Mapping a 50-spin-qubit network through correlated sensing

Spins associated to optically accessible solid-state defects have emerged as a versatile platform for exploring quantum simulation, quantum sensing and quantum communication. Pioneering experiments have shown the sensing, imaging, and control of multiple nuclear spins surrounding a single electron spin defect. However, the accessible size of these spin networks has been constrained by the spectral resolution of current methods. Here, we map a network of 50 coupled spins through high-resolution correlated sensing schemes, using a single nitrogen-vacancy center in diamond. We develop concatenated double-resonance sequences that identify spin-chains through the network. These chains reveal the characteristic spin frequencies and their interconnections with high spectral resolution, and can be fused together to map out the network. Our results provide new opportunities for quantum simulations by increasing the number of available spin qubits. Additionally, our methods might find applications in nano-scale imaging of complex spin systems external to the host crystal.

What should be included in case report forms? Development and application of novel methods to inform surgical study design: a mixed methods case study in parastomal hernia prevention

OBJECTIVES

To describe the development and application of methods to optimise the design of case report forms (CRFs) for clinical studies evaluating surgical procedures, illustrated with an example of abdominal stoma formation.

DESIGN

(1) Literature reviews, to identify reported variations in surgical components of stoma formation, were supplemented by (2) intraoperative qualitative research (observations, videos and interviews), to identify unreported variations used in practice to generate (3) a 'long list' of items, which were rationalised using (4) consensus methods, providing a pragmatic list of CRF items to be captured in the Cohort study to Investigate the Prevention of parastomal HERnias (CIPHER) study.

SETTING

Two secondary care surgical centres in England.

PARTICIPANTS

Patients undergoing stoma formation, surgeons undertaking stoma formation and stoma nurses.

OUTCOME MEASURES

Successful identification of key CRF items to be captured in the CIPHER study.

RESULTS

59 data items relating to stoma formation were identified and categorised within six themes: (1) surgical approach to stoma formation; (2) trephine formation; (3) reinforcing the stoma trephine with mesh; (4) use of the stoma as a specimen extraction site; (5) closure of other wounds during the procedure; and (6) spouting the stoma.

CONCLUSIONS

This study used multimodal data collection to understand and capture the technical variations in stoma formation and design bespoke CRFs for a multicentre cohort study. The CIPHER study will use the CRFs to examine associations between the technical variations in stoma formation and risks of developing a parastomal hernia.

TRIAL REGISTRATION NUMBER

ISRCTN17573805.

Fault-tolerant operation of a logical qubit in a diamond quantum processor

Solid-state spin qubits is a promising platform for quantum computation and quantum networks^1,2. Recent experiments have demonstrated high-quality control over multi-qubit systems^3–8, elementary quantum algorithms^8–11 and non-fault-tolerant error correction^12–14. Large-scale systems will require using error-corrected logical qubits that are operated fault tolerantly, so that reliable computation becomes possible despite noisy operations^15–18. Overcoming imperfections in this way remains an important outstanding challenge for quantum science^15,19–27. Here, we demonstrate fault-tolerant operations on a logical qubit using spin qubits in diamond. Our approach is based on the five-qubit code with a recently discovered flag protocol that enables fault tolerance using a total of seven qubits^28–30. We encode the logical qubit using a new protocol based on repeated multi-qubit measurements and show that it outperforms non-fault-tolerant encoding schemes. We then fault-tolerantly manipulate the logical qubit through a complete set of single-qubit Clifford gates. Finally, we demonstrate flagged stabilizer measurements with real-time processing of the outcomes. Such measurements are a primitive for fault-tolerant quantum error correction. Although future improvements in fidelity and the number of qubits will be required to suppress logical error rates below the physical error rates, our realization of fault-tolerant protocols on the logical-qubit level is a key step towards quantum information processing based on solid-state spins.

By using a five-qubit error-correcting code with a recently discovered flag protocol, a logical qubit that is operated fault-tolerantly is realized based on solid-state spin qubits in diamond.

Computed Tomography Colonography (CTC): Is It Really the Non-Invasive Option We Think It Is? A Patient Experience Study

Aims: Computed tomography colonography (CTC) is seen as a more tolerable alternative to colonoscopy, but patients struggle with the steps required for optimal diagnostic imaging. This prospective study aims to understand the experience of patients undergoing CTC. Methods: A survey was completed by a convenience sample of patients before and after CTC over 7 months. The 13-item questionnaire covered pre-test information, overall and specific experience of the test. The responses were tabulated and analyzed using descriptive statistics. Qualitative free-text responses were coded for content and thematic analysis. Results: At a response rate of 51%, surveys were received from 41 patients. Overall, most patients (54%) found the investigation better than expected. However, 18% stated they were not informed of potential side effects. Side effects were experienced by 49% of patients, including diarrhea (34%) and abdominal pain (24%). About 59% experienced discomfort with gas insufflation, and 86% found turning during the investigation difficult. Conclusion: A significant proportion of patients undergoing CTC experience side effects and difficulties completing the investigation. Patient information is important to improve patient experience of CTC.

Many-body-localized discrete time crystal with a programmable spin-based quantum simulator

[Figure: see text].

Local delivery of FTY720 induces neutrophil activation through chemokine signaling in an oronasal fistula model

Purpose

Cleft palate repair surgeries lack a regenerative reconstructive option and, in many cases, develop complications including oronasal fistula (ONF). Our group has developed a novel murine phenocopy of ONF to study the oral cavity wound healing program. Using this model, our team previously identified that delivery of FTY720 on a nanofiber scaffold had a unique immunomodulatory effect directing macrophages and monocytes into a pro-regenerative state during ONF healing. Here, the objective of this study was to determine the effects of local biomaterial-based FTY720 delivery in the ONF model on the early bulk gene expression and neutrophil phenotypic response within the regenerating tissue.

