Parent and grandparent neonatal intensive care unit visitation for preterm infants

OBJECTIVE

Characterize family NICU visitation and examine associations with maternal health and social factors and infant health outcomes.

STUDY DESIGN

Retrospective cohort study of 167 infants born ≤32 weeks at two urban NICUs 01/2019-03/2020. Average nurse-documented family member visitation and associations of visitation with maternal and infant factors and outcomes were compared.

RESULTS

Mothers visited 4.4 days/week, fathers 2.6 days/week, and grandparents 0.4 days/week. Older maternal age, nulliparity, and non-English primary language were associated with more frequent family visitation. Mothers with depression or anxiety history visited less. Maternal depression and public insurance were associated with fewer father visits. Low parental visitation was associated with lower odds of feeding any maternal milk at discharge and low maternal visitation with 11.5% fewer completed infant subspecialty appointments in the year following discharge (95% CI -20.0%, -3.0%).

CONCLUSION

Families with social disadvantage visited less often. Parental visitation was associated with infant feeding and follow-up.

Validating a robust double-quantum-filtered (1) H MRS lactate measurement method in high-grade brain tumours

(1) H MRS measurements of lactate are often confounded by overlapping lipid signals. Double-quantum (DQ) filtering eliminates lipid signals and permits single-shot measurements, which avoid subtraction artefacts in moving tissues. This study evaluated a single-voxel-localized DQ filtering method qualitatively and quantitatively for measuring lactate concentrations in the presence of lipid, using high-grade brain tumours in which the results could be compared with standard acquisition as a reference. Paired standard acquisition and DQ-filtered (1) H MR spectra were acquired at 3T from patients receiving treatment for glioblastoma, using fLASER (localization by adiabatic selective refocusing using frequency offset corrected inversion pulses) single-voxel localization. Data were acquired from 2 × 2 × 2 cm(3) voxels, with a repetition time of 1 s and 128 averages (standard acquisition) or 256 averages (DQ-filtered acquisition), requiring 2.15 and 4.3 min respectively. Of 37 evaluated data pairs, 20 cases (54%) had measureable lactate (fitted Cramér-Rao lower bounds ≤ 20%) in either the DQ-filtered or the standard acquisition spectra. The measured DQ-filtered lactate signal was consistently downfield of lipid (1.33 ± 0.03 ppm vs 1.22 ± 0.08 ppm; p = 0.002), showing that it was not caused by lipid breakthrough, and that it matched the lactate signal seen in standard measurements (1.36 ± 0.02 ppm). In the absence of lipid, similar lactate concentrations were measured by the two methods (mean ratio DQ filtered/standard acquisition = 1.10 ± 0.21). In 7/20 cases with measurable lactate, signal was not measureable in the standard acquisition owing to lipid overlap but was quantified in the DQ-filtered acquisition. Conversely, lactate was undetected in seven DQ-filtered acquisitions but visible using the standard acquisition. In conclusion, the DQ filtering method has proven robust in eliminating lipid and permits uncontaminated measurement of lactate. This is important validation prior to use in tissues outside the brain, which contain large amounts of lipid and which are often susceptible to motion.

Balloon Angioplasty for Arteriovenous Graft Stenosis

Purpose:

To retrospectively review the long-term outcome as well as the cost effectiveness of thrombolytic therapy and balloon angioplasty (TBA) versus surgical thrombectomy and balloon angioplasty (SBA) in the treatment of prosthetic dialysis access grafts.

Methods:

Between February 1996 and February 1999, 63 hemodialysis patients (35 women; mean age 62.2 years) were treated for 105 thromboses in 6-mm polytetrafluoroethylene straight or loop bridge arteriovenous grafts. Choice of treatment was at the discretion of the surgeon or interventional radiologist: either Fogarty balloon thrombectomy followed by balloon dilation of the venous anastomotic stenosis or urokinase thrombolysis followed by angioplasty.

Results:

Forty-eight SBAs and 55 TBAs were performed in 63 patients without complications. The primary patency rates in the entire cohort were 34%, 29%, and 17% at 1, 2, and 3 months, respectively. Primary patency after TBA was 29%, 18%, and 11%, and that for SBA, 45%, 45%, and 33% over the same time intervals. The mean graft survival was 10 days for TBA versus 31 days for SBA. Repeat angioplasty performed in 23 grafts produced secondary patency rates of 52% at 1 month, 34% at 3 months, and 5% at 5 months. The Medicare reimbursement for both treatments was identical ($1638 for TBA and $1670 for SBA).

Conclusions:

The poor patency rate and high cost of TBA and SBA suggests that these procedures should not be routinely used for salvage of thrombosed arteriovenous grafts with outflow stenosis. Patch angioplasty or creation of simultaneous temporary and new permanent accesses may be a more cost-effective approach in these patients.

Crowdsourcing the General Public for Large Scale Molecular Pathology Studies in Cancer

BACKGROUND

Citizen science, scientific research conducted by non-specialists, has the potential to facilitate biomedical research using available large-scale data, however validating the results is challenging. The Cell Slider is a citizen science project that intends to share images from tumors with the general public, enabling them to score tumor markers independently through an internet-based interface.

METHODS

From October 2012 to June 2014, 98,293 Citizen Scientists accessed the Cell Slider web page and scored 180,172 sub-images derived from images of 12,326 tissue microarray cores labeled for estrogen receptor (ER). We evaluated the accuracy of Citizen Scientist's ER classification, and the association between ER status and prognosis by comparing their test performance against trained pathologists.

FINDINGS

The area under ROC curve was 0.95 (95% CI 0.94 to 0.96) for cancer cell identification and 0.97 (95% CI 0.96 to 0.97) for ER status. ER positive tumors scored by Citizen Scientists were associated with survival in a similar way to that scored by trained pathologists. Survival probability at 15 years were 0.78 (95% CI 0.76 to 0.80) for ER-positive and 0.72 (95% CI 0.68 to 0.77) for ER-negative tumors based on Citizen Scientists classification. Based on pathologist classification, survival probability was 0.79 (95% CI 0.77 to 0.81) for ER-positive and 0.71 (95% CI 0.67 to 0.74) for ER-negative tumors. The hazard ratio for death was 0.26 (95% CI 0.18 to 0.37) at diagnosis and became greater than one after 6.5 years of follow-up for ER scored by Citizen Scientists, and 0.24 (95% CI 0.18 to 0.33) at diagnosis increasing thereafter to one after 6.7 (95% CI 4.1 to 10.9) years of follow-up for ER scored by pathologists.

