Clinical and biological heterogeneity of multisystem inflammatory syndrome in adults following SARS-CoV-2 infection: a case series

Importance

Multisystem inflammatory syndrome in adults (MIS-A) is a poorly understood complication of SARS-CoV-2 infection with significant morbidity and mortality.

Objective

Identify clinical, immunological, and histopathologic features of MIS-A to improve understanding of the pathophysiology and approach to treatment.

Design

Three cases of MIS-A following SARS-CoV-2 infection were clinically identified between October 2021 - March 2022 using the U.S. Centers for Disease Control and Prevention diagnostic criteria. Clinical, laboratory, imaging, and tissue data were assessed.

Findings

All three patients developed acute onset cardiogenic shock and demonstrated elevated inflammatory biomarkers at the time of hospital admission that resolved over time. One case co-occurred with new onset Type 1 diabetes and sepsis. Retrospective analysis of myocardial tissue from one case identified SARS-CoV-2 RNA. All three patients fully recovered with standard of care interventions plus immunomodulatory therapy that included intravenous immunoglobulin, corticosteroids, and in two cases, anakinra.

Conclusion

MIS-A is a severe post-acute sequela of COVID-19 characterized by systemic elevation of inflammatory biomarkers. In this series of three cases, we find that although clinical courses and co-existent diseases vary, even severe presentations have potential for full recovery with prompt recognition and treatment. In addition to cardiogenic shock, glucose intolerance, unmasking of autoimmune disease, and sepsis can be features of MIS-A, and SARS-CoV-2 myocarditis can lead to a similar clinical syndrome.

Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

Peripheral blood leucocyte telomere length is associated with progression of interstitial lung disease in systemic sclerosis

BACKGROUND

Peripheral blood leucocyte telomere length (PBL-TL) is associated with outcomes in patients with idiopathic pulmonary fibrosis. Whether PBL-TL is associated with progression of systemic sclerosis-associated interstitial lung disease (SSc-ILD) is unknown.

METHODS

A retrospective observational cohort study was performed using prospectively collected data from 213 patients with SSc followed at the University of California San Francisco (UCSF) Scleroderma Center. PBL-TL was measured by quantitative PCR of DNA isolated from peripheral blood. Associations between PBL-TL and pulmonary function test trends in patients with SSc-ILD were assessed by longitudinal analysis using Generalised Linear Mixed Models. Findings were validated in a cohort of 61 patients with SSc-ILD enrolled in the Stanford University Scleroderma Center database.

RESULTS

Patients with UCSF SSc with ILD were found to have shorter PBL-TL compared with those without ILD (6554±671 base pairs (bp) vs 6782±698 bp, p=0.01). Shorter PBL-TL was associated with the presence of ILD (adjusted OR 2.1 per 1000 bp TL decrease, 95% CI [1.25 to 3.70], p=0.006). PBL-TL was shorter in patients with SSc-ILD lacking SSc-specific autoantibodies compared with seropositive subjects (6237±647 bp vs 6651±653 bp, p=0.004). Shorter PBL-TL was associated with increased risk for lung function deterioration with an average of 67 mL greater loss in per year for every 1000 bp decrease in PBL-TL in the combined SSc-ILD cohorts (longitudinal analysis, adjusted model: 95% CI -104 mL to -33 mL, p<0.001).

CONCLUSIONS

These findings suggest that telomere dysfunction may be associated with SSc-ILD progression and that PBL-TL measurement may be useful for stratifying risk for SSc-ILD progression.

A 21-Year-Old Woman with Joint Pain and Skin Ulceration

The illness started with pain and stiffness in her bilateral hands and wrists four months prior, with progression to bilateral elbows, knees, and ankles. The pain and stiffness were worse in the morning and limited her ability to use her hands or walk comfortably. She also noted swelling of her hands, knees, and ankles. The pain and swelling improved slightly with ibuprofen. She also noted increased fatigue, alopecia, decreased appetite, and nausea. She went to urgent care one month earlier and a physician prescribed ibuprofen and obtained initial serologies.

Quality Measures and Quality Improvement Initiatives in Osteoporosis-an Update

PURPOSE OF REVIEW

The aims of this review are to summarize current performance for osteoporosis quality measures used by Centers for Medicare and Medicaid (CMS) for pay-for-performance programs and to describe recent quality improvement strategies around these measures.

