Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Geriatric Services Hub - A Collaborative Frailty Management Model between The Hospital and Community Providers

BACKGROUND

Frailty is an important geriatric syndrome especially with ageing populations. Frailty can be managed or even reversed with community-based interventions delivered by a multi-disciplinary team. Innovation is required to find community frailty models that can deliver cost-effective and feasible care to each local context.

OBJECTIVES

We share pilot data from our Geriatric Service Hub (GSH) which is a novel frailty care model in Singapore that identifies and manages frailty in the community, supported by a hospital-based multi-disciplinary team.

METHODS

We describe in detail our GSH model and its implementation. We performed a retrospective data analysis on patient characteristics, uptake, prevalence of frailty and sarcopenia and referral rates for multi-component interventions.

RESULTS

A total of 152 persons attended between January 2020 to May 2021. Majority (59.9%) were female and mean age was 81.0 ± 7.1 years old. One-fifth (21.1%) of persons live alone. Mean Charlson Co-morbidity Index was 5.2 ± 1.8. Based on the clinical frailty risk scale (CFS), 31.6% were vulnerable, 51.3% were mildly frail and 12.5% were moderately frail. Based on SARC-F screening, 45.3% were identified to be sarcopenic whilst 56.9% had a high concern about falling using the Falls-Efficacy Scale-International. BMD scans were done for 41.4% of participants, of which 58.7% were started on osteoporosis treatment. In terms of referrals to allied health professionals, 87.5% were referred for physiotherapy, 71.1% for occupational therapy and 50.7% to dieticians.

CONCLUSION

The GSH programme demonstrates a new local model of partnering with community service providers to bring comprehensive population level frailty screening and interventions to pre-frail and frail older adults. Our study found high rates of frailty, sarcopenia and fear of falling in community-dwelling older adults who were not presently known to geriatric care services.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Performance Metrics for Slaughter and Dressing Hygiene at Australian Beef Export Establishments

ABSTRACT

A study was undertaken to examine hygienic control of the slaughter and dressing process for beef cattle at Australian export processing establishments. Samples were collected from two points during the process: immediately after hide removal and at the completion of dressing before the commencement of chilling. Hindquarter and forequarter samples were collected from 24 establishments, half of which (n = 12) used some form of microbial intervention (in addition to trimming). The overall contamination level on carcass sides was low and was reduced between hide removal and entering the chiller. The concentration and prevalence of indicator bacteria were higher on samples from hindquarters than on samples from forequarters. Application of an intervention, such as hot water, in addition to trimming resulted in a greater reduction in the concentration and prevalence of indicator bacteria than trimming alone, although the level of Escherichia coli and coliform bacteria on all samples was too low to allow meaningful comparisons to be made. Salmonellae were isolated from 2.09 and 0.56% of samples after hide removal and before chilling, respectively. Application of an intervention in addition to trimming did not result in a significant reduction (P = 0.4) of Salmonella prevalence on prechill carcasses. Low levels of bacteria were found on carcasses after hide removal. This, combined with small reductions as a result of trimming and sometimes other interventions, resulted in carcasses with very low levels of bacterial contamination. If performance metrics were to be applied to the slaughter and dressing process, a measure of the expected contamination at the end of the process would provide a more unequivocal measure of the process than either contamination on the carcass after hide removal or any reduction achieved as a result of the dressing process.

HIGHLIGHTS

Underestimation of spirometry if recommended testing guidance is not followed

Background

Lung function measured at work is used to make important employment decisions. Improving its quality will reduce misclassification and allow more accurate longitudinal interpretation over time.

Aims

To assess the amount by which lung function (forced expiratory volume in 1 second [FEV1] and forced vital capacity [FVC]) values will be underestimated if recommended spirometry testing guidance is not followed.

Methods

Lung function was measured in a population of workers. Knowledge of the final reproducible FEV1 and FVC for each worker allowed estimation of the underestimates that would have occurred if less forced manoeuvres than recommended had been performed.

Results

A total of 667 workers (661 males, mean age 43 years, range 18-66) participated. Among them, 560 (84%) achieved reproducible results for both FEV1 and FVC; 470 (84%) of these did so after three technically acceptable forced expiratory manoeuvres, a cumulative total of 533 after four, 548 after five, 557 after six, 559 after seven and 560 after eight blows. If only one (or first two) technically acceptable blow(s) had been performed, mean underestimates were calculated for FEV1 of 115.1 ml (35.4 ml) and for FVC of 143.4 ml (42.3 ml).