INTERPRETATION

Crowdsourcing of the general public to classify cancer pathology data for research is viable, engages the public and provides accurate ER data. Crowdsourced classification of research data may offer a valid solution to problems of throughput requiring human input.

Evaluation of lactate detection using selective multiple quantum coherence in phantoms and brain tumours

Lactate is a product of glucose metabolism. In tumour tissues, which exhibit enhanced glycolytic metabolism, lactate signals may be elevated, making lactate a potential useful tumour biomarker. Methods of lactate quantitation are complicated because of overlap between the lactate methyl doublet CH3 resonance and a lipid resonance at 1.3 ppm. This study presents the use of a selective homonuclear multiple quantum coherence transfer sequence (SelMQC-CSI), at 1.5 T, to better quantify lactate in the presence of lipids. Work performed on phantoms showed good lactate detection (49%) and lipid suppression (98%) efficiencies. To evaluate the method in the brain, the sequence was tested on a group of 23 patients with treated brain tumours, either glioma (N=20) or secondary metastases in the brain (N=3). Here it was proved to be of use in determining lactate concentrations in vivo. Lactate was clearly seen in SelMQC spectra of glioma, even in the presence of lipids, with high grade glioma (7.3 ± 1.9 mM, mean ± standard deviation) having higher concentrations than low grade glioma (1.9 ± 1.5 mM, p=0.048). Lactate was not seen in secondary metastases in the brain. SelMQC-CSI is shown to be a useful technique for measuring lactate in tumours whose signals are otherwise contaminated by lipid.

Thoracic outlet syndrome in children and young adults

OBJECTIVES

Thoracic outlet syndrome has been well described in the population between 25 and 40 years of age, and is less frequently reported in those in the first two decades of life. The objective of this study was to review results with onset of TOS in the first two decades of life to determine type of presentation and outcomes from surgical intervention.

METHODS AND MATERIALS

Charts of all patients in the first two decades of life, operated on for TOS between 1994 and 2006 were reviewed with follow-up by clinic visit and phone survey to assess the patients' current level of activity and relief from symptoms.

RESULTS

Twelve patients were identified (13 operations), with a mean age of 16.8 years. Acute ischemic symptoms were the initial presentation for 38%, venous TOS in 24%, and neurogenic symptoms in 38%. All patients had symptom relief with surgery with a mean time to resolution of 10.9 weeks. All patients remained symptom free or improved at follow-up.

CONCLUSIONS

Vascular TOS is much more common in TOS presenting in the first two decades of life. Surgical intervention for TOS in this population results in long-lasting symptom relief and should be considered for all subtypes of patients.

The relationship between cognitive function and clinical and functional outcomes in major depressive disorder

BACKGROUND

Although cognitive variables have been shown to be useful in predicting outcomes in late-life depression, there has not yet been a comprehensive study in younger persons with depression.

METHOD

The clinical symptoms and cognitive performance of participants were evaluated at admission to one of two university teaching hospitals and again at 3 months after remission and discharge. A total of 52 participants with a DSM-IV diagnosis of major depressive disorder, aged between 20 and 60 years and with a Hamilton Depression Rating Scale score 17 > or = entered the study. The sample for this paper comprises the 48 subjects (mean age 37.9 years, s.d.=10.7) who received admission and follow-up assessments; an attrition rate of 7.7%.

RESULTS

More perseverative errors on the shortened Wisconsin Card Sorting Test at admission predicted a worse clinical outcome at follow-up. Poor event-based prospective memory and more perseverative errors on the shortened Wisconsin Card Sorting Test at admission predicted worse social and occupational outcome at follow-up.

CONCLUSIONS

These results suggest that a brief cognitive screen at hospital admission, focusing on executive function, would have a useful prognostic value in depression. Determining early predictors of individuals at risk of poorer outcomes is important for identifying those who may need altered or additional treatment approaches.

Identification and characterisation of childhood cerebellar tumours by in vivo proton MRS

(1)H MRS has great potential for the clinical investigation of childhood brain tumours, but the low incidence in, and difficulties of performing trials on, children have hampered progress in this area. Most studies have used a long-TE, thus limiting the metabolite information obtained, and multivariate analysis has been largely unexplored. Thirty-five children with untreated cerebellar tumours (18 medulloblastomas, 12 pilocytic astrocytomas and five ependymomas) were investigated using a single-voxel short-TE PRESS sequence on a 1.5 T scanner. Spectra were analysed using LCModel to yield metabolite profiles, and key metabolite assignments were verified by comparison with high-resolution magic-angle-spinning NMR of representative tumour biopsy samples. In addition to univariate metabolite comparisons, the use of multivariate classifiers was investigated. Principal component analysis was used for dimension reduction, and linear discriminant analysis was used for variable selection and classification. A bootstrap cross-validation method suitable for estimating the true performance of classifiers in small datasets was used. The discriminant function coefficients were stable and showed that medulloblastomas were characterised by high taurine, phosphocholine and glutamate and low glutamine, astrocytomas were distinguished by low creatine and high N-acetylaspartate, and ependymomas were differentiated by high myo-inositol and glycerophosphocholine. The same metabolite features were seen in NMR spectra of ex vivo samples. Successful classification was achieved for glial-cell (astrocytoma + ependymoma) versus non-glial-cell (medulloblastoma) tumours, with a bootstrap 0.632 + error, e(B.632+), of 5.3%. For astrocytoma vs medulloblastoma and astrocytoma vs medulloblastoma vs ependymoma classification, the e(B.632+) was 6.9% and 7.1%, respectively. The study showed that (1)H MRS detects key differences in the metabolite profiles for the main types of childhood cerebellar tumours and that discriminant analysis of metabolite profiles is a promising tool for classification. The findings warrant confirmation by larger multi-centre studies.