RECENT FINDINGS

Healthcare Effectiveness Data and Information (HEDIS) quality measures for the managed care population indicate gradual improvement in osteoporosis screening, osteoporosis identification and treatment following fragility fracture, and documentation of fall risk assessment and plan of care between 2006 and 2016. However, population-based studies suggest achievement for these process measures is lower where reporting is not mandated. Performance gaps remain, particularly for post-fracture care. Elderly patients with increased comorbidity are especially vulnerable to fractures, yet underperformance is documented in this population. Gender and racial disparities also exist. As has been shown for other areas of health care, education alone has a limited role as a quality improvement intervention. Multifactorial and systems-based interventions seem to be most successful in leading to measurable change for osteoporosis care and fall prevention. Despite increasing recognition of evidence-based quality measures for osteoporosis and incentives to improve upon performance for these measures, persistent gaps in care exist that will require further investigation into sustainable and value-adding quality improvement interventions.

Improving Adolescent Depression Screening in Pediatric Primary Care

OBJECTIVE

Depression among adolescents is a leading public health problem. Although screening for adolescent depression in primary care is strongly recommended, screening rates remain low. Effective quality improvement (QI) initiatives can facilitate change. This study aims to assess the impact of a QI learning collaborative on adolescent depression screening and initial plans of care in primary care.

METHODS

Seventeen pediatric-serving practices in Vermont participated in a QI learning collaborative aimed at improving practitioner knowledge and office systems around adolescent depression screening. Monthly medical record reviews provided monitoring of adolescent depression screening and initial plans of care over 7 months for QI. Randomly sampled annual medical record review data allowed comparison of screening and initial plans of care after the QI learning collaborative between participating and 21 control practices.

RESULTS

As practices improved their office systems around adolescent depression screening and initial plans of care, data showed marked improvement in depression screening at all 17 practices, from 34% to 97% over 7 months. Adolescents at participating practices had 3.5 times greater odds (95% confidence interval [CI], 1.14-10.98, P = .03) of being screened for depression and 37.5 times greater odds (95% CI, 7.67-183.48, P < .0005) of being screened with a validated tool than adolescents at control practices, accounting for patient characteristics.

CONCLUSIONS

There were significant within practice increases in adolescent depression screening after a QI learning collaborative, as well as in comparison with control practices 1 year later.

Non-invasive right ventricular load adaptability indices in patients with scleroderma-associated pulmonary arterial hypertension

Scleroderma-associated pulmonary arterial hypertension (SSc-PAH) is associated with worse outcome than idiopathic pulmonary arterial hypertension (IPAH), potentially due to worse right ventricular adaptation to load as suggested by pressure–volume loop analysis. The value of non-invasive load-adaptability metrics has not been fully explored in SSc-PAH. This study sought to assess whether patients with incident SSc-PAH have worse echocardiographic load-adaptability metrics than patients with IPAH. Twenty-two patients with incident SSc-PAH were matched 1:1 with IPAH based on pulmonary vascular resistance. Echocardiographic load-adaptability indices were divided into: surrogates of ventriculo-arterial coupling (e.g. right ventricular area change/end-systolic area), indices reflecting the proportionality of load adaptation (e.g. tricuspid regurgitation velocity-time integral normalized for average right ventricular radius), and simple ratios (e.g. tricuspid annular plane systolic excursion/right ventricular systolic pressure). The prognostic value of these indices for clinical worsening (i.e. death, transplant, or hospitalization for heart failure) at one year was explored. The two groups were comprised of patients of similar age, with similar cardiac index, pulmonary resistance, capacitance and NT-proBNP levels (p > 0.10). There was no difference in baseline right ventricular dimension, function or load-adaptability indices. At one year, eight (36.4%) SSc-PAH patients had experienced clinical worsening (eight hospitalizations and two deaths) versus one hospitalization in the IPAH group. Load adaptation at one year in survivors was not worse in SSc-PAH (p > 0.33). Patients with IPAH responded better to therapy than SSc-PAH in terms of reduction of right ventricular areas at one year (p < 0.05). Right ventricular load-adaptability echocardiographic indices do not appear to capture the increased risk of negative outcomes at one year associated with SSc-PAH.

