of function. The patients' physicians were notified of the screening results and were asked to return a one-month follow-up questionnaire. The physicians answered whether the presumed problem had been confirmed and whether a treatment plan for a new problem had been developed.

RESULTS

Patient acceptance of the case-finding program was good; 252 of 338 eligible patients (75%) agreed to participate, and 281 conditions were detected for 242 screened patients (96%). The most frequently reported problems were with: performing the activities of daily living (79%); vision (55%); lack of influenza vaccination (54%); home environment (49%); mental status (46%); general health (41%); falls (40%); and depression (36%). The physicians returned questionnaires for 153 patients (63%); 76 patients (50%) were evaluated at follow-up visits, during which 47 newly identified problems (62%) were confirmed and treatment plans were developed for 25 problems (53%) among 21 patients. A mean time of 17.7 +/- 10.2 minutes was required to complete the screen.

CONCLUSIONS

A brief comprehensive case-finding program for functional, cognitive, and social impairment among elderly ED patients is feasible. The screening uncovered a significant amount of morbidity among older patients visiting EDs.

Extramedullary toxicity of a conditioning regimen containing busulphan, cyclophosphamide and etoposide in 84 patients undergoing autologous and allogenic bone marrow transplantation

Relapse is still a common problem after bone marrow transplant (BMT) and teh value of adding etoposide to standard conditioning agents is being tested. The aim of the study was to assess the extramedullary toxicity which resulted from adding etoposide to busulphan 16 mg/kg and cyclophoshamide 120 mg/kg (BuCY2). Eighty four patients received etoposide 40 mg/kg in addition to BuCY2 as conditioning for autologous and allogeneic BMT for leukemia and lymphoma. The Bearman system of grading extramedullary toxicity was used along with a system of grading skin toxicity that we devised. There were seven acute toxic deaths (8%) and in total 15 patients experienced life-threatening or fatal toxicity. The major finding was a striking increase in pulmonary toxicity with six deaths (five alveolar hemorrhage and one pulmonary embolus). Five of seven of the patients with severe pulmonary toxicity had been given irradiation to the lung fields (P < 0.001). Thirty nine per cent of patients had veno-occlusive disease of the liver but the case fatality rate was low (1 of 33). Dermatologic toxicity was experienced by 82% of patients and was symptomatically troublesome but rapidly reversible. The addition of etoposide to BuCY2 increases non-hematological toxicity. This regimen is associated with severe pulmonary toxicity in patients with a history of prior chest irradiation. A high incidence of skin toxicity was seen; a system for describing this toxicity is proposed.