Methods

Using a mouse model of ONF formation, a palate defect was created and was treated with FTY720 nanofiber scaffolds or (blank) vehicle control nanofibers. At 1 and 3 days post-implantation, ONF oral mucosal tissue from the defect region was collected for RNA sequencing analysis or flow cytometry. For the RNA-seq expression profiling, intracellular pathways were assessed using the KEGG Pathway database and Gene Ontology (GO) Terms enrichment interactive graph. To assess the effects of FTY720 on different neutrophil subpopulations, flow cytometry data was analyzed using pseudotime analysis based on Spanning-tree Progression Analysis of Density-normalized Events (SPADE).

Results

RNA sequencing analysis of palate mucosa injured tissue identified 669 genes that were differentially expressed (DE) during the first 3 days of ONF wound healing after local delivery of FTY720, including multiple genes in the sphingolipid signaling pathway. Evaluation of the DE genes at the KEGG Pathway database also identified the inflammatory immune response pathways (chemokine signaling, cytokine-cytokine receptor interaction, and leukocyte transendothelial migration), and the Gene Ontology enrichment analysis identified neutrophil chemotaxis and migration terms. SPADE dendrograms of CD11b⁺Ly6G⁺ neutrophils at both day 1 and day 3 post-injury showed significantly distinct subpopulations of neutrophils in oral mucosal defect tissue from the FTY720 scaffold treatment group compared to the vehicle control group (blank). Increased expression of CD88 and Vav1, among other genes, were found and staining of the ONF area demonstrated increased VAV1 staining in FTY720‐treated healing oral mucosa.

Conclusion

Treatment of oral mucosal defects using FTY720 scaffolds is a promising new immunotherapy to improve healing outcomes and reducing ONF formation during cleft palate surgical repair. Local delivery of FTY720 nanofiber scaffolds during ONF healing significantly shifted early gene transcription associated with immune cell recruitment and modulation of the immune microenvironment results in distinct neutrophil subpopulations in the oral mucosal defect tissue that provides a critical shift toward pro-regenerative immune signaling.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40883-021-00208-z.

Dementia patients have greater anti-cholinergic drug burden on discharge from hospital: A multicentre cross-sectional study

Introduction

Anticholinergic medications block cholinergic transmission. The central effects of anticholinergic drugs can be particularly marked in patients with dementia. Furthermore, anticholinergics antagonise the effects of cholinesterase inhibitors, the main dementia treatment.

Objectives

This study aimed to assess anticholinergic drug prescribing among dementia patients before and after admission to UK acute hospitals.

Methods

352 patients with dementia were included from 17 hospitals in the UK. All were admitted to surgical, medical or Care of the Elderly wards in 2019. Information about patients’ prescriptions were recorded on a standardised form. An evidence-based online calculator was used to calculate the anticholinergic drug burden of each patient. The correlation between two subgroups upon admission and discharge was tested with Spearman’s Rank Correlation.

Results

Table 1 shows patient demographics. On admission, 37.8% of patients had an anticholinergic burden score ≥1 and 5.68% ≥3. At discharge, 43.2% of patients had an anticholinergic burden score ≥1 and 9.1% ≥3. The increase was statistically significant (rho 0.688; p=2.2x10-16). The most common group of anticholinergic medications prescribed at discharge were psychotropics (see Figure 1). Among patients prescribed cholinesterase inhibitors, 44.9% were also taking anticholinergic medications.

Conclusions

This multicentre cross-sectional study found that people with dementia are frequently prescribed anticholinergic drugs, even if also taking cholinesterase inhibitors, and are significantly more likely to be discharged with a higher anticholinergic drug burden than on admission to hospital.

Conflict of interest

This project was planned and executed by the authors on behalf of SPARC (Student Psychiatry Audit and Research Collaborative). We thank the National Student Association of Medical Research for allowing us use of the Enketo platform. Judith Harrison was su

Association between preadmission frailty and care level at discharge in older adults undergoing emergency laparotomy

Background

Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge.

Methods

The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level.

Results

A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit.

Conclusion

Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.

Trapped-Ion Quantum Logic with Global Radiation Fields

Trapped ions are a promising tool for building a large-scale quantum computer. However, the number of required radiation fields for the realization of quantum gates in any proposed ion-based architecture scales with the number of ions within the quantum computer, posing a major obstacle when imagining a device with millions of ions. Here, we present a fundamentally different approach for trapped-ion quantum computing where this detrimental scaling vanishes. The method is based on individually controlled voltages applied to each logic gate location to facilitate the actual gate operation analogous to a traditional transistor architecture within a classical computer processor. To demonstrate the key principle of this approach we implement a versatile quantum gate method based on long-wavelength radiation and use this method to generate a maximally entangled state of two quantum engineered clock qubits with fidelity 0.985(12). This quantum gate also constitutes a simple-to-implement tool for quantum metrology, sensing, and simulation.

A protein-truncating R179X variant in RNF186 confers protection against ulcerative colitis

Protein-truncating variants protective against human disease provide in vivo validation of therapeutic targets. Here we used targeted sequencing to conduct a search for protein-truncating variants conferring protection against inflammatory bowel disease exploiting knowledge of common variants associated with the same disease. Through replication genotyping and imputation we found that a predicted protein-truncating variant (rs36095412, p.R179X, genotyped in 11,148 ulcerative colitis patients and 295,446 controls, MAF=up to 0.78%) in RNF186, a single-exon ring finger E3 ligase with strong colonic expression, protects against ulcerative colitis (overall P=6.89 × 10(-7), odds ratio=0.30). We further demonstrate that the truncated protein exhibits reduced expression and altered subcellular localization, suggesting the protective mechanism may reside in the loss of an interaction or function via mislocalization and/or loss of an essential transmembrane domain.