Isolation and Characterization of Electrochemically Active Subsurface Delftia and Azonexus Species

Continental subsurface environments can present significant energetic challenges to the resident microorganisms. While these environments are geologically diverse, potentially allowing energy harvesting by microorganisms that catalyze redox reactions, many of the abundant electron donors and acceptors are insoluble and therefore not directly bioavailable. Extracellular electron transfer (EET) is a metabolic strategy that microorganisms can deploy to meet the challenges of interacting with redox-active surfaces. Though mechanistically characterized in a few metal-reducing bacteria, the role, extent, and diversity of EET in subsurface ecosystems remains unclear. Since this process can be mimicked on electrode surfaces, it opens the door to electrochemical techniques to enrich for and quantify the activities of environmental microorganisms in situ. Here, we report the electrochemical enrichment of microorganisms from a deep fractured-rock aquifer in Death Valley, CA, USA. In experiments performed in mesocosms containing a synthetic medium based on aquifer chemistry, four working electrodes (WEs) were poised at different redox potentials (272, 373, 472, 572 mV vs. SHE) to serve as electron acceptors, resulting in anodic currents coupled to the oxidation of acetate during enrichment. The anodes were dominated by Betaproteobacteria from the families Comamonadaceae and Rhodocyclaceae. A representative of each dominant family was subsequently isolated from electrode-associated biomass. The EET abilities of the isolated Delftia strain (designated WE1-13) and Azonexus strain (designated WE2-4) were confirmed in electrochemical reactors using WEs poised at 522 mV vs. SHE. The rise in anodic current upon inoculation was correlated with a modest increase in total protein content. Both genera have been previously observed in mixed communities of microbial fuel cell enrichments, but this is the first direct measurement of their electrochemical activity. While alternate metabolisms (e.g., nitrate reduction) by these organisms were previously known, our observations suggest that additional ‘hidden’ interactions with external electron acceptors are also possible. Electrochemical approaches are well positioned to dissect such extracellular interactions that may be prevalent in the subsurface.

Pulmonary Veno-Occlusive Disease

Pulmonary hypertension is a well-known though poorly characterized disease in veterinary medicine. In humans, pulmonary veno-occlusive disease (PVOD) is a rare cause of severe pulmonary hypertension with a mean survival time of 2 years without lung transplantation. Eleven adult dogs (5 males, 6 females; median age 10.5 years, representing various breeds) were examined following the development of severe respiratory signs. Lungs of affected animals were evaluated morphologically and with immunohistochemistry for alpha smooth muscle actin, desmin, CD31, CD3, CD20, and CD204. All dogs had pulmonary lesions consistent with PVOD, consisting of occlusive remodeling of small- to medium-sized pulmonary veins, foci of pulmonary capillary hemangiomatosis (PCH), and accumulation of hemosiderophages; 6 of 11 dogs had substantial pulmonary arterial medial and intimal thickening. Ultrastructural examination and immunohistochemistry showed that smooth muscle cells contributed to the venous occlusion. Increased expression of CD31 was evident in regions of PCH indicating increased numbers of endothelial cells in these foci. Spindle cells strongly expressing alpha smooth muscle actin and desmin co-localized with foci of PCH; similar cells were present but less intensely labeled elsewhere in non-PCH alveoli. B cells and macrophages, detected by immunohistochemistry, were not co-localized with the venous lesions of canine PVOD; small numbers of CD3-positive T cells were occasionally in and around the wall of remodeled veins. These findings indicate a condition in dogs with clinically severe respiratory disease and pathologic features resembling human PVOD, including foci of pulmonary venous remodeling and PCH.

Soft drink consumption patterns among Western Australians

OBJECTIVE

To examine soft drink consumption across age, gender, socioeconomic, and body weight status groups within an adolescent and adult population.

DESIGN

Cross-sectional telephone survey.

PARTICIPANTS

Western Australian residents (n = 1,015) aged 16-65 years, selected through random dialing.

VARIABLES MEASURED

Frequency and quantity of sugar-sweetened and diet soft drinks consumption, sociodemographic characteristics.

ANALYSIS

The Kruskal-Wallis test of association for non-parametric data was used to explore differences in quantity of soft drinks consumed. Logistic regression models used to explore type of soft drinks consumed by sociodemographic factors and weight status.

RESULTS

A greater proportion of females consumed no soft drinks (29.2%) or diet soft drinks only (20.9%), compared with males (21.7% and 14.0%, respectively) (P < .05). The youngest (16-24 years) consumers of sugar-sweetened soft drinks consumed twice (median, 3 cups/wk) as much as the eldest (55-65 years) (1.5 cups/wk) (P < .05). Respondents classified as overweight or obese were 1.7 times more likely to drink both sugar-sweetened and diet soft drinks compared with other respondents (P = .02).