Conclusions

In this study, reproducible spirometry was achievable in most workers. Not adhering to standards underestimates lung function by clinically significant amounts.

A survey of modelling methods for high-fidelity wind farm simulations using large eddy simulation

Large eddy simulations (LES) of wind farms have the capability to provide valuable and detailed information about the dynamics of wind turbine wakes. For this reason, their use within the wind energy research community is on the rise, spurring the development of new models and methods. This review surveys the most common schemes available to model the rotor, atmospheric conditions and terrain effects within current state-of-the-art LES codes, of which an overview is provided. A summary of the experimental research data available for validation of LES codes within the context of single and multiple wake situations is also supplied. Some typical results for wind turbine and wind farm flows are presented to illustrate best practices for carrying out high-fidelity LES of wind farms under various atmospheric and terrain conditions.This article is part of the themed issue 'Wind energy in complex terrains'.

Occupational chronic obstructive pulmonary disease: a standard of care

BACKGROUND

Consistent evidence from population studies report that 10-15% of the total burden of chronic obstructive pulmonary disease (COPD) is associated with workplace exposures. This proportion of COPD could be eliminated if harmful workplace exposures were controlled adequately.

AIMS

To produce a standard of care for clinicians, occupational health professionals, employers and employees on the identification and management of occupational COPD.

METHODS

A systematic literature review was used to identify published data on the prevention, identification and management of occupational COPD. Scottish Intercollegiate Guidance Network grading and the Royal College of General Practitioner three star grading system were used to grade the evidence.

RESULTS

There are a number of specific workplace exposures that are established causes of COPD. Taking an occupational history in patients or workers with possible or established COPD will identify these. Reduction in exposure to vapours, gases, dusts and fumes at work is likely to be the most effective method for reducing occupational COPD. Identification of workers with rapidly declining lung function, irrespective of their specific exposure, is important. Individuals can be identified at work by accurate annual measures of lung function.

CONCLUSIONS

Early identification of cases with COPD is important so that causality can be considered and action taken to reduce causative exposures thereby preventing further harm to the individual and other workers who may be similarly exposed. This can be achieved using a combination of a respiratory questionnaire, accurate lung function measurements and control of exposures in the workplace.

A baseline survey of the microbiological quality of chicken portions and carcasses at retail in two Australian states (2005 to 2006)

Raw poultry products were purchased from the retail market place in two Australian states, New South Wales (n = 549) and South Australia (n = 310). The products sampled on a proportional volume basis were chicken portions with the skin off or skin on, in bulk or tray packs, and whole carcasses. They were collected from butcher shops, supermarkets, and specialty stores from urban areas during the winter (2005) and summer (2006) months. The samples were analyzed to determine the prevalence and concentration of Escherichia coli, Salmonella, and Campylobacter spp. in addition to total viable counts. Salmonella was found in 47.7 and 35.5% of retail chicken samples (35.3 and 21.9% were the less virulent Salmonella Sofia), at mean counts of -1.42 and -1.6 log MPN/cm2 in New South Wales and South Australia, respectively. Campylobacter was found in 87.8 and 93.2% of samples at mean counts of 0.87 and 0.78 log CFU/cm2, respectively. In both states in both seasons, the mean total viable count was 5 log CFU/cm2. On whole birds, E. coli was detected in all winter samples and on 92.9 and 85.7% of summer samples in New South Wales and South Australia, respectively; the log of the geometric mean per square centimeter was 0.5 in winter and slightly lower in summer. On chicken portions, E. coli was detected in around 90% of winter samples in both states, and in summer on 75.1 and 59.6% of samples in New South Wales and South Australia, respectively. The log of the geometric mean CFU per square centimeter for E. coli was 0.75 and 0.91 in winter, and 0.66 and 0.5 in summer in New South Wales and South Australia, respectively.

Day-case peripheral angioplasty using nurse-led admission, discharge, and follow-up procedures: arterial closure devices are not necessary

AIM

To audit the safety of day-case peripheral arterial intervention without the use of arterial-closure devices using nurse-led admission, discharge, and follow-up procedures.