Ground-State Cooling of a Trapped Ion Using Long-Wavelength Radiation

We demonstrate ground-state cooling of a trapped ion using radio-frequency (rf) radiation. This is a powerful tool for the implementation of quantum operations, where rf or microwave radiation instead of lasers is used for motional quantum state engineering. We measure a mean phonon number of n[over ¯]=0.13(4) after sideband cooling, corresponding to a ground-state occupation probability of 88(7)%. After preparing in the vibrational ground state, we demonstrate motional state engineering by driving Rabi oscillations between the |n=0⟩ and |n=1⟩ Fock states. We also use the ability to ground-state cool to accurately measure the motional heating rate and report a reduction by almost 2 orders of magnitude compared with our previously measured result, which we attribute to carefully eliminating sources of electrical noise in the system.

Outcome of laparoscopic ventral mesh rectopexy for external rectal prolapse

AIM

The study assessed the efficacy of laparoscopic ventral mesh rectopexy (LVMR) for full thickness external rectal prolapse (ERP), including recurrent prolapse.

METHOD

A prospective database identified all patients undergoing LVMR for ERP over the 16-year period to December 2013. Clinical outcome, Cleveland Clinic Incontinence Score (CCIS), quality of life (QOL) and patient-reported outcome were evaluated.

RESULTS

In total, 190 LVMRs (87% women) were performed during the study period, with a median active follow-up of 29 (1-196) months; 120 had a follow-up > 5 years and 16 > 10 years. The median time from surgery was 73 (1-196) months. The 60-day mortality, recurrence and mesh-related complication rates were 1%, 3% and 3.7%. The mean improvement in CCIS was 8 (P < 0.0001). Sixty-two patients returned a complete sequence of QOL scores (Birmingham Bowel and Urinary Symptoms Questionnaire 22), which had improved by 46% at year 1 and were sustained at a median of 4 years (P < 0.001). Mean patient-reported outcome measures for satisfaction at final review in 119 responders was 9.1/10. Thirty-nine patients underwent LVMR for recurrent ERP following perineal repair. Of these, full thickness recurrence occurred in one and there were no mesh complications. The same sustained improvement in QOL was observed.

CONCLUSION

LVMR for ERP is associated with low morbidity and recurrence and a long-term improvement in function and QOL. LVMR achieves the same benefits after a failed perineal procedure.

Laparoscopic rectopexy for external prolapse in children

PURPOSE

This study reports the results of laparoscopic rectopexy in children.

METHODS

Results were obtained from a prospective database for all laparoscopic rectopexy procedures performed for external prolapse in a tertiary referral centre from 2006 to 2013. Outcomes included recurrence of symptoms and/or visible prolapse as well as the need for further surgery

RESULTS

Eighteen procedures including both suture and mesh rectopexy were performed in 11 patients. Six had solitary rectal ulcers. All patients had failed conservative management, including laxative therapy, and one patient had previously had a trial of injection of hypertonic saline. At a median follow up of 33months (6-75) complete resolution was seen in 7 cases and partial resolution, with some continuing symptoms, was seen in 1 patient. All suture rectopexy cases ultimately failed and required a redo rectopexy procedure. Three patients had persistent failure with recurrence of prolapse during the study period despite repeated procedures. There were no serious complications.

CONCLUSIONS

Laparoscopic mesh rectopexy can be safely performed in children and can lead to complete resolution of external prolapse. There is a cohort for whom it fails to relieve the problem. In this series there was a trend towards less recurrence with mesh rectopexy.

Endemic infection reduces transmission potential of an epidemic parasite during co-infection

Endemic, low-virulence parasitic infections are common in nature. Such infections may deplete host resources, which in turn could affect the reproduction of other parasites during co-infection. We aimed to determine whether the reproduction, and therefore transmission potential, of an epidemic parasite was limited by energy costs imposed on the host by an endemic infection. Total lipids, triacylglycerols (TAG) and polar lipids were measured in cockroaches (Blattella germanica) that were fed ad libitum, starved or infected with an endemic parasite, Gregarina blattarum. Reproductive output of an epidemic parasite, Steinernema carpocapsae, was then assessed by counting the number of infective stages emerging from these three host groups. We found both starvation and gregarine infection reduced cockroach lipids, mainly through depletion of TAG. Further, both starvation and G. blattarum infection resulted in reduced emergence of nematode transmission stages. This is, to our knowledge, the first study to demonstrate directly that host resource depletion caused by endemic infection could affect epidemic disease transmission. In view of the ubiquity of endemic infections in nature, future studies of epidemic transmission should take greater account of endemic co-infections.

Delayed surgery for acute severe colitis is associated with increased risk of postoperative complications

BACKGROUND

This study determined the long-term outcome after colectomy for acute severe ulcerative colitis (ASUC) and assessed whether the duration of in-hospital medical therapy is related to postoperative outcome.

METHODS

All patients who underwent urgent colectomy and ileostomy for ASUC between 1994 and 2000 were identified from a prospective database. Patient details, preoperative therapy and complications to last follow-up were recorded.

RESULTS

Eighty patients were identified, who were treated with intravenous steroids for a median of 6 (range 1-22) days before surgery. Twenty-three (29 per cent) also received intravenous ciclosporin. There were 23 complications in 22 patients in the initial postoperative period. Sixty-eight patients underwent further planned surgery, including restorative ileal pouch-anal anastomosis in 57. During a median follow-up of 5.4 (range 0.5-9.0) years, 48 patients (60 per cent) developed at least one complication. Patients with a major complication at any time during follow-up had a significantly longer duration of medical therapy before colectomy than patients with no major complications (median 8 versus 5 days; P = 0.036).

CONCLUSION

Delayed surgery for patients with ASUC who do not respond to medical therapy is associated with an increased risk of postoperative complications.