Evaluation of a screening protocol to exclude the diagnosis of deep venous thrombosis among emergency department patients

OBJECTIVE

The purpose of this study was to evaluate the efficacy and cost effectiveness of a deep venous thrombosis (DVT) screening protocol incorporating DVT pretest probability (PTP), selective D-dimer assay, and venous duplex imaging (VDI) to exclude the diagnosis of DVT among emergency department (ED) patients.

METHODS

A prospective study of all patients evaluated in the ED for suspected DVT during 1 year was undertaken. Patients were classified into PTP risk category by ED physicians before VDI. Correlation studies were completed using VDI as the gold standard. Charges associated with the protocol were calculated.

RESULTS

One hundred fourteen patients were included. The incidence of DVT was 9.6% (11). Thirty-six (55%) patients were classified as high risk, 23 (35%) as moderate, and 7 (10%) as low risk. All patients diagnosed with DVT were in the high-risk group (incidence, 16.7%). The sensitivity and negative predictive value were both 100% when PTP and D-dimer were used, but fell to 80% and 95%, respectively, when only D-dimer was considered. The true negative rates were 23% and 37%, respectively. Based on this study, we propose the following screening: for high-risk patients, use direct VDI (no D-dimer); for low-risk or moderate-risk patients, obtain D-dimer, and if it is positive, use VDI, and if it is negative, no further action is required. The average charge associated with the protocol was 170.50 dollars as opposed to 202.00 dollars for global VDI.

CONCLUSION

A screening protocol using PTP along with selective D-dimer and VDI to exclude the diagnosis of DVT among ED patients is efficacious and cost efficient. This screening approach establishes criteria to satisfy billing requirements, can eliminate unnecessary VDI in 23% of ED referrals, and can reduce charges by 16%.

Fermentation characterization and flux analysis of recombinant strains of Clostridium acetobutylicum with an inactivated solR gene

The effect of solR inactivation on the metabolism of Clostridium acetobutylicum was examined using fermentation characterization and metabolic flux analysis. The solR-inactivated strain (SolRH) of this study had a higher rate of glucose utilization and produced higher solvent concentrations (by 25%, 14%, and 81%, respectively, for butanol, acetone, and ethanol) compared to the wild type. Strain SolRH(pTAAD), carrying a plasmid-encoded copy of the bifunctional alcohol/aldehyde dehydrogenase gene (aad) used in butanol production, produced even higher concentrations of solvents (by 21%, 45%, and 62%, respectively, for butanol, acetone, and ethanol) than strain SolRH. Clarithromycin used for strain SolRH maintenance during SolRH(pTAAD) fermentations did not alter product formation; however, tetracycline used for pTAAD maintenance resulted in 90% lower solvent production.

The relationship between inflated personal responsibility and exaggerated danger expectancies in obsessive-compulsive concerns

The association between responsibility for a negative outcome, perceived severity of the outcome and perceived likelihood of the outcome was examined in a sample of 70 undergraduate students. Participants were asked to rate the likelihood and severity of 10 negative outcomes, five related to contamination and five related to checking. Thirty-eight participants completed a version of the questionnaire that presented the subject as responsible for the action that may lead to a negative outcome ('personally responsible' group). The remaining 32 completed a version of the questionnaire that presented someone else performing the actions that may lead to a negative outcome ('other responsible' group). Significant differences emerged between the personally responsible and other responsible groups for severity of outcome ratings but not for likelihood of outcome ratings. Specifically, for both washing and checking concerns, participants in the personally responsible group rated the severity of the potential negative outcome as greater than did those in the other responsible group. The results support the claimed general tendency for individuals to regard an outcome as more aversive if they are personally responsible for that outcome, rather than someone else being responsible. The results suggest that, in general, increasing perceptions of personal responsibility will increase cost or severity estimates in subjective danger calculations, and that responsibility may influence OCD phenomena in this way. Finally, the results suggest that attempts to manipulate responsibility in the laboratory may be confounded by necessarily impacting on cost estimates, and therefore on danger expectancies.

Intravenous leiomyomatosis with cardiac extension: tumor thrombectomy through an abdominal approach

Intravenous leiomyomatosis is an uncommon vascular tumor that may be seen with potentially life-threatening symptoms resulting from intracardiac extension. This tumor is frequently misdiagnosed and treated without appropriate preoperative imaging and planning, which at times leads to inadequate treatment and incomplete resections. The appropriate therapy is complete excision of the tumor. We describe a patient who was treated with a new approach involving a single-stage operation without the need for median sternotomy, cardiopulmonary bypass graft, or hypothermic arrest by resection of the tumor from the point of attachment in the abdominal portion of the inferior vena cava.

Characterization of recombinant strains of the Clostridium acetobutylicum butyrate kinase inactivation mutant: need for new phenomenological models for solventogenesis and butanol inhibition?

Two metabolic engineering tools, namely gene inactivation and gene overexpression, were employed to examine the effects of two genetic modifications on the fermentation characteristics of Clostridium acetobutylicum. Inactivation of the butyrate kinase gene (buk) was examined using strain PJC4BK, while the combined effect of buk inactivation and overexpression of the aad gene-encoding the alcohol aldehyde dehydrogense (AAD) used in butanol formation-was examined using strain PJC4BK(pTAAD). The two strains were characterized in controlled pH > or = 5.0 fermentations, and by a recently enhanced method of metabolic flux analysis. Strain PJC4BK was previously genetically characterized, and fermentation experiments at pH > or = 5.5 demonstrated good, but not exceptional, solvent-production capabilities. Here, we show that this strain is a solvent superproducer in pH > or = 5.0 fermentations producing 225 mM (16.7 g/L) of butanol, 76 mM of acetone (4.4 g/L), and 57 mM (2.6 g/L) of ethanol. Strain PJC4BK(pTAAD) produced similar amounts of butanol and acetone but 98 mM (4.5 g/L) of ethanol. Both strains overcame the 180 mM (13 g/L) butanol toxicity limit, without any selection for butanol tolerance. Work with strain PJC4BK(pTAAD) is the first reported use of dual antibiotic selection in C. acetobutylicum. One antibiotic was used for selection of strain PJC4BK while the second antibiotic selected for the pTAAD presence. Overexpression of aad from pTAAD resulted in increased ethanol production but did not increase butanol titers, thus indicating that AAD did not limit butanol production under these fermentation conditions. Metabolic flux analysis showed a decrease in butyrate formation fluxes by up to 75% and an increase in acetate formation fluxes of up to 100% during early growth. The mean specific butanol and ethanol formation fluxes increased significantly in these recombinant strains, up to 300% and 400%, respectively. Onset of solvent production occurred during the exponential-growth phase when the culture optical density was very low and when total and undissociated butyric acid levels were <1 mM. Butyrate levels were low throughout all fermentations, never exceeding 20 mM. Thus, threshold butyrate concentrations are not necessary for solvent production in these stains, suggesting the need for a new phenomenological model to explain solvent formation.