CONCLUSIONS AND IMPLICATIONS

This study identified a high prevalence of soft drink consumption within the population (74.5%). These results identify young people (16-24 years of age), as well as males, as population groups to target through public health interventions to reduce soft drink consumption.

131I-MIBG followed by consolidation with busulfan, melphalan and autologous stem cell transplantation for refractory neuroblastoma

BACKGROUND

(131) I-metaiodobenzylguanidine (MIBG) produces a 37% response rate in relapsed/refractory neuroblastoma, and could be used to improve remission status prior to myeloablative chemotherapy with autologous stem cell transplant (ASCT). The purpose of our report was to evaluate safety and response with MIBG therapy followed by myeloablative busulfan and melphalan (BuMel) with ASCT in patients with refractory neuroblastoma.

METHODS

Retrospective chart review was done on patients treated with MIBG (18 mCi/kg) on Day 1 and ASCT on day 14. Six to eight weeks after MIBG, patients without progressive disease received IV busulfan on days -6 to -2 (target Css 700-900), melphalan (140 mg/m2 IV) on day -1, and ASCT on Day 0. Response and toxicity were evaluated after MIBG and again after myeloablative therapy.

RESULTS

Eight patients completed MIBG/ASCT followed by BuMel/ASCT. MIBG was well tolerated, with grade 3 or 4 non-hematologic toxicity limited to one patient with sepsis. Grade 3 mucositis occurred in six patients after BuMel/ASCT. One patient developed sinusoidal obstructive syndrome (SOS) and died 50 days post-ASCT following myeloablative conditioning. All patients engrafted neutrophils (median 16.5 days) and platelets (median 32 days) after BuMel, excluding the patient with SOS. After all therapy, there were three complete, two partial, and one minor response in seven evaluable patients.

CONCLUSIONS

MIBG at doses up to 18 mCi/kg can be safely administered 6 weeks prior to a BuMel consolidative regimen for refractory neuroblastoma. Preceding MIBG did not impair engraftment following BuMel. This regimen is being further evaluated in a Children's Oncology Group (COG) trial.

Using educational outreach and a financial incentive to increase general practices' contribution to chlamydia screening in South-East London 2003-2011

BACKGROUND

The London Boroughs of Lambeth and Southwark have high levels of sexually transmitted infections including Chlamydia trachomatis. Modelling studies suggest that reductions in the prevalence of chlamydia infection will require a high level of population screening coverage and positivity among those screened. General practice has a potentially important role to play in delivering these levels of coverage since large numbers (up to 60%) of young people visit their general practice every year but previous work suggests that there are barriers to delivering screening in this setting. The aim of this study was to evaluate an intervention to increase chlamydia screening in general practice within Primary Care Trusts (PCTs) of Lambeth and Southwark, a strategy combining financial incentives and supportive practice visits to raise awareness and solve problems.

METHODS

Data on age, gender, venue and chlamydia result for tests on under 25 s in Lambeth from 2003-11 was obtained from the National Chlamydia Screening Programme. We analysed the number and percentage of tests generated in general practice, and looked at the number of practices screening more than 10% of their practice cohort of 15-24 year olds, male/female ratio and positivity rates across other screening venues. We also looked at practices screening less than 10% and studied change over time. We compared data from Lambeth and Southwark with London and England. We also studied features of the level and type of educational and financial incentive interventions employed.

RESULTS

Chlamydia tests performed in general practice increased from 23 tests in 2003-4 to 4813 tests in 2010-11 in Lambeth. In Southwark they increased from 5 tests in 2003/04 to 4321 in 2010/11. In 2011, 44.6% of tests came from GPs in Lambeth and 46% from GP's in Southwark. In Lambeth 62.7% of practices tested more than 10% of their cohort and in Southwark this was 55.8%. In Lambeth, postivity rate in 2010/11 was 5.8% in men and 6.0% in women. In Southwark positivity rate was 3.9% in men and 5.3% in women. In 2003/04 13% tests in general practice (Lambeth) were from men, this increased to 25% in 2010/11. In Southwark this increased from 20% in 2003/04 to 27.6% in 2010/11. We compared the results with London and national data and showed significant differences between GP testing in Lambeth and Southwark, and GP testing in London and the rest of England.