MATERIALS AND METHODS

Patients referred for elective, peripheral vascular intervention were selected for day-case care according to pre-determined criteria using telephone triage. Post-procedure haemostasis was achieved using manual compression. After 3h bed-rest, patients were mobilized and discharged at 5h. Patients were contacted by telephone next working day to audit complications.

RESULTS

One hundred and eighty-three elective day-case peripheral interventions were performed over 2 years, predominantly using 6 F sheaths. No closure devices were used. Five patients (2%) returned to the department because of persistent groin symptoms the next day. One of these had a false aneurysm. Four required no further treatment. A single patient returned at day 6 with a delayed false aneurysm.

CONCLUSION

Day-case peripheral vascular intervention can be safely performed in appropriately selected patients without the use of arterial closure devices. Specialist radiology nurses have a major role in the counselling, care, and follow-up of these patients.

Relationships between the density of different indicator organisms on sheep and beef carcasses and in frozen beef and sheep meat

AIM

To describe the relationship between the concentration of different indicator bacteria in red meat.

METHODS AND RESULTS

Enumeration data for aerobic plate count (APC), Enterobacteriaceae, coliforms and Escherichia coli biotype I were analysed from an Australia-wide survey of beef carcasses, sheep carcasses, frozen beef and frozen sheep meat. In all commodities, there was only low-to-moderate rank correlation (0.16-0.47) between concentration of APC and concentration of each Gram-negative indicator. Rank correlations between counts of Gram-negative indicators were much higher (0.47-0.92) especially when nondetections were excluded from analysis (0.78-0.94). Receiver-operator characteristics analysis showed that detection of coliforms can predict the presence of E. coli biotype I with almost 100% sensitivity but fails to predict absence in 2.7-8.5% of samples not containing E. coli biotype I.

CONCLUSIONS

Enumeration of coliforms is a useful adjunct to enumeration of E. coli biotype I or Enterobacteriaceae in red meat. The density of coliforms or Enterobacteriaceae can be used to predict the presence or absence of E. coli biotype I, although when the latter is at low prevalence errors in positive test prediction can be large.

SIGNIFICANCE AND IMPACT OF THE STUDY

A quantitative basis is provided for comparing the concentration of different indicator bacteria measured in the production, regulation and trade of red meat.

Performance Evaluation of the Latest Fully Automated Hematology Analyzers in a Large, Commercial Laboratory Setting:A 4-Way, Side-by-Side Study

Gamma-Dynacare is a Canadian-based community laboratory partnership formed in the mid-1990s through the merger of 3 prominent Ontario medical diagnostic laboratories. Laboratory Corporation of America acquired an interest in the GD partnership in mid 2002. We service more than 10,000 community-based Canadian clinicians, hospital partners, and private clients with an integrated customer-focused system that includes specimen collection, transportation, and results reporting services. With more than 1,700 highly qualified medical, technical, and support staff and a network of laboratories, Gamma Dynacare aims to be at the forefront of technological innovation to better service the clinician base and ultimately deliver better patient care. We were looking for a hematology analyzer that would allow. (1) standardization throughout Ontario in our 4 largest sites and (2) better performance to effectively handle aged samples and minimize slide review. To select the best, most productive hematology analyzer for our environment, it was decided to perform a side-by-side comparison of the top hematology analyzers from Abbott (Cell-Dyn 3500), Beckman Coulter (LH 750), Bayer (Advia 120), and Sysmex (XE 2100), utilizing the same samples. CBC, differential and reticulocyte parameters were all evaluated according to CLSI (formerly NCCLS) and established hematology analyzer evaluation guidelines. We assessed each analyzer for precision, linearity, carryover, stability, differential capabilities, slide review rates, and throughput (clean bench studies). Two hundred samples were assessed for differential and morphology flagging on each analyzer using the reference 400 cell manual differential for comparison. Throughput was assessed by analyzing 700 consecutive samples representative of our workload mix. Stability studies at 24 hours showed that the Beckman Coulter LH 750 was least affected by EDTA, effect with minimal changes in the mean corpuscular volume (MCV) and hematocrit. Both the Bayer Advia 120 and Sysmex XE 2100 showed an elevation of the MCV (up to 5 fL) and Hematocrit over the 24 hours. Analysis of the 200 randomly selected patient samples showed that, while the false-negative rates on each of the instruments were comparable, there were significant differences in the false-positive rates. This has important implications for slide review rates. For our specimen mix, the Sysmex XE 2100 had the highest false-positive rate (15%), followed by the Cell-Dyn 3500 (8%), Advia 120 (6.5%) and the Beckman Coulter LH 750 (1.5%). Reticulocyte analysis performance was observed to be satisfactory with the Beckman Coulter LH 750, Cell-Dyn 3500, and XE 2100, while the Bayer Advia 120 showed a decrease in retic values after 12 hours. In conclusion, many laboratories will not be able to perform a 4-way evaluation such as described here due to time, space, and resource constraints. For our laboratories, result quality, sample stability performance, slide review rates, and efficiency were the primary criteria in selection of the most suitable hematology analyzer. Our 4-way evaluation resulted in selection of the Beckman Coulter LH 750 for Gamma-Dynacare Laboratories because it enabled the lowest slide review rate and handled aged samples better than the other analyzers.