Isolated iliac artery aneurysms in patients with or without previous abdominal aortic aneurysm repair

BACKGROUND

Isolated iliac artery aneurysms (IAA) in patients with or without previous abdominal aortic aneurysm (AAA) repair are rare. We wanted to compare the presentation, distribution, treatment, outcome and patterns of subsequent aneurysm formation in these patients.

METHODS

We retrospectively reviewed patients with isolated IAA over a 10-year period. Patients with primary isolated IAA (group 1) were compared with patients who presented with IAA after previous AAA repair (group 2).

RESULTS

There were 23 patients in each group. Demographics and comorbidities were similar. No aneurysms were detected outside of the iliac system in group 1; 22% of patients in group 2 had other aneurysms. The mean time after AAA repair to IAA diagnosis was 8.8 +/- 3.2 years for operated on patients. The in-hospital mortality was 0% for elective cases and 50% for emergency cases for both groups. Three patients in group 2 (13%) developed new aneurysms during follow-up, whereas the only new aneurysm in group 1 was a contralateral IAA.

CONCLUSIONS

Patients with new IAA after AAA repair have a greater tendency to develop further aneurysms in other sites, synchronously or metachronously. The time to detection of new IAA after AAA repair is at least 5 years in most cases. In both groups, a quarter to a third of patients present with rupture, with a resultant mortality of 30% to 50%, whereas those operated on electively have minimal morbidity and almost no mortality.

Metabolic flux analysis elucidates the importance of the acid-formation pathways in regulating solvent production by Clostridium acetobutylicum

Metabolic flux analysis was used to investigate the roles of the acid formation pathways in Clostridium acetobutylicum. The acid formation pathways were revealed to serve different roles in wildtype fermentations than previously expected. Specifically, enzymes known to catalyze butyrate formation were found to uptake butyrate without concomitant production of acetone. This role was further corroborated by flux analysis of a recombinant strain overexpressing the butyrate formation enzymes. Analysis of wildtype fermentation data also revealed an important role for the acetate formation enzymes, namely the cycling of carbon between acetate and acetylCoA during the stationary phase. Next, metabolic flux analysis was used to compare the patterns of activity in two butyrate kinase deficient strains of C. acetobutylicum. The strain developed by gene inactivation, PJC4BK, exhibited a shift in acid formation fluxes toward acetate while the strain developed by antisense RNA strategies, 824(pRD4), did not exhibit such a shift. However, both strains exhibited altered solvent formation patterns. PJC4BK exhibited a strong transient enhancement of solvent formation fluxes. In contrast, 824(pRD4) exhibited relatively lower levels of solvent formation fluxes, although fluxes were sustained over a longer period of time.

Molecular epidemiologic evaluation of transmissibility and virulence of Mycobacterium tuberculosis

Discovery of genotypic markers associated with increased transmissibility in Mycobacterium tuberculosis would represent an important step in advancing mycobacterial virulence studies. M. tuberculosis strains may be classified into one of three genotypes on the basis of the presence of specific nucleotide substitutions in codon 463 of the katG gene (katG-463) and codon 95 of the gyrA gene (gyrA-95). It has previously been reported that two of these three genotypes are associated with increased IS6110-based clustering, a potential proxy of virulence. We designed a case-control analysis of U.S.-born patients with tuberculosis in San Francisco, Calif., between 1991 and 1997 to investigate associations between katG-463 and gyrA-95 genotypes and epidemiologically determined measures of strain-specific infectivity and pathogenicity and IS6110-based clustering status. We used a new class of molecular probes called molecular beacons to genotype the isolates rapidly. Infectivity was defined as the propensity of isolates to cause tuberculin skin test conversions among named contacts, and pathogenicity was defined as their propensity to cause active disease among named contacts. The molecular beacon assay was a simple and reproducible method for the detection of known single nucleotide polymorphisms in large numbers of clinical M. tuberculosis isolates. The results showed that no genotype of the katG-463- and gyrA-95-based classification system was associated with increased infectivity and pathogenicity or with increased IS6110-based clustering in San Francisco during the study period. We speculate that molecular epidemiologic studies investigating clinically relevant outcomes may contribute to the knowledge of the significance of laboratory-derived virulence factors in the propagation of tuberculosis in human communities.

Evidence for fear of restriction and fear of suffocation as components of claustrophobia

Recent investigations of the aetiology and treatment of specific phobias have focused on clarifying the concerns underlying phobic anxiety. It has been proposed that claustrophobic fear is comprised of separable confinement and suffocation components. This paper presents data from 78 general medical outpatients undergoing magnetic resonance imaging (MRI) scans in two major teaching hospitals. The findings support the two factor structure of claustrophobia, in that exposure to confinement reduced confinement subscale scores, but did not influence suffocation scores.

Impact of curricular change in an undergraduate program for speech pathologists on perceived preparedness for the workplace

Recently, educational policymakers have emphasized the need for undergraduate programs to develop in their graduates generic skills and attributes beyond discipline-specific skills and knowledge. The generic skills and attributes should mesh with the requirements of the workplaces where the graduates will find employment. The present study examined the impact of curricular revisions to a program of study for speech pathologists on the perceptions of the graduates regarding their preparation in appropriate skill and knowledge domains. The curricular revisions sought to develop independent learning, critical thinking, research and evaluation skills, written and oral communication skills, and skills for seeking and providing support to peers. Seventy-eight graduates of the earlier program and 21 graduates of the revised program offered by the School of Communication Disorders at The University of Sydney completed a 52-item questionnaire concerning the extent to which the program had equipped them for the workplace. Eleven scales were derived from the questionnaire responses, reflecting skills endorsed by university educators and workplace supervisors of allied health professionals as being necessary for success in the workplace. The relative levels of perceived preparation on the 11 dimensions were similar across graduates of the revised program and those of the earlier program. Graduates of the revised program were significantly more positive about their preparation on five of the 11 dimensions, compared with earlier graduates of approximately equivalent age and experience. The dimensions where differences were observed generally reflected those targeted by the curricular revisions.