Hair loss with chemotherapy: at a loss over its management?

Alopecia is a common side effect of chemotherapy treatments for cancer; for some individuals this results in complete hair loss. The extent of this depends on many factors including the type or combination of drugs administered, and their doses. Further, it can in some cases be lessened through use of scalp cooling techniques. This method of reducing hair loss has been available since the 1970s. However, previous evidence suggests that nurses are apathetic about its use, which in turn might mean that patients are not always offered this intervention. This small exploratory study investigated perceptions held by nurses administering chemotherapy towards alopecia and its management through scalp cooling. It entailed completion of a survey questionnaire by 13 nurses that regularly administered intravenous chemotherapy. These data were then augmented by those attained from follow-up, semi-structured interviews that were conducted with three of the sample. It determined that perceptions of scalp cooling were influenced by individuals' subjective notions of its efficacy constructed from their experiences of having administered scalp cooling. Furthermore, attempts to prevent hair loss were mediated by their cognitions of the experience of hair loss itself. This study determined that views held about scalp cooling varied considerably, and that it was unlikely to be offered to all suitable patients or administered in a systematic manner. Such variation in provision has implications both for patients wishing to access this treatment and for nurses wishing to audit its use and efficacy.

Expression in plants and immunogenicity of plant virus-based experimental rabies vaccine

A new approach to the production and delivery of vaccine antigens is the use of engineered amino virus-based vectors. A chimeric peptide containing antigenic determinants from rabies virus glycoprotein (G protein) (amino acids 253-275) and nucleoprotein (N protein) (amino acids 404-418) was PCR-amplified and cloned as a translational fusion product with the alfalfa mosaic virus (AlMV) coat protein (CP). This recombinant CP was expressed in two plant virus-based expression systems. The first one utilized transgenic Nicotiana tabacum cv. Samsun NN plants providing replicative functions in trans for full-length infectious RNA3 of AlMV (NF1-g24). The second one utilized Nicotiana benthamiana and spinach (Spinacia oleracea) plants using autonomously replicating tobacco mosaic virus (TMV) lacking native CP (Av/A4-g24). Recombinant virus containing the chimeric rabies virus epitope was isolated from infected transgenic N. tabacum cv. Samsun NN plants and used for parenteral immunization of mice. Mice immunized with recombinant virus were protected against challenge infection. Based on the previously demonstrated efficacy of this plant virus-based experimental rabies vaccine when orally administered to mice in virus-infected unprocessed raw spinach leaves, we assessed its efficacy in human volunteers. Three of five volunteers who had previously been immunized against rabies virus with a conventional vaccine specifically responded against the peptide antigen after ingesting spinach leaves infected with the recombinant virus. When rabies virus non-immune individuals were fed the same material, 5/9 demonstrated significant antibody responses to either rabies virus or AlMV. Following a single dose of conventional rabies virus vaccine, three of these individuals showed detectable levels of rabies virus-neutralizing antibodies, whereas none of five controls revealed these antibodies. These findings provide clear indication of the potential of the plant virus-based expression systems as supplementary oral booster for rabies vaccinations.

Emmeline Jean Hanson, 14 November 1919--10 August 1973

Emmeline Jean Hanson died suddenly and prematurely on 10 August 1973 at the height of her career. She was known throughout the world for her own contributions to muscle research, for the warmth and generosity of her personality; and for her outstanding encouragement and help to younger colleagues. It is perhaps some small measure of her character that she was affectionately known as ‘Jean’ to all her colleagues, even the most junior members of the laboratory.

Psychological impact of genetic counselling and testing in women previously diagnosed with breast cancer

BACKGROUND

The recent discovery of susceptibility genes relating to breast cancer, BRCA1 and BRCA2, now allows women with breast cancer and a family history of breast/ovarian cancer to undergo genetic testing to identify a causative germ-line mutation. The present study assessed the psychological status over time of women affected by breast cancer requesting genetic testing (cases; n = 32) compared with matched controls (n = 28).

METHODS

Subjects were recruited through two Sydney-based hospitals. Data were collected via questionnaire and telephone interview at baseline, and 2 weeks and 3-6 months following counselling.

RESULTS

Genetic test results were not received by the subjects within the study period. Cases showed a greater increase in knowledge of cancer genetics following counselling compared with controls, and this was maintained over time. Psychological symptoms remained stable over the study period and there were no differences between groups.

CONCLUSIONS

Increased knowledge following genetic counselling was not accompanied by an increase in anxiety or depression. Further assessment will be required in the long term to determine the psychological impact of receiving a genetic test result.

The effects of creatine dietary supplementation on anterior compartment pressure in the lower leg during rest and following exercise

OBJECTIVE

To examine the effects of creatine supplementation on anterior compartment pressure of the lower leg at rest and following exercise.

DESIGN

14 college-age males received creatine or placebo supplementation for 34 days. At baseline, anterior compartment pressure was measured preexercise, immediately postexercise, and 1, 5, and 15 minutes postexercise after a level treadmill run for 20 minutes at 80% of maximal aerobic power.

INTERVENTION

Following baseline testing, subjects began a 6-day creatine or placebo loading phase at a dosage of 0.3 g x kg body mass(-1) x d(-1). This was followed by a 28-day maintenance phase at a dosage of 0.03 g x kg body mass(-1) x d(-1). Subjects and investigators were blinded as to treatment administration. Subjects continued to exercise during the supplementation period. After 6 days and 34 days of supplementation. anterior compartment pressure was measured at rest and following exercise.

RESULTS

Creatine supplementation for 6 days significantly increased compartment pressure compared with the placebo group at rest (76%), immediately post- (150%), 1 minute post- (125%), 5 minute post- (106%), and 15 minute postexercise (77%). Anterior compartment pressures continued to remain significantly higher for the creatine group compared with the placebo group at rest (72%), immediately post- (125%) and 1 minute postexercise (180%) after 34 days of creatine supplementation.