Speciation of Antechinus stuartii and A. subtropicus (Marsupialia : Dasyuridae) in eastern Australia: molecular and morphological evidence

This paper evaluates the systematic status of the Antechinus populations of northern New South Wales and southern Queensland, using a combined morphological and molecular (allozymes and mitochondrial DNA) approach. Analysis of the d-loop section of the mitochondrial DNA control region revealed two highly supported clades within A. stuartii sensu lato that were sympatric in the Border Ranges of northern New South Wales. However, genetic distances between these clades were small (approximately 3%), indicating that time of divergence was probably relatively recent. Allozyme electrophoresis also showed very small differences between clades/species. Analyses of cranial and dental characters showed that the members of each of these clades differed morphologically and that the clades corresponded to A. stuartii and the recently described A.�subtropicus. The combined results support the species status of A. stuartii and A.�subtropicus, and suggest that speciation was likely a result of a recent vicariant event.

Caring in nursing: a different interpretation

AIM

To apply Habermas' (1995) Theory of Moral Consciousness and Communicative Action to the nurse-patient relationship, offering a different interpretation to the nurse-patient relationship that is caring in nursing.

RATIONALE

Many authors have described the nurse-patient relationship, but Habermas' theory synthesizes the components into a complex matrix that is caring in nursing.

FINDINGS

The theory offers three claims to normative validity: the claim to truth which is the factual objective knowledge; the claim to truthfulness which refers to the intrasubjective self; and the claim to right which is the intersubjective interaction. The validity claims explain the patient's personal and illness self, the nurse's personal and professional self, and the interaction/discourse. The interaction is situation specific, and is identified as moral because dialogue/discourse requires a 'considerateness' of each for the other. 'Considerateness' in discourse requires certain rules, including that each participant has an equal voice, be followed in order for the Principle of Universalization to occur. Habermas draws on Kohlberg's (1981), and Selman's (1980) work to develop three levels of moral maturity of communication. These are preconventional, conventional, and postconventional. Initial moral maturity is egocentric, subjective, and obedient to authority. Maturity develops with recognition of other and reciprocity. At the postconventional level there is mutuality and the ability for abstract reasoning. There is a third person objectivity combining speaker and addressee/listener perspectives. Norms are not just accepted, they are reasoned through. This leads to justification of the norm, which is then accepted as valid. When the three validity claims are met and there is genuine 'considerateness' in the interaction there is communicative action. The reverse is strategic action, where the communication is coercive. When there is communicative action both patient and nurse are validated with a sense of fulfillment or <physis>.

CONCLUSION

Habermas' (1995) theory offers a new paradigm for caring in nursing.

"Neighbourhood" size, dispersal and density estimates in the prickly forest skink (Gnypetoscincus queenslandiae) using individual genetic and demographic methods