CONCLUSIONS

General practices can be important potential providers of chlamydia tests.With a combination of sustained support, financial incentives and feedback on performance, general practice may be able to test a large percentage of 15-24 year olds. General practice is also a potentially important provider of chlamydia tests to young men.

Role of routine chest radiographs in the evaluation of patients with stable blunt chest trauma--a prospective analysis

OBJECTIVE

The study sought to assess the test performance characteristics of clinical judgement in the evaluation of stable blunt chest trauma patients compared with chest radiography (CXR) in the determination of significant intra-thoracic injury.

METHODS

We prospectively enrolled all adult patients (older than 16years) who were considered to have stable blunt chest trauma over a six-month period (May 1-October 31, 2009). We defined the latter as patients who were unintubated, normotensive (systolic blood pressure > 90 mm Hg) and without hypoxia (oxygen saturation> 95% at room air). Patients eligible for the study were sent for anteroposterior (AP) CXRs which were then interpreted by the same consultant radiologist throughout the study period. Both test (clinical judgement) and disease status (CXR) were assigned and correlated as binary measures. We compared the test performance characteristics such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic likelihood ratios of clinical judgement to CXR findings in the determination of significant intra-thoracic injury.

RESULTS

During the six-month period, data were collected from 77 eligible stable blunt chest trauma patients (age over 16 years). Fifty-nine patients (76.6%) were male. Nine patients (11.7%) were radiologically confirmed to have significant blunt chest injuries including rib fractures, pneumothorax and an isolated case of pulmonary contusion. All nine (11.7%) patients had a positive (abnormal) radiograph for rib fractures. In addition, three (3.9%) of them also had both rib fracture and pneumothoraces and one (1.3%) had both a rib fracture and pulmonary contusion. Clinical judgementfor the diagnosis of significant blunt chest injuries matched with the CXR finding with 95% confidence intervals (CIs): sensitivity 100% (95% CI 66.4, 100), specificity 32.4% (95% CI 21.5, 44.8), prevalence 11.7%, PPV 16.4% (95% CI 7.77, 28.8), NPV100% (95% CI 84.6, 100), DLR+ 1.48 (95% CI 1.25, 1.74).

CONCLUSION

The majority ofpatients who sustained blunt chest injuries and were assessed as stable patients do not require CXR routinely. This study revealed that physicians in the local Emergency Department may be over-utilizing CXRfor patients who have stable blunt chest trauma.

[The chronic patient and the nurse-managed hospital unit]

In this article we discuss the implementation of a hospital nursing care unit in a local health authority in Rome (Italy), The hospital involved provides a wide range of healthcare and social services. The project is a very innovative one at the national level, with respect to healthcare services offered to patients with chronic disorders and associated disabilities. Starting from the concept of "centrality of the patient" in the area of healthcare services, we developed an organizational model where nursing care represents one of the basic elements.

Systematic screens of a Candida albicans homozygous deletion library decouple morphogenetic switching and pathogenicity

Candida albicans is the most common cause of serious fungal disease in humans. Creation of isogenic null mutants of this diploid organism, which requires sequential gene targeting, allows dissection of virulence mechanisms. Published analyses of such mutants show a near-perfect correlation between C. albicans pathogenicity and the ability to undergo a yeast-to-hypha morphological switch in vitro. However, most studies used mutants constructed with a marker that is itself a virulence determinant and therefore complicates their interpretation. Using alternative markers, we created ~3000 homozygous deletion strains affecting 674 genes or roughly 11% of the C. albicans genome. Screening for infectivity in a mouse model and for morphological switching and cell proliferation in vitro, we identified 115 infectivity-attenuated mutants, of which nearly half demonstrated normal morphological switching and proliferation. Analysis of such mutants identified the glycolipid, glucosylceramide, as the first small molecule synthesized by this pathogen to be required specifically for virulence.

Can a participatory approach contribute to food chain risk analysis?

We consider food chain risks and specifically address stakeholder participation in the risk analysis process. We combine social and natural science perspectives to explore the participation process in relation to food risks and, in particular, to consider how some specific participation processes might be scientifically evaluated and how stakeholder participation in general might be incorporated into food risk decision making. We have built considerations based on three large integrative case studies that examine aspects of participatory processes. Here we use the case studies collectively to illustrate observations and beliefs concerning the nature of the interaction of stakeholders with established quantitative risk methodologies. This account is not supported by any large volume of analysis. The views in the report are expressed in relation to an accepted risk analysis framework and also with respect to probabilistic modeling of risks and are illustrated where possible with anecdotal reports of actual case study events.