CONCLUSIONS

These data indicate that creatine supplementation abnormally increases anterior compartment pressure in the lower leg at rest and following 20 minutes of level running at 80% of maximal aerobic power.

Analysis of individual human trigeminal ganglia for latent herpes simplex virus type 1 and varicella-zoster virus nucleic acids using real-time PCR

Herpes simplex virus type 1 (HSV-1) and varicella-zoster virus (VZV) establish latent infections in the peripheral nervous system following primary infection. During latency both virus genomes exhibit limited transcription, with the HSV-1 LATs and at least four VZV transcripts consistently detected in latently infected human ganglia. In this study we used real-time PCR quantitation to determine the viral DNA copy number in individual trigeminal ganglia (TG) from 17 subjects. The number of HSV-1 genomes was not significantly different between the left and right TG from the same individual and varied per subject from 42.9 to 677.9 copies per 100 ng of DNA. The number of VZV genomes was also not significantly different between left and right TG from the same individual and varied per subject from 37.0 to 3,560.5 copies per 100 ng of DNA. HSV-1 LAT transcripts were consistently detected in ganglia containing latent HSV-1 and varied in relative expression by >500-fold. Of the three VZV transcripts analyzed, only transcripts mapping to gene 63 were consistently detected in latently infected ganglia and varied in relative expression by >2,000-fold. Thus, it appears that, similar to LAT transcription in HSV-1 latently infected ganglia, VZV gene 63 transcription is a hallmark of VZV latency.

Noninvasive positive-pressure ventilation: a utilization review of use in a teaching hospital

BACKGROUND

The use of noninvasive positive-pressure ventilation (NIPPV) for acute respiratory failure (ARF) has become more widespread over the past decade, but its prescription, use and outcomes in the clinical setting remain uncertain. The objective of this study was to review the use of NIPPV for ARF with respect to clinical indications, physician ordering, monitoring strategies and patient outcomes.

METHODS

A total of 91 consecutive adult patients admitted between June 1997 and September 1998 to a university-affiliated tertiary care hospital in Hamilton, Ont., who received 95 trials of NIPPV for ARF were included in an observational cohort study. Data abstraction forms were completed in duplicate, then relevant clinical, physiologic, prescribing, monitoring and outcome data were abstracted from the NIPPV registry and hospital records.

RESULTS

The most common indications for NIPPV were pulmonary edema (42 of 95 trials [44.2%]) and exacerbation of chronic obstructive pulmonary disease (23 of 95 trials [24.2%]). NIPPV was started primarily in the emergency department (62.1% of trials), however, in terms of total hours of NIPPV the most frequent sites of administration were the intensive care unit (30.9% of total hours) and the clinical teaching unit (20.2% of total hours). NIPPV was stopped in 48.4% of patients because of improvement and in 25.6% because of deterioration necessitating endotracheal intubation. The median time to intubation was 3.0 hours (interquartile range 0.8-12.2 hours). The respirology service was consulted for 28.4% of the patients. Physician orders usually lacked details of NIPPV settings and monitoring methods. We found no significant predictors of the need for endotracheal intubation. The overall death rate was 28.6%. The only independent predictor of death was a decreased level of consciousness (odds ratio 2.9, 95% confidence interval 1.0-8.4).

INTERPRETATION

NIPPV was used for ARF of diverse causes in many hospital settings and was started and managed by physicians with various levels of training and experience. The use of this technique outside the critical care setting may be optimized by a multidisciplinary educational practice guideline.

Ventilator circuit and secretion management strategies: a Franco-Canadian survey

OBJECTIVE

To determine the use of ventilator circuit and secretion management strategies in France and Canada.

DESIGN

Binational cross-sectional survey.

POPULATION

Intensive care unit (ICU) directors in French and Canadian university hospitals.

MEASUREMENTS

We compared responses between countries regarding the use of seven circuit and secretion strategies, the rationales against their use, decisional responsibility for these strategies, whether ventilator-associated pneumonia (VAP) practice was audited, and whether VAP prevention guidelines addressing these strategies were used.

RESULTS

The response rate was 72/84 (85.7%) for French and 31/32 (96.9%) for Canadian ICUs. Endotracheal intubation was predominantly oral in both countries. Changing the ventilator circuits only for every new patient was more frequent in France than in Canada (p < .0001). Heated humidifiers were used more in Canada than France (p = .0003). Closed endotracheal suctioning was used more frequently in Canada (p < .0001). In both countries, subglottic secretion drainage and kinetic beds were rarely used. Semirecumbent positioning was reported more often by French than Canadian ICUs (p = .003). Reasons for nonuse of these strategies included adverse effects (heat and moisture exchangers), cost (kinetic beds), lack of convincing benefit (subglottic secretion drainage), and nurse inconvenience (semirecumbency). Decisional responsibility for each strategy differed among institutions. VAP prevention practice was periodically reviewed in 53% of French and 68% of Canadian ICUs (p = .20). VAP prevention guidelines were used in 64% and 30% of these ICUs, respectively (p = .002).

CONCLUSIONS

Our study does not support the notion that published recommendations substantially impact reported use of several ventilator circuit and secretion management strategies. Based on the use of more frequent ventilator circuit changes, closed suctioning systems, heated humidifiers, and respiratory therapists, ventilator circuit and secretion management practice appears more costly in Canada than in France.