Dispersal, or the amount of dispersion between an individual's birthplace and that of its offspring, is of great importance in population biology, behavioural ecology and conservation, however, obtaining direct estimates from field data on natural populations can be problematic. The prickly forest skink, Gnypetoscincus queenslandiae, is a rainforest endemic skink from the wet tropics of Australia. Because of its log-dwelling habits and lack of definite nesting sites, a demographic estimate of dispersal distance is difficult to obtain. Neighbourhood size, defined as 4piDsigma2 (where D is the population density and sigma2 the mean axial squared parent-offspring dispersal rate), dispersal and density were estimated directly and indirectly for this species using mark-recapture and microsatellite data, respectively, on lizards captured at a local geographical scale of 3 ha. Mark-recapture data gave a dispersal rate of 843 m2/generation (assuming a generation time of 6.5 years), a time-scaled density of 13 635 individuals * generation/km2 and, hence, a neighbourhood size of 144 individuals. A genetic method based on the multilocus (10 loci) microsatellite genotypes of individuals and their geographical location indicated that there is a significant isolation by distance pattern, and gave a neighbourhood size of 69 individuals, with a 95% confidence interval between 48 and 184. This translates into a dispersal rate of 404 m2/generation when using the mark-recapture density estimation, or an estimate of time-scaled population density of 6520 individuals * generation/km2 when using the mark-recapture dispersal rate estimate. The relationship between the two categories of neighbourhood size, dispersal and density estimates and reasons for any disparities are discussed.

Microbiological quality of Australian beef

A survey of the microbiological quality of beef carcasses and boneless beef produced in Australia was conducted during the period June to November 1998. Sponge samples were collected from 1,275 carcasses, and meat samples were drilled from 990 cartons of frozen boneless beef. Carcass and boneless beef samples were respectively collected from 21 and 27 establishments that concentrated on export and from 38 and 3 establishments supplying the Australian domestic market of which 31 were very small plants slaughtering no more than 150 cattle equivalents per week. The mean log total viable counts (TVCs) were 2.42/cm2 and 2.52/g for carcasses and boneless meat, respectively. Escherichia coli was detected on 10.3% of carcasses and 5.1% of boneless beef samples and coagulase-positive staphylococci on 24.3% of carcasses and 17.5% of boneless beef. Salmonella was detected on 0.2% of carcasses and 0.1% of boneless beef and E. coli O157:H7 recovered from 0.1% of carcasses but not detected on 990 boneless beef samples. Mean log TVCs/cm2 differed significantly (P < 0.05) between establishment types. They were lower on carcasses from export establishments (2.20) compared with domestic (2.61) and very small plants (3.10). There were no significant differences in prevalence of Salmonella or E. coli O157:H7 between establishment types. Excision samples were taken from 670 carcasses to make comparisons with the first baseline study of Australian meat, carried out in 1993 to 1994. While there were differences in sampling and microbiological techniques between the two studies that require detailed consideration, there were small but significant improvements in several microbiological criteria for carcasses and boneless meat.

Microbiological quality of Australian sheep meat

Microbiological quality of sheep carcasses and boneless sheep meat produced in Australia was surveyed during the period June to November 1998. Sponge samples were collected from 917 carcasses, and meat samples were drilled from 467 cartons of frozen boneless meat. Carcass and boneless meat samples were respectively collected from 7 and 10 establishments that concentrated on export, and from 36 and 5 establishments supplying the Australian domestic market of which 31 were very small plants slaughtering cattle and sheep but no more than 1,200 sheep equivalents per week. The mean log total viable counts were 3.55/cm2 and 3.30/g for carcasses and boneless meat, respectively. Escherichia coli was detected on 29.2% of carcasses and 24.5% of boneless meat samples and coagulase-positive staphylococci on 24.1% of carcasses, and 38.6% of boneless meat samples. Salmonella was detected on 0.1% of carcasses and 1.3% of boneless meat samples. E. coli O157:H7 was recovered from 0.7% of carcasses and 1.3% of boneless sheep meat. There were statistically significant differences between establishment types for some microbiological criteria, although there were no significant differences in prevalence of Salmonella or E. coli O157:H7 between establishment types. While there were differences in sampling and microbiological techniques between this study and another conducted in 1993 to 1994 that require detailed consideration, there were small but significant improvements in several microbiological criteria for boneless meat. While data that would allow for comparison of carcass data were not gathered, it is unlikely that improvements in the microbiological quality of boneless sheep meat could accrue without improvements to carcasses.