[In the heart of the district. 50 interviews with the health professionals of the Lazio Region districts, Italy]

This article aims to explore some key issues relating to the health districts of the Lazio Region, in particular the major critical aspects as well as some strengths highlighted by the operators. In the Lazio Region there are 12 Local Health Units, divided into 55 health districts. In recent years, the majority of the authors analized theoretical models proposed by regional standards, while the strengths and weaknesses of the district, as well as the organizational difficulties and problems experienced daily by the operators have not been investigated. It was decided to use qualitative methods of research, through open interviews with 50 operators in 15 health districts of the Region. Interviews were analysed utilizing software Nvivo. Some codes were identified to guide interviews. We can summarize the emergency issues at least in three major areas: 1) the organization of the district, 2) the management of personnel and resources, 3) the care pathways. It is hoped that, during next years, the research directed at health district analysis will grow, with particular reference to quantitative and qualitative investigations, in order to build a body of knowledge from practical experience of health professionals.

Staining for intracytoplasmic lumina and CAM5.2 increases the detection rate for bile duct cancers

BACKGROUND AND STUDY AIMS

Endoscopic biopsies have a low sensitivity for diagnosing malignant bile duct strictures. Tumor markers detected by mucin staining and immunohistochemistry may help to determine the malignancy of a biopsy specimen where histologic evaluation alone is nondiagnostic.

PATIENTS AND METHODS

61 patients who underwent forceps biopsies were retrospectively identified, yielding 49 and 40 biopsy specimens for strictures finally diagnosed as benign and malignant, respectively. Biopsy specimens were histologically evaluated and stained for p53, Ki-67, carcinoembryonic antigen (CEA), CA19-9, CAM5.2, and presence of intracytoplasmic lumina (ICL). Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios (PLR and NLR) were calculated to evaluate the performance of each test.

RESULTS

Histology alone provided sensitivity and specificity of 53 % and 100 %. Addition of ICL or CAM5.2 increased sensitivity to 73 % or 60 %, respectively, and provided excellent specificity, PPV, and PLR (ICL, 98 %, 97 %, and 36; CAM5.2, 100 %, 100 %, and infinite). Both stains in combination increased the sensitivity to 75 %. Staining for Ki-67, p53, CEA, and CA19-9 increased the sensitivity to detect malignancy (range 60 % to 83 %), but significantly reduced the specificity, PPV and PLR (ranges 73 % to 90 %, 72 % to 86 %, and 3 to 7, respectively). Markers in all combinations performed poorly as a negative test (NPV 69 % to 87 %, and NLR 0.19 to 0.55).

CONCLUSIONS

Staining for tumor markers ICL and CAM5.2 can improve the diagnostic value of endoscopic biopsies, and may change the course of management for patients with indeterminate histological findings.

Delays in presentations of stroke patients at the University Hospital of the West Indies

Thrombolytic therapy has been proven to be beneficial in selected patients with ischaemic strokes. Early diagnosis is paramount because there is a narrow therapeutic window for these patients to derive benefit from thrombolytics. We sought to evaluate the timing of stroke presentations at the University Hospital of the West Indies (UHWI) in order to assess the potential eligibility for definitive therapy A retrospective audit of all consecutive patients who had emergent computed tomographic (CT) scans for suspected ischaemic stroke at the UHWI was performed over a six-month period between February 2006 and July 2006. Data were extracted from the hospital records and analysed using SPSS version 12. There were 331 patients evaluated with brain CT for a clinically suspected stroke during the study period. Complete time documentation and CT scans were available for analysis in 171 patients with ischaemic strokes. The average age was 64.5 years (range +/- SD: 3-98 +/- 19.9 years) with a slight male preponderance (58% vs. 42%). There was considerable pre-hospital delay with 63% of patients presenting more than 12 hours after the onset of symptoms. There were also long inhospital delays. Only 52% of patients were assessed by a physician within an hour of presentation to hospital and only 55% of patients had CT scans completed within three hours of a physician s request. Although thrombolysis is not routinely performed for ischaemic strokes at our institution, sensitization of physicians and the general public in our setting to symptoms and signs of this disease is urgently needed to improve stroke management, whereby definitive treatment can be considered for selected patients.