Identification of a signal peptide for oryzacystatin-I

A previously unidentified extension of an open reading frame from the genomic DNA of Japonica rice (Oryza sativa L.) encoding oryzacystatin-I (OC-I; access. M29259, protein ID AAA33912.1) has been identified as a 5' gene segment coding for the OC-I signal peptide. The signal peptide appears to direct a pre-protein (SPOC-I; Accession No. AF164378) to the endoplasmic reticulum, where it is processed into the mature form of OC-I. The start codon of SPOC-I begins 114 bp upstream from that previously published for OC-I. A putative proteolytic site. which may yield a mature OC-I approximately 12 residues larger than previously described, has been identified within SPOC-I between Ala-26 and Glu-27. The signal peptide sequence was amplified by polymerase chain reaction using genomic DNA from O. sativa seedlings and ligated to the 5' end of the truncated OC-I gene at the endogenous SalI site. Partially purified protein extracts from Escherichia coli expressing SPOC-I reacted with polyclonal antibodies raised against OC-I and revealed a protein of the expected molecular weight (15,355 Da). In-vitro translation of SPOC-I in the presence of microsomal membranes yielded a processed product approximately 2.7 kDa smaller than the pre-protein. Nicotiana tabacum L. cv. Xanthi plants independently transformed with the SPOC-I gene processed SPOC-I and accumulated the mature form of OC-I (approximately 12.6 kDa), which co-migrated with natural, mature OC-I extracted from rice seed when separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis.

Development, dissemination, implementation and evaluation of a clinical pathway for oxygen therapy

BACKGROUND

Oxygen is commonly administered to patients in hospital, but prescribing and monitoring of such therapy may be suboptimal. The objective of this study was to develop, disseminate, implement and evaluate a multidisciplinary clinical pathway for the administration of oxygen.

METHODS

The authors developed a clinical pathway for the ordering, titration and discontinuation of oxygen, which was disseminated through teaching sessions, in-service training sessions and information posters in a medical clinical teaching unit (CTU). Implementation of the pathway was ensured by means of reminders and patient-centred audit and feedback to CTU nurses and house staff. During a 3-month intervention phase, consecutive patients requiring supplemental oxygen were treated according to the pathway. During a 1-month "wash-out" phase followed by a 3-month non-intervention phase, patients were treated at the discretion of the CTU team. Clinical and economic data were collected in both phases.

RESULTS

In the 2 phases, patient characteristics, the concentration and duration of oxygen prescribed, the frequency of oxygen saturation monitoring, the frequency of arterial blood gas testing and the clinical outcomes were similar. However, there were more discontinuation orders in the intervention phase (p < 0.001). In the intervention phase, costs were higher for monitoring of oxygen saturation ($44.95/patient v. $36.17/patient, p = 0.048) and for order transcription ($2.71/patient v. $1.28/patient, p < 0.001); total costs, including those for personnel, were also higher in the intervention phase ($76.93/patient v. $56.67/patient, p = 0.02). The cost of education about the oxygen pathway was $45.71/patient. When the education cost was included, the total cost of oxygen therapy during the intervention phase was $122.64/patient; this was significantly higher than the total cost of oxygen therapy during the non-intervention phase ($56.67/patient) (p < 0.001).

INTERPRETATION

This multidisciplinary, multimethod oxygen pathway led to changes in oxygen-prescribing behaviour, consumed more resources than standard management and was not associated with changes in patient outcome. Appropriate management of oxygen prescribing and monitoring by physicians and nurses take time and costs money.

Neighborhood solutions for neighborhood problems: an empirically based violence prevention collaboration

Youth antisocial behavior is influenced, in part, by neighborhood context. Yet, rather than attempting to ameliorate factors contributing to youth antisocial behavior, service dollars are primarily devoted to expensive and often ineffective out-of-home placements. This article describes the development and implementation of a collaborative partnership designed to empower an economically disadvantaged neighborhood to address violent criminal behavior, substance abuse, and other serious antisocial problems of its youth while maintaining youth in the neighborhood. Through a collaboration between a university research center and neighborhood stakeholders, services are being provided to address the key priorities identified by neighborhood residents, and extensive efforts are being made to develop family and neighborhood contexts that are conducive to prosocial youth behavior.

Home-based multisystemic therapy as an alternative to the hospitalization of youths in psychiatric crisis: clinical outcomes

OBJECTIVE

The primary purpose of this study was to determine whether multisystemic therapy (MST), modified for use with youths presenting psychiatric emergencies, can serve as a clinically viable alternative to inpatient psychiatric hospitalization.

METHOD

One hundred sixteen children and adolescents approved for emergency psychiatric hospitalization were randomly assigned to home-based MST or inpatient hospitalization. Assessments examining symptomatology, antisocial behavior, self-esteem, family relations, peer relations, school attendance, and consumer satisfaction were conducted at 3 times: within 24 hours of recruitment into the project, shortly after the hospitalized youth was released from the hospital (1-2 weeks after recruitment), and at the completion of MST home-based services (average of 4 months postrecruitment).

RESULTS

MST was more effective than emergency hospitalization at decreasing youths' externalizing symptoms and improving their family functioning and school attendance. Hospitalization was more effective than MST at improving youths' self-esteem. Consumer satisfaction scores were higher in the MST condition.

CONCLUSIONS

The findings support the view that an intensive, well-specified, and empirically supported treatment model, with judicious access to placement, can effectively serve as a family- and community-based alternative to the emergency psychiatric hospitalization of children and adolescents.

Psychiatric comorbidity and the 16-month trajectory of substance-abusing and substance-dependent juvenile offenders

OBJECTIVES

To examine the concurrent correlates of internalizing and externalizing disorders among substance-abusing and substance-dependent juvenile offenders and to determine the association between psychiatric comorbidity and psychosocial functioning of the youths 16 months later.

METHOD

Participants were 118 juvenile offenders meeting DSM-III-R criteria for substance abuse or dependence and their families. A multisource measurement battery was used to assess drug use, criminal activity, family relations, peer relations, school functioning, and out-of-home placements.