Distribution and identity of species in the Antechinus stuartii - A. flavipes group (Marsupialia : Dasyuridae) in south-eastern Australia

This study describes genetical differences between three morphologically similar species of Antechinus in south-eastern Australia, and uses the climatic model BIOCLIM to clarify their expected geographical distributions. Allozyme electrophoresis revealed Nei’s distances of >0.2 between A. flavipes and A. stuartii and A. flavipes and A. agilis, the latter a newly recognised species in south-eastern Australia. Fixed allele differences were determined in five proteins between A. stuartii and A. flavipes from an area of sympatry in northern New South Wales, confirming their genetic distinctness. A smaller distance (0.08) separated A. stuartii from A. agilis, but fixed allele differences in albumin and mannose phosphate isomerase distinguished these species clearly. Locality records for the three species were compiled from the electrophoretic results, museum specimen records and published data, and used to generate expected distributions for each species. A. flavipes is predicted to occur primarily in warm, inland areas of south- eastern Australia with a mean annual rainfall of 785 mm, but to occur along the coast in South Australia and southern Queensland. In contrast, the distributions of A. stuartii and A. agilis are predicted to be broadly coastal, with the former occurring in northern New South Wales and southern Queensland in areas with high mean annual rainfall (1430 mm) and temperature (16.0°C), the latter in southern New South Wales and Victoria in cooler areas (11.8°C annual mean) with intermediate rainfall (1071 mm). Sympatry appears to be limited between A. flavipes and its two congeners; A. stuartii and A. agilis are predicted to be parapatric with only two small areas of overlap being evident.

Apnea after immunization of preterm infants

OBJECTIVE

To determine the frequency of adverse reactions, particularly the occurrence of apnea, among preterm infants after immunization with diphtheria and tetanus toxoids and whole cell pertussis vaccine adsorbed (DTP) and Haemophilus influenzae type b conjugate (HibC) vaccine in the neonatal intensive care unit.

STUDY DESIGN

After the occurrence of apnea in two preterm infants following immunization with DTP and HibC, a prospective surveillance of 97 preterm infants younger than 37 weeks of gestation who were immunized with DTP (94 also received HibC at the same time) in the neonatal intensive care unit was performed to assess the frequency of adverse reactions and in particular, the occurrence of apnea. For each infant, data were recorded for a 3-day period before and after receipt of the immunization.

RESULTS

The majority of preterm infants tolerated immunizations with DTP and HibC without ill effects. However, 12 (12%) infants experienced a recurrence of apnea, and 11 (11%) had at least a 50% increase in the number of apneic and bradycardic episodes in the 72 hours after immunization. This occurred primarily among smaller preterm infants who were immunized at a lower weight (p = 0.01), had experienced more severe apnea of prematurity (p = 0.01), and had chronic lung disease (p = 0.03).

CONCLUSION

The temporal association observed between immunization of preterm infants and a transient increase or recurrence of apnea after vaccination merits further study. Cardiorespiratory monitoring of these infants after immunization may be advisable.

Visual estimation of ejection fraction by two-dimensional echocardiography: the learning curve

Our purpose was to determine the learning curve of visual estimation of ejection fraction (EF) by echocardiography. Sixty consecutive patients, who had clinically indicated echocardiography and radionuclide ventriculography (RVG) within 1 month were selected. Five standard views were reviewed independently by a first-year cardiology fellow, a private cardiologist, and an experienced echocardiographer. Observers were given feedback of the RVG EFs immediately after estimating the EF on each study. To assess the effect of learning, the echocardiographic studies were divided into three groups of 20 and were read successively by each observer. A statistical comparison of the two methods was performed for each group. The correlation between the two techniques for the first group of studies was marginal. There was a significant improvement in the correlation with subsequent groups. The correlation did not change significantly with the last group of studies compared with the second group. In conclusion, visual estimation of EF by two-dimensional echocardiography can be learned, with a learning curve of approximately 20 studies if immediate feed-back is available.

Improving the efficiency and service of computed tomographic scanning

RATIONALE AND OBJECTIVES

This study quantified the impact on service and costs of operational changes in CT.

METHODS

Operational and financial analyses were performed in 1988 and 1991 after process flow and management changes were made.

RESULTS

The backlog decreased from about 6 weeks to 1 week. The cost per scan decreased 25%. Volume increased 50%. Two technologists were assigned per scanner doing some steps of the process in parallel rather than sequentially. Decreasing throughput time accounted for three fifths of the cost decrease. The reduction in number of scanners and hours of operation, change in radiologists' practice patterns, coordination of scheduling, CT priority for escort personnel, and personnel changes accounted for two fifths of the cost decrease.

CONCLUSIONS

It is possible to simultaneously decrease costs and improve the quality of service by careful operations analysis and management. Operational changes had synergistic effects that allowed more improvement than might be anticipated. Advisable management changes may be counterintuitive.