Mood and prospective memory

This study considered the relationship between mood states, prospective memory, and retrospective memory among a non-clinical sample of undergraduate students. Multiple regression analyses with simultaneous entry of variables were undertaken to examine the unique contributions of the alternate memory test and the emotional states to memory test performance. As expected, retrospective free recall performance and anxiety made unique and significant contributions to performance on the prospective memory task. However, only prospective memory performance emerged as a significant predictor of retrospective free recall. It is suggested that none of the mood measures emerged as a significant predictor of retrospective memory performance because they do not account for unique variance. In contrast, the relationship between anxiety and prospective memory appears to be due to factors uniquely associated with anxiety, and unrelated to depression.

The convergent validity of the Phobia Origins Questionnaire (POQ): a review of the evidence

The Phobic Origins Questionnaire (POQ) [Ost, L.-G. & Hugdahl, K. (1981). Acquisition of phobias and anxiety response patterns in clinical patients. Behaviour Research and Therapy, 19, 439-447.] is the most commonly cited instrument for determining the origins of phobic anxiety and data obtained using this instrument strongly support the role of conditioning in the acquisition of fear reactions. The construct validity of the POQ in assessing episodes of conditioning has been questioned [e.g. Menzies, R. G. & Clarke, J. C. (1994). Retrospective studies of the origins of phobias: a review. Anxiety, Stress and Coping, 7, 305-318.] This paper examined the convergent validity of the POQ by comparing origins' classifications based on the POQ to classifications based on alternative instruments. The convergent validity of the POQ was found to be extremely poor. The POQ was consistently associated with a much greater likelihood of classifying the origin of fear reactions as due to direct conditioning episodes than was found using alternative instruments. The findings question the usefulness of the POQ in examining the origins of phobic anxiety.

Premature peripheral vascular disease: clinical profile and abnormal lipid peroxidation

The aim of this study was to determine any biochemical differences between early-onset peripheral vascular disease and typical onset atherosclerosis, and age-matched controls. A subset of patients present at a young age ( < 50 years) with peripheral vascular disease which pursues an aggressive course. As lipid oxidation seems important in atherosclerosis, total lipid peroxides, oxidized subfractions, and Trolox equivalent antioxidant capacity (TEAC) were studied in patients with premature peripheral vascular disease. Charts were reviewed of patients operated on for vascular occlusive disease over a 5-year period. Patients with early-onset peripheral vascular disease (group I) were evaluated for biochemical abnormalities and compared with typical onset atherosclerotics (group II) and age-matched controls (group III). Sixteen patients with early-onset peripheral vascular disease underwent biochemical evaluation. Conventional lipid profiles did not differ statistically from those of age-matched controls, except for mild elevations in LDL and VLDL in patients with vascular occlusive disease (207 and 195 mg/dl in groups I and 11 versus 157 mg/dl in group III). Total oxidative potential was significantly elevated (P = 0.006) 3.04, 2.15 and 2.04 nmol/ml in groups I, II and III, respectively. Levels of oxidized LDL and VLDL were even more significantly elevated (P = 0.0009) for premature peripheral vascular disease, (1.2, 0.58 and 0.47 nmol/ml in groups I-II). TEAC values did not differ significantly between groups (0.83, 0.82, 0.82 nmol/ml) and did not correlate with total lipid peroxide values for individual patients. In conclusion, lipid peroxides were significantly elevated in patients with premature peripheral vascular disease, the most marked changes being seen in oxidized LDL and VLDL subfractions. Lipid peroxides were elevated when standard lipid profiles were only mildly abnormal. The poor long-term prognosis in these patients suggests the need for aggressive evaluation and treatment of lipid abnormalities.

Health science graduates: preparation for the workplace

The research reported in this article was undertaken to assess the perceptions of health science graduates in the fields of health information management, occupational therapy, orthoptics, physiotherapy, and speech pathology regarding their perceptions of the adequacy of undergraduate preparation in meeting the demands of a changing health care environment. An instrument was devised for use by graduates on the basis of the skills and workplace behaviours specified by experienced practitioners in the above fields as necessary in newly recruited graduates. A total of 527 health science graduates completed the 52 item instrument. The statistical analyses indicated that 11 factors define the adequacy of graduates' preparation for the workplace. Health science graduates perceived themselves to have been more thoroughly prepared on certain workplace dimensions than on others. Specifically, graduates perceived themselves to be ill-equipped on dimensions concerned with workplace management, knowledge of the health industry, and coping in the workplace. Graduates also perceived themselves to be inadequately prepared in terms of communicating with clients, health professionals, and the general public. The strengths of their courses were perceived to be in completing essential tasks, having confidence in the clinical role, in ethical practice, in pursuit and application of knowledge, and having a realistic expectation of the workplace role. The results are discussed in terms of the need to address curriculum changes.

Screening for asymptomatic deep vein thrombosis in surgical intensive care patients

PURPOSE

To identify the presence of occult deep vein thrombosis (DVT) in surgical intensive care unit (SICU) patients and to avoid unnecessary screening, we reviewed our experience with routine duplex screening for DVT in SICU patients.

METHODS

Over a 24-month period, all patients who were admitted to an SICU with an anticipated length of stay greater than 36 hours were studied to determine the prevalence of risk factors for asymptomatic proximal DVT. Risk factors, demographics, and operative data were collected and analyzed with multilinear regression, t tests and chi 2 analysis.

RESULTS

There was a 7.5% prevalence of major DVT in the 294 patients studied. APACHE II scores (14.5 +/- 6.24 vs 10.3 +/- 3.15; p < 0.0001) and emergent procedures (45.5% vs 23.2%; p > 0.0344) were associated with DVT by multifactorial analysis. Age was significant by univariate analysis. An algorithm based on the presence of any one of the three risk factors identified (APACHE II score 12 or more; emergent procedures; or age 65 or greater) could be used to limit screening by 30% while achieving a 95.5% sensitivity for identification of proximal DVT.