RESULTS

Comorbidity for externalizing disorders was associated with high rates of antisocial behavior and predicted worse 16-month outcomes than substance abuse alone or substance abuse with comorbid internalizing disorders. For criminal activity and drug use, the presence of internalizing disorders buffered the deleterious effect of externalizing disorders on substance-abusing and substance-dependent juvenile offenders.

CONCLUSIONS

Even in substance-abusing delinquents, a population already extreme in antisocial behavior, the presence of externalizing disorders indicates high risk for deterioration.

Genomic organization of the gene coding for TIRC7, a novel membrane protein essential for T cell activation

A novel human membrane protein, TIRC7, was recently identified and demonstrated to be essential in T cell activation. Here we report on the genomic organization of the TIRC7 gene, which is composed of 15 exons and spans 7.9 kb. The seven predicted transmembrane-spanning domains of the TIRC7 protein coincide well with exon-intron boundaries. TIRC7 and OC116, a recently described putative subunit of the vacuolar proton pump that was demonstrated to be expressed in an osteoclastoma tumor as well as in a human pancreatic adenocarcinoma cell line, are demonstrated to be alternative transcripts of the same gene. OC116 consists of 20 exons with the last 14 introns and exons being identical with those of TIRC7. The chromosomal locus for both transcripts was identified on chromosome 11q13.4-q13.5. In human alloactivated T lymphocytes, mRNA expression of TIRC7, but not OC116, is demonstrated, indicating that OC116 is not involved in regular T cell proliferation.

The human homolog of Drosophila cornichon protein is differentially expressed in alloactivated T-cells

To identify novel genes induced in the early stage of T-cell activation, mRNA expression in alloactivated human lymphocytes was examined. Differential display-reverse transcription PCR analysis revealed a 207-bp cDNA fragment which was upregulated 24 h after allostimulation of a human T-cell line. The corresponding complete 1396 bp cDNA, named TGAM77, encodes a predicted 134 amino acid protein which shares 63% homology with the cornichon (cni) protein of Drosophila melanogaster. Upregulation of TGAM77 mRNA in the early phase of T-cell activation was confirmed by Northern blot and RT-PCR analysis of activated human lymphocytes. TGAM77 mRNA is expressed in a variety of human tissues with various expression levels. In analogy to cni which is involved in an epidermal growth factor-like signaling pathway inducing cellular asymmetry in Drosophila oogenesis, TGAM77 might function in similar signaling establishing vectorial re-localization and concentration of signaling events in T-cell activation.

Prevention of acute allograft rejection by antibody targeting of TIRC7, a novel T cell membrane protein

A novel 75 kDa membrane protein, TIRC7, is described that exhibits a central role in T cell activation in vitro and in vivo. Modulation of TIRC7-mediated signals with specific anti-TIRC7 antibodies in vitro efficiently prevents human T cell proliferation and IL-2 secretion. Moreover, anti-TIRC7 antibodies specifically inhibit type 1 subset specific IFN-gamma expression but spare the type 2 cytokine IL-4. Diminished proliferation but not IFN-gamma secretion is reversible by exogenous rIL-2. An anti-TIRC7 antibody that cross-reacts with the 75 kDa rat homolog exhibits inhibition of rat alloimmune response in vitro and significantly prolongs kidney allograft survival in vivo. Targeting of TIRC7 may provide a novel therapeutic approach for modulation of the immune response.

Differential display cloning of a novel human histone deacetylase (HDAC3) cDNA from PHA-activated immune cells

The nucleosomal histones can be modified through reversible acetylation by histone acetyltransferases (HATs) and deacetylases (HDACs). HATs induce nucleosomal relaxation and allow DNA-binding by transcriptional activators. HDACs from corepressor complexes which negatively regulate cell growth. However, the HDAC inhibitors butyrate and Trichostatin A block T cell proliferation, suggesting that not all effects of HDACs lead to repression. Using mRNA differential display and 5'RACE we isolated human HDAC3, a novel gene that is upregulated in PHA-activated T cell clones. HDAC3 is homologous to other human HDACs and yeast RPD3. In peripheral blood mononuclear cells (PBMCs), activation by PHA, PMA and alpha-CD3 increased HDAC mRNA but no effect was seen with IFN-gamma, LPS, or IL-4. In contrast, GMCSF downregulated PBMC levels of HDAC3 mRNA. All HDACs were found to be ubiquitously expressed in immune and non-immune tissues. In human myeloid leukemia THP-1 cells, HDAC3 transfection resulted in increased size, aberrant nuclear morphology and cell cycle G2/M cell accumulation. Functional activity of the expressed HDAC3 protein was confirmed in alpha-HDAC3 antibody immunoprecipitates by a histone deacetylase assay. Our study suggests the participation of HDACs in cell cycle progression and activation.

Partial cloning and characterization of Slc12a2: the gene encoding the secretory Na+-K+-2Cl- cotransporter

The Slc12a2 gene encodes a widely expressed bumetanide-sensitive Na+-K+-2Cl- cotransporter that participates in various functions such as Cl- secretion and cell volume regulation. We isolated and characterized 75 kilobases of the murine gene encoding the cotransporter. The cotransport protein is encoded by 27 exons. Ribonuclease protection assay and primer extension demonstrated tissue-specific transcription initiation sites located within 270 base pairs upstream of the start codon. Nucleotide sequence analysis of the proximal 5'-flanking region revealed the presence of a weak TATA box, multiple Sp1/GC consensus sites, and the consensus sequence of a putative transcriptional initiator. Transfection of luciferase reporter gene constructs in mouse inner medullary collecting duct (mIMCD-3) cells confirmed the location of the minimal promoter within a 120-base pair fragment upstream of the cDNA. We also report the identification of an alternatively spliced variant of the cotransporter, expressed primarily in brain. This new spliced variant lacks exon 21, which encodes a 16-amino acid peptide located in the COOH-terminal tail of the protein. The absence of this exon causes the loss of the single protein kinase A consensus site of the cotransport protein.