Sexual abuse: giving support to nurses

Nurses dealing with people who have been sexually abused as children need strong support and supervision systems to enable them to cope with the feelings of helplessness and sadness that can arise. Such a system has been set up at a psychiatric day hospital in London to help nurses provide consistent, long-term and non-judgemental care.

Photoaffinity labeling of methylenetetrahydrofolate reductase with 8-azido-S-adenosylmethionine

Methylenetetrahydrofolate reductase commits tetrahydrofolate-bound one carbon units to use in the regeneration of the methyl group of adenosylmethionine (AdoMet) in eucaryotes and its activity is allosterically inhibited by AdoMet. Limited proteolysis and scanning transmission electron microscopy have been employed to show that the enzyme is a dimer of identical subunits and that each subunit is composed of spatially distinct domains with molecular masses of approximately 40 and 37 kDa (Matthews, R. G., Vanoni, M. A., Hainfeld, J. F., and Wall, J. (1984) J. Biol. Chem. 259, 11647-11650). We now report the use of the photoaffinity label 8-azido-S-adenosylmethionine (8-N3AdoMet) to locate the binding site for the allosteric inhibitor on the 37-kDa domain. In the absence of light, 8-N3AdoMet is itself an inhibitor of methylenetetrahydrofolate reductase activity, with a Ki value 4.8-fold higher than AdoMet, and like AdoMet it induces slow transitions between active and inactive forms. Photoaffinity labeling is dependent on irradiation with ultraviolet light and is prevented by AdoMet but not by ATP. Limited proteolysis of the photolabeled enzyme results in the formation of a labeled 37-kDa fragment which is further processed to a labeled 34-kDa fragment. On conversion of the 34-kDa fragment to a 31-kDa polypeptide, all label is lost, suggesting that the labeling is restricted to an approximately 3-kDa region near one end of the 37-kDa polypeptide. Limited proteolysis of the native enzyme, while completely desensitizing the enzyme to inhibition by AdoMet or 8-N3AdoMet, does not prevent subsequent photolabeling of the 37-kDa peptide fragment. This photolabeling does not occur in the presence of excess AdoMet. These latter experiments suggest that the desensitization of the enzyme eliminates the ability of allosteric effectors to stabilize an inactive form of the enzyme, but does not abolish specific binding of 8-N3AdoMet or AdoMet.

1980 Melbourne marathon study

Most of the 5423 entrants in the Melbourne 1980 Big M Marathon were non-elite athletes. A study of a stratified random sample of 459 entrants (which represented a 42% response rate) found that, while entrants reflected the community standards of disease, they pursued healthier lifestyles. Preparation for the marathon led to a number of positive changes in the health standard of runners. The principal negative consequence of marathon training was the high rate of musculoskeletal problems (30%). Before the race, only 4% of participants had an adequate fluid intake; 33% had pre-existing problems, mainly involving muscles and joints (63%) and viral or gastrointestinal illnesses (41%). These entrants had a 60% less chance of finishing the race. Symptoms during the race were reported by 92% of entrants, but most of these were not serious; only 6% of entrants were unable to finish the race. The pattern of symptoms after the race was similar to that during the race; 50% of these resolved within three hours. Ninety-seven entrants (2%) required medical attention during the race. Serious problems were rare (only in three entrants), and no runner required admission to hospital for longer than 24 hours. Entrants were at greater risk of requiring medical attention or experiencing problems during and after the race if they had a shorter preparation (less than two months), ran fewer kilometres per week (less than 60 km/week) in the last two or three months before the race, and had performed fewer long training runs (more than 24 km).

Effect of nursing-staff support groups on the quality of newborn intensive care

ICU support groups are widely recommended to mitigate the effects of stress on staff performance, thereby improving patient care. The usefulness of a nursing-staff support group was assessed in the neonatal ICUs of both a city/county hospital (10,000 births/yr) and a private hospital (3200 births/yr). Support-group meetings focused on communication and patient care and were conducted every 1 to 2 wk by psychiatrists experienced in intensive care support groups. Nevertheless, attendance diminished and the groups lasted only 6 to 7 months. Moreover, the quality of routine, emergency, and overall care did not differ significantly during intervention vs. control months. Our findings suggest that sources of ICU stress may be best addressed by methods other than nursing-staff support groups. Under the conditions of the study, we found little evidence to justify the expense and effort required to conduct ICU support groups.