CONCLUSION

Absence of all three risk factors indicates a very low risk for DVT (1.1%). Screening of SICU patients is indicated because of a high prevalence of asymptomatic disease. Patients who have proximal DVT require active therapy and not prophylaxis. Costs and resources may be contained by using the above risk factors as a filter for duplex screening.

Small bowel obstruction secondary to enterolith impaction complicating jejunal diverticulitis

A case of small bowel obstruction secondary to enterolith impaction in the presence of jejunal diverticular disease is described. Only 27 cases of small bowel obstruction by enterolith expelled from small bowel diverticula have been reported in the literature. The reported incidence of jejunal diverticulosis in the general population ranges from 0.02 to 7.1%. Most patients are asymptomatic, but 10% develop complications requiring surgical intervention. Surgical treatment is an enterotomy and stone extraction or manually crushing and milking the stone distally into the colon. Small bowel resection and anastomosis or laparoscopic-assisted small bowel resection are indicated for the treatment of diverticulitis, bowel perforation, or multiple diverticuli. Jejunal diverticular disease should be considered in the differential diagnosis of mechanical small bowel obstruction without an obvious cause, especially in the elderly population.

Genetic manipulation of acid formation pathways by gene inactivation in Clostridium acetobutylicum ATCC 824

Integrational plasmid technology has been used to disrupt metabolic pathways leading to acetate and butyrate formation in Clostridium acetobutylicum ATCC 824. Non-replicative plasmid constructs, containing either clostridial phosphotransacetylase (pta) or butyrate kinase (buk) gene fragments, were integrated into homologous regions on the chromosome. Integration was assumed to occur by a Campbell-like mechanism, inactivating either pta or buk. Inactivation of the pta gene reduced phosphotransacetylase and acetate kinase activity and significantly decreased acetate production. Inactivation of the buk gene reduced butyrate kinase activity, significantly decreased butyrate production and increased butanol production.

Long-term follow-up of patients with early atherosclerosis

PURPOSE

Patients with premature peripheral vascular disease may respond differently than their older counterparts. To determine the impact of early onset of atherosclerosis on outcome, we decided to compare a group of these patients with a group of patients with typical onset of atherosclerosis with regard to early complications, indications for intervention, site of disease at initial presentation (aortoiliac, infrainguinal, or cerebrovascular), and long-term outcomes (secondary revascularization, amputation, and death).

METHOD

All patients younger than 50 years old requiring operative intervention between 1987 and 1992 were retrospectively compared with a group of patients greater than 60 years old, randomly selected from patients who underwent operation during the same time period. Patients were evaluated and compared for indications, risk factors, and early and late outcomes.

RESULTS

Patients with early onset atherosclerosis at the aortoiliac or infrainguinal level had a higher late amputation rate (17% versus 3.9%, p = 0.02) and poorer overall outcome than their older cohorts. Patients with cerebrovascular disease in both cohorts had similarly good prognoses.

CONCLUSION

Aortoiliac or infrainguinal disease diagnosed in patients less than 50 years of age portends a poorer outcome than does similar disease in an older patient population.

External carotid endarterectomy with internal carotid artery transposition flap angioplasty for symptomatic internal carotid artery occlusion

The external carotid artery is an important collateral pathway for cerebral perfusion when the internal carotid artery is occluded. After internal carotid artery occlusion, there is a definite risk of ipsilateral neurological events. The authors retrospectively examined their experience with endarterectomy of the external carotid artery for symptomatic internal carotid artery occlusion. Results based on the authors' experience and on historical data show external carotid endarterectomy to be a safe procedure. Obliteration of the cul-de-sac appears to be a very important factor in the prevention of reocclusion or recurrence of symptoms after external carotid endarterectomy. Use of the internal carotid artery stump for patching of the endarterectomized external carotid artery is both safe and effective in treating symptomatic internal carotid artery occlusion.

Vascular reactivity in patients with peripheral vascular disease

Noninvasive techniques have been used to demonstrate a specific pattern of impaired vasoactive response in the normal brachial artery of patients with clinical atherosclerosis. This is a physiologic reflection of the systemic nature of atherosclerosis and may be useful as a marker for identifying patients with preclinical atherosclerotic disease.

Establishment of conditions for the detection of bovine herpesvirus-1 by polymerase chain reaction using primers in the thymidine kinase region

Polymerase chain reaction (PCR) for detection of bovine herpesvirus-1 (BHV-1) was developed and optimized using 22 bp sense and 20 bp antisense primers in the thymidine kinase (TK) coding region. The amplification product is 183 bp long. The PCR optimization was done using BHV-1 tissue culture supernate (BHV-1TCS), concentrated BHV-1 tissue culture supernate (cBHV-1TCS) and sucrose gradient purified BHV-1 (pBHV-1). The sensitivity of four methods of sample preparation which are standard DNA extraction, modified proteinase K (PK) digestion, GeneReleaserTM + 34 cycles or + 44 cycles, and boiling were compared with virus isolation (VI) using BHV-1TCS. The incorporation of 10% glycerol in the reaction mixture, the incubation in PK for 18 hours and predenaturation of samples and cooling in ice prior to PCR were essential for the amplification of BHV-1 DNA for samples prepared by standard DNA extraction and modified PK digestion. The preparation of samples by Gene-ReleaserTM, a proprietary nucleic acid releasing cocktail, showed 10 to 1,000-fold increase in sensitivity compared to standard DNA extraction and modified PK digestion. No amplification was observed in samples prepared by boiling. The sample preparation of BHV-1 LA strain by GeneReleaserTM showed sensitivity equivalent to virus isolation. The BHV-1 TK PCR using GeneReleaserTM has a detection limit of 1 picogram and 10 fentograms of purified BHV-1 DNA using ethidium bromide stained gel and Southern blot hybridization, respectively. It could detect viral DNA in 1,000 infected cells in a total suspension of 10,000 cells using either ethidium bromide stained gel or Southern blot hybridization.