Investigating family-based alternatives to institution-based mental health services for youth: lessons learned from the pilot study of a randomized field trial

The development and validation of family-based alternatives to out-of-home placements for children is an important goal in the mental health services field. The rigorous evaluation of such alternatives, however, can be difficult to accomplish. The purpose of this article is to describe initial barriers experienced during the pilot study of a randomized trial, funded by the National Institute of Mental Health, conducted in a field setting, and the strategies that were used to overcome these barriers. The randomized trial is examining home-based multisystemic therapy as an alternative to the psychiatric hospitalization of youths presenting psychiatric emergencies. The pilot study illuminated the interface of treatment and services research issues, prompting significant changes in the project's clinical procedures, organization, and supervisory processes, as well as in the project's interface with existing community resources for serving youths with serious emotional disturbances.

Four exemplary preceptors' strategies for efficient teaching in managed care settings

To identify time-efficient and educationally effective methods for teaching in ambulatory care and managed care settings, the authors studied four exemplary preceptors who taught family medicine clerks in managed care clinics. They interviewed all four preceptors and observed three of them. All of these preceptors claimed to practice more efficiently with students than without them. Analysis of 33 patients encounters involving students revealed that each of the five students observed spent an average of 12.0 minutes conducting a history and physical examination, 2.2 minutes presenting the case to the preceptor, 7.9 minutes observing the preceptor reviewing and/or repeating the examination with the patient, and 1.8 minutes receiving direct instruction and feedback from the preceptor. The total time per patient encounter was 23.7 minutes, 11.7 minutes of which directly involved the preceptor. The authors then compared these 33 encounters with encounters involving the preceptors alone; these encounters took an average of 10.6 minutes of the preceptors' time. The 1.1-minute difference between the amount of time preceptors spent in encounters involving students and the amount of time they spent in encounters on their own was not statistically significant as measured by t-test (p < .05). However, in calculating this time difference, possible time saved by students' assistance with charting was not accounted for. In interviews the preceptors identified three major instructional strategies for time-efficient teaching; planning and preparing; teaching with patients; and charting, giving feedback, and reflecting. Students described these preceptors as enthusiastic teachers and good role models; however, they also felt that their first two years of education had not prepared them for seeing patients in fast-paced ambulatory care settings. The challenge for medical schools is to better prepare both students and preceptors for learning and teaching in productivity driven ambulatory care and managed care environments.

Generalized covariance-adjusted discriminants: perspective and application

When discriminant analysis is used in practice for assessing the usefulness of diagnostic markers, the lack of control over covariates motivates the need for their adjustment in the analysis. This necessity for adjustment arises especially when the researcher's aim is classification based on a set of diagnostic markers and is not based on a set of covariates for which there exists known heterogeneity among the subjects with respect to the groups under consideration. The traditional covariance-adjusted approach is restrictive for such applications in that they assume linear covariates and a normal distribution for the the feature vector. Further, there is no available method for variable selection in using such covariance-adjusted models. In this paper, we generalize the traditional covariance-adjusted model to a general normal and logistic model, where these generalized models not only relax the distributional assumptions on the feature vector but also allow for nonlinear covariates. Exact and asymptotic tests are also derived for the problem of variable selection for these new models. The methodology is illustrated with both simulated data and an actual data set from a psychiatric study on using the Social Rhythm Metric for patients with anxiety disorders.

Transcriptional responses to tubule challenges

Adaptation to physiological stimuli often involves changes in gene transcription. Studies of hyperosmolar stress in renal epithelial cells have provided an ideal paradigm for understanding regulation of gene expression. Renal epithelial cells respond very differently to hyperosmolar NaCl and urea and several strategies including cloning based on known biological function, candidate gene analysis, and differential display analysis have successfully identified many genes induced by these hyperosmolar challenges. Hyperosmolar NaCl produces adverse effects on cellular biosynthetic processes and compensatory increases are observed in transcription of transporters, stress proteins, and metabolic enzymes. In contrast, hyperosmolar urea fails to inhibit biosynthetic processes but, nonetheless, initiates a very specific program of gene expression in renal epithelial cells. This program appears to involve a urea sensor/receptor system which activates transcription and translation of the zinc-finger transcription factor Egr-1. This work highlights the concept that rapid analysis of differential gene expression will enable one to define cellular programs of gene expression involving up- and down-regulation of functionally-related gene families.

Osmotic stress protein 94 (Osp94). A new member of the Hsp110/SSE gene subfamily

Preservation of cell viability and function in the hyperosmolar environment of the renal medulla is a complex process that requires selective gene expression. We have identified a new member of the heat shock protein (hsp) 70 superfamily that is up-regulated in renal inner medullary collecting duct cells (mIMCD3 cells) during exposure to hyperosmotic NaCl stress. Known as osmotic stress protein 94, or Osp94, this 2935-base pair cDNA encodes an 838-amino acid protein that shows greatest homology to the recently discovered hsp110/SSE gene subfamily. Like the hsps, Osp94 has a putative amino-terminal ATP-binding domain and a putative carboxyl-terminal peptide-binding domain. The in vitro translated Osp94 product migrated as a 105-110-kDa protein on SDS-polyacrylamide gel electrophoresis. In mIMCD3 cells, Osp94 mRNA expression was greatly up-regulated by hyperosmotic NaCl or heat stress. In mouse kidney, Osp94 mRNA expression paralleled the known corticomedullary osmolality gradient showing highest expression in the inner medulla. Moreover, inner medullary Osp94 expression was increased during water restriction when osmolality is known to increase. Thus, Osp94 is a new member of the hsp110/SSE stress protein subfamily and likely acts as a molecular chaperone.

Diagnostic ophthalmology. Orbital mast cell neoplasia

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