The clustering of health risk behaviours in a Western Australian adult population

ISSUE ADDRESSED

Human behaviours influence health. Most people partake in numerous behaviours that increase their risk of chronic disease. For years health promotion interventions have been changing behaviour to improve health. While it is known that most people exhibit more than one health risk behaviour, it is not clear if health behaviours occur in patterns within population subgroups. This paper aims to explore the clustering patterns of six health risk behaviours among Australian adults.

METHODS

Data collected from four (1992, 1994, 1998 and 2002) community-based surveys were used to explore the relationships between a variety of health risk behaviours. The behaviours included were smoking, unsafe alcohol consumption, low fruit consumption, low vegetable consumption, insufficient physical activity and poor sun protection practices. The sample comprised 8,668 West Australian residents aged 16-69 years. A k-means cluster analysis was used to determine groups of people with similar health behaviours.

RESULTS

Four health risk behaviour clusters were identified, one overall health promoting 'Safe', two 'Risky' and one 'Moderate' (mix of healthy and unhealthy behaviours). These health behaviour clusters were distinguishable by demographic characteristics, where by women aged 40 years and older on high incomes were most likely to be part of the 'Safe' cluster, younger people the risky smoker cluster and older men the risky drinker cluster.

CONCLUSION

The results of this study support the idea that people exhibit on average three risky health behaviours and that these behaviours inter-relate. The results further suggest that sub-groups in the study population were differentiated by the type of risky health behaviours they exhibit.

Pilot series of radiofrequency ablation of Barrett's esophagus with or without neoplasia

BACKGROUND AND STUDY AIMS

Radiofrequency ablation is a rapidly evolving therapeutic modality for Barrett's esophagus. The aim of this ongoing 12-month trial is to assess Barrett's esophagus eradication after radiofrequency ablation using a balloon-based (HALO-360) and a plate-based (HALO-90) device. We report here our experience with the first 10 patients (out of 40) who have completed 12 months of follow-up.

PATIENTS AND METHODS

Following radiofrequency ablation using the HALO-360 device all patients were maintained on double-dose proton pump inhibitor therapy. Endoscopic evaluation was performed at 3 and 12 months postablation. Patients with residual Barrett's esophagus at 3 months underwent repeat ablation. Ten patients, seven with nondysplastic Barrett's esophagus, two with low-grade and one with high-grade dysplasia have completed the study to date.

RESULTS

Complete Barrett's esophagus eradication was achieved in seven patients, and partial eradication was achieved in three. There were no major complications. One case of buried Barrett's metaplasia was encountered and successfully re-ablated, with complete Barrett's esophagus eradication achieved at 12 months.

CONCLUSIONS

In this study, Barrett's eradication rates were comparable to previously published reports. One case of buried Barrett's metaplasia was identified out of 247 biopsies and was eradicated with repeat ablation.

The evolution of emergency medicine in Jamaica

Emergency Medicine in Jamaica has evolved rapidly over the past 20 years and has gained recognition as a specialty. A residency training programme has been established, trademark life support courses are now available, moves to develop areas of sub-specialization have begun and an emergency medicine association has been formed. There has been an increase in the diagnostic modalities in the main teaching institution, the University Hospital of the West Indies (UHWI). There is an urgent need for improvements in pre-hospital care. This will require the development of an efficient Emergency Medical Service (EMS). More emphasis and attention is required on disaster medicine, toxicology and trauma. Increased training of emergency physicians and nurses, advances in academia and research, and greater advocacy by local emergency physicians will further advance the specialty.

Penetrating neck trauma and the aberrant subclavian artery

Vascular injuries from penetrating trauma to the base of the neck are accompanied by significant morbidity and potential mortality. These injuries require several diagnostic adjuncts in order to facilitate early diagnosis and appropriate treatment. Herein reported is the case of a patient who sustained penetrating injury to the thoracic inlet but had a fortuitous anomaly that prevented vascular injury and its attendant complications.

Association between exposure/non-exposure to the mandatory seat belt law with regards to compliance in vehicle accident victims--a hospital review

OBJECTIVE

Injuries sustained in motor vehicle accidents (MVAs) are a major challenge to the Jamaican healthcare system. In November 1999, Jamaica enacted legislation to make seat belt usage in motor vehicles compulsory. The effect of this policy change on seat belt usage is unclear. This study therefore sought to determine the prevalence of seat belt usage and to determine the association between exposure/non-exposure to the mandatory seat belt law and seat belt use in subjects who presented to the Accident and Emergency Department (A&E) of the University Hospital of the West Indies (UHWI) as a result of motor vehicle accidents.