Amplification of strains of bovine herpesvirus 1 by use of polymerase chain reaction with primers in the thymidine kinase region

A primer pair was designed from the published nucleotide sequence of the coding region of the bovine herpesvirus 1 (BHV-1) thymidine kinase (tk) gene for use in detection of the virus by use of polymerase chain reaction (PCR) amplification of 12 BHV-1 strains (3 ATCC and 9 local isolates). A tk deletion mutant BHV-1, and 2 BHV-4 strains from ATCC were used as negative controls. One strain each of feline herpes-virus, equine herpesvirus, and bovine adenovirus, and 2 noninoculated bovine cultured cells--bovine fetal testis and Madin-Darby bovine kidney--also were examined to verify specificity of the primers. A PCR product, 183 bp long, was detected by ethidium bromide staining after agarose gel electrophoresis, when purified DNA from cell cultures infected with BHV-1 strain LA was used as template. Specificity of the PCR product was confirmed by restriction digestion with Sac II enzyme and Southern blot hybridization. Amplification was detected by ethidium bromide staining of agarose gels and/or Southern blot hybridization with the radiolabeled PCR product of the LA strain in similarly prepared DNA templates of 5 other BHV-1 strains, 2 obtained from ATCC and 3 of the 9 local isolates. In a modified PCR protocol, using virus suspensions treated with a nucleic acid-releasing cocktail, substantial amplification was obtained for the 3 BHV-1 strains from ATCC and for all 9 local bovine herpesvirus field isolates.(ABSTRACT TRUNCATED AT 250 WORDS)

Early results with cryopreserved saphenous vein allografts for infrainguinal bypass

PURPOSE

Cryopreserved saphenous vein allografts (CSVA) are available for use in arterial reconstructions; however, patency rates in the infrainguinal position are not well described.

METHODS

We reviewed our experience with 38 patients who underwent 43 infrainguinal bypasses with CSVA as the conduit. The group includes 21 women and 17 men with a mean age of 69 +/- 11 years. Mean follow-up is 8.2 +/- 5.5 months. Logistic regression was used to analyze five variables in an attempt to identify predictors of success or failure: distal anastomosis to the popliteal artery versus a crural artery, one-vessel versus two- or three-vessel runoff, postoperative anticoagulation versus none, primary reconstructions versus reoperations, and one segment versus two segments of CSVA required.

RESULTS

The cumulative patency rate at 12 months by life-table analysis is 66%. Logistic regression revealed that primary reconstructions were more likely to succeed than reoperations (p = 0.03) and operations completed with one segment of CSVA were more likely to succeed than those requiring more than one segment of vein (p = 0.03).

CONCLUSIONS

We conclude that (1) the short-term patency of infrainguinal bypasses with CSVA suggests that they may be acceptable alternatives to prosthetic grafts in the below-knee position, and (2) primary reconstructions performed with one segment of CSVA are more likely to succeed.

Ruptured abdominal aortic aneurysms: factors affecting mortality rates

Outcome of 113 operations for ruptured abdominal aortic aneurysms were reviewed to determine the contribution of perioperative events to mortality rates. Preoperative, intraoperative, and postoperative factors were examined with regard to their influence on early and late deaths. A mortality rate of 64% (72/113) was unrelated to age, gender, and preexistent medical conditions. Death within 48 hours occurred in 42 of 72 patients (58%). Preoperative status, including cardiac arrest, loss of consciousness, and acidosis influenced early deaths (less than 48 hours) but not late deaths. Early deaths were also influenced by severe operative hypotension and excessive transfusion requirements. Late deaths (greater than 48 hours) occurred in 30/72 cases (42%) at a mean of 24.6 +/- 22.9 days. Late death was related to postoperative organ system failure, specifically renal and respiratory failure, and the need for reoperation. The overall mortality rate was influenced by preoperative, intraoperative, and postoperative factors. Postoperative renal failure was the strongest predictor of overall deaths. Survival after ruptured abdominal aortic aneurysm depends on intraoperative and postoperative complications as well as preoperative conditions. Late death, the greatest strain on resources, is independent of preoperative status. The thesis that some patients with ruptured abdominal aortic aneurysm should be denied operation to conserve resources is not supported by these data. Efforts to improve survival should focus on reducing intraoperative complications and improving management of postoperative organ failure.

Liver lacerations--a marker of severe but sometimes subtle intra-abdominal injuries in adults

Experience with conservative management of solid viscus injuries from abdominal trauma in children has produced the impetus for a similar management in adults. To explore the implications of such a policy, we reviewed the records of 82 patients with hepatic injuries noted at laparotomy. Indications for laparotomy were positive findings on diagnostic peritoneal lavage (DPL) or CT scan, or a history of penetrating trauma. The liver injuries were graded according to severity: grade I, 19 patients; grade II, 20 patients (low severity = LS); grade III, 14 patients; grade IV, 6 patients (high severity = HS). Twenty-three injuries were not classified by the operating surgeon. Of the 53 patients with blunt hepatic trauma, 23 (43%) had concomitant injuries that required operative intervention. Twenty-nine patients had penetrating liver injuries. Fourteen (48%) had associated injuries requiring intervention. Patients most likely to have nonoperative management, those with grade I and grade II liver injuries (LS), comprised 48 of the total. In this subgroup there were 26 (54.2%) associated injuries requiring operative intervention. Shock could not be used as a factor to differentiate patients not requiring operative intervention. Nineteen of the LS patients requiring operative intervention secondary to associated injury were never in shock. In adult trauma victims positive DPL findings secondary to minor hepatic injuries that might not require operative intervention serve as a marker for associated injuries that do require operation. The risk of nonoperative management of hepatic injuries based upon radiologic diagnosis is not the result of complications from the hepatic injury.(ABSTRACT TRUNCATED AT 250 WORDS)

The major low-molecular-weight heat shock protein in chloroplasts shows antigenic conservation among diverse higher plant species

Several plant species are known to synthesize low-molecular-weight nucleus-encoded heat shock proteins (HSPs) which localize to chloroplasts. DNA sequence analysis of chloroplast HSP cDNAs from pea (Pisum sativum) and soybean (Glycine max) has shown that the carboxyl-terminal halves of these proteins are homologous to low-molecular-weight HSPs from a wide range of eucaryotes (E. Vierling, R. T. Nagao, A. E. DeRocher, and L. M. Harris, EMBO J. 7:575-581, 1988). We used a pea cDNA to construct fusion proteins containing either the carboxyl-terminal heat shock domain or the amino-terminal domain of the chloroplast HSP. The fusion proteins were overexpressed in Escherichia coli and used to produce choloroplast HSP-specific polyclonal antibodies. The carboxyl-terminal antibodies recognized chloroplast HSP precursor proteins from pea and from three divergent plant species, Arabidopsis thaliana, petunia (Petunia hybrida), and maize (Zea mays). The amino-terminal antibodies recognized effectively only the pea precursor. When intact plants of each species were subjected to a heat stress regime mimicking field growth conditions, significant levels of the mature forms of the chloroplast HSPs accumulated in pea, A. thaliana, and maize. The levels of accumulated HSPs remained unchanged for 12 h following the stress treatment. We conclude that the synthesis of chloroplast-localized HSPs is an important component of the stree response in all higher plants and that chloroplast HSPs from dicotyledonous and monocotyledonous plants have a conserved carboxyl-terminal domain.

A heat shock protein localized to chloroplasts is a member of a eukaryotic superfamily of heat shock proteins

We have isolated cDNA clones from soybean and pea that specify nuclear-encoded heat shock proteins (HSPs) which localize to chloroplasts. The mRNAs for these HSPs are undetectable at control temperatures, but increase approximately 150-fold during a 2-h heat shock. Hybridization-selection followed by in vitro translation demonstrates that these HSPs are synthesized as precursor proteins which are processed by the removal of 5-6.5 kd during import into isolated chloroplasts. The nucleotide sequence of the cDNAs shows the derived amino acid sequences of the mature pea and soybean proteins are 79% identical. While the predicted transit peptide encoded by the pea cDNA has some characteristics typical of transit sequences, including high Ser content, multiple basic residues and no acidic residues, it lacks two domains proposed to be important for import and maturation of other chloroplast proteins. The carboxy-terminal region of the chloroplast HSP has significant homology to cytoplasmic HSPs from soybean and other eukaryotes. We hypothesize that the chloroplast HSP shares a common structural and functional domain with low mol. wt HSPs which localize to other parts of the cell, and may have evolved from a nuclear gene.

Trisomy 18/trisomy 13 mosaicism in an adult with profound mental retardation and multiple malformations

We report on an adult woman with profound mental retardation and multiple anomalies who consists of 3 cell lines: one with trisomy 18, one with trisomy 13, and a normal cell line. Her phenotype includes manifestations of both trisomy syndromes. The origin of these cell lines could have been a doubly aneuploid (48,XX + 13, + 18) or singly aneuploid (47,XX + 18 or 47,XX + 13) zygote with subsequent mitotic nondisjunctions, or a normal zygote with multiple mitotic nondisjunctions. There have been four previous reports of mosaicism involving both trisomy D and trisomy E; all died in the first six months of life. Two of these cases had a doubly aneuploid (48,XX, + D + E) cell line. Our patient illustrates the need for study of several tissues in patients with complex aneuploidy syndromes or atypical manifestations of a given syndrome (such as prolonged survival), as well as the need for caution in counseling families about prognosis for survival in autosomal trisomies which usually are lethal.

Survival and growth of Campylobacter fetus subsp. jejuni on meat and in cooked foods

Twelve strains of Campylobacter fetus subsp. jejuni isolated from humans and animals grew at temperatures ranging from 34 to 45 degrees C and pH minima between 5.7 and 5.9. Only one strain grew at pH 5.8 with lactic acid present at a concentration similar to that in meat. All strains had decimal reduction times of less than 1 min at 60 degrees C. Further examination of a typical strain showed that it grew at 37 degrees C on high-pH meat but not at 37 degrees C on normal-pH meat. Bacterial numbers on both high (6.4)-pH and normal (5.8)-pH inoculated meat declined at a similar rate when the meat was stored at 25 degrees C. At -1 degree C, the rate of die-off was somewhat slower on normal-pH meat but was very much slower on high-pH meat. The initial fall in bacterial numbers that occurred when meat was frozen was also greater for normal-pH meat than for high-pH meat. The organism exhibited a long lag phase (1 to 2 days) when grown in cooked-meat medium at 37 degrees C and died in meat pies stored at 37 or 43 degrees C. Evaluation of the risk of Campylobacter contamination of red-meat carcasses to human health must take into account the limited potential of the organism to grow or even survive on fresh meats and in warm prepared foods.

Contamination of red-meat carcasses by Campylobacter fetus subsp. jejuni

Campylobacter fetus subsp. jejuni was commonly present in the feces of unweaned calves (2 to 3 weeks old) and from two of four groups of sheep. One new season lamb (12 to 16 weeks old) carried the organism, but the bacteria were not isolated from cattle. With unweaned calves, the fractions of animals infected and carcasses contaminated were similar. Contamination of carcasses usually involved low densities of C. fetus subsp. jejuni (ca. 1 to 10/cm2), which were isolated from flank but not rump areas. The organism was recovered less frequently from chilled carcasses and deboned veal. Small numbers of C. fetus subsp. jejuni could be recovered from equipment during the processing of unweaned calves but not after routine cleaning.

A comprehensive, interdisciplinary approach to the care of the institutionalized person with epilepsy

This report summarizes the experience of a comprehensive, interdisciplinary pilot program for improved care of institutionalized persons with epilepsy. From a hospital population of nearly 3,000 persons with diseases of the nervous system, virtually all having varying degrees of retardation, 892 persons were identified as epileptic and classified by seizure frequency: 13% uncontrolled, 24% partially controlled, and 63% controlled. These three categories were similar in respect to levels of retardation and functional disability. The project personnel consisted of a full-time nurse specialist in epilepsy, a part-time health resource analyst, and neurological consultants. Effects on health status were identified by comparing demographic and health data collected during the project. The typical patient was an adult epileptic, functioning at a severely to profoundly retarded level and institutionalized for over 15 years. A significant reduction in anticonvulsant toxicity was observed. A 48% decrease in episodes of status epilepticus and a 73% decrease in the number of seizure-related deaths were demonstrated. During the second year, 23% of the uncontrolled group, representing all retardation levels, became seizure free. In addition to improved care, an effective model for dealing with institutionalized epileptics is proposed.