METHODS

Subjects were recruited from June to November 2003, post-seat belt law (POBL) period, and May to October 1999, pre-seat belt law (PRBL) period. Data collected included demographic variables, seat belt use and position of the occupants in the vehicle.

RESULTS

Of the 277 patients who were eligible for inclusion, data were complete in 258 subjects, 87 in the PRBL period and 171 in the POBL period. The prevalence of seat belt use was 47% (PRBL) and 63% (POBL) respectively. There was no significant gender difference at each period. The odds of wearing seat belt in the rear of a motor vehicle were significantly lower than that of a driver (Table 3, OR 0.19, 95% CI 0.07, 0.48). Adjusting for age, gender and position in vehicle exposure, there was about 100% increase in the odds of seat belt use during the post seat belt law era (OR = 2.09, 95% CI 1.21, 3.61).

CONCLUSION

It is concluded from this hospital-based study that the mandatory seat belt law legislature was associated with increased seat belt use in motor vehicle accident victims. However, current data from the Road Traffic Agency indicate that there is still an alarming number of fatalities. This clearly suggests that additional public health measures are needed to address the epidemic of motor vehicle trauma in Jamaica.

What young Dutch adults say they do to keep from gaining weight: self-reported prevalence of overeating, compensatory behaviours and specific weight control behaviours

OBJECTIVE

The aim of this study was to explore the prevalence of and differences in self-reported occasions of overeating (such as at celebrations and other parties), compensatory behaviours and specific weight gain prevention strategies among young Dutch adults according to sociodemographics and overweight status.

DESIGN AND SUBJECTS

Cross-sectional data were analysed from Dutch adults aged 20-40 years, recruited from an Internet research panel (n = 857, response rate = 76.6%). Using electronic questionnaires, self-report data were collected on sociodemographics, body mass index (BMI), occasions of overeating, compensatory behaviours, and diet and physical activity used as weight gain prevention strategies. Associations were tested using multiple linear and logistic regression analyses.

RESULTS

Of the participants, 48.6% reported occasions of overeating at least once a week during the 4-week period, 44.6% reported compensating for these occasions and 72.9% reported engaging in dietary and physical activities specifically for weight gain prevention purposes. Only 32.1% of the respondents reported using the recommended combination of diet and physical activity as a weight gain prevention strategy. In addition, results showed that overweight people (BMI > or = 25 kg m-2) and women were more likely to report overeating than people with healthy body weights (odds ratio (OR) = 1.79; 95% confidence interval (CI) 1.32-2.42) and men (OR = 1.50; 95% CI 1.14-1.97). Overweight people, women and people who regularly reported overeating were also significantly more likely to report compensatory behaviours by eating less and to report specific weight gain prevention strategies using diet and physical activity.

CONCLUSION

The present study suggests that people experience frequent occasions of overeating and try to compensate for such occasions in different ways. However, the combination of dietary changes and physical activity recommended by experts was seldom reported.

Regulation of rRNA synthesis by TATA-binding protein-associated factor Mot1

Mot1 is an essential, conserved, TATA-binding protein (TBP)-associated factor in Saccharomyces cerevisiae with well-established roles in the global control of RNA polymerase II (Pol II) transcription. Previous results have suggested that Mot1 functions exclusively in Pol II transcription, but here we report a novel role for Mot1 in regulating transcription by RNA polymerase I (Pol I). In vivo, Mot1 is associated with the ribosomal DNA, and loss of Mot1 results in decreased rRNA synthesis. Consistent with a direct role for Mot1 in Pol I transcription, Mot1 also associates with the Pol I promoter in vitro in a reaction that depends on components of the Pol I general transcription machinery. Remarkably, in addition to Mot1's role in initiation, rRNA processing is delayed in mot1 cells. Taken together, these results support a model in which Mot1 affects the rate and efficiency of rRNA synthesis by both direct and indirect mechanisms, with resulting effects on transcription activation and the coupling of rRNA synthesis to processing.

Are current processes for nuclear emergency management in Europe adequate?

We describe the results of process mapping of nuclear emergency management procedures in four European countries. We find clear differences and explore these in relation to their suitability for building a shared understanding across the emergency management team of the evolving situation and a balanced appreciation of the uncertainties. Our findings indicate that there are some issues that cause concern in that the procedures may run smoothly and efficiently but they may also risk underestimating uncertainty or ignore key issues that have only been identified by a minority of experts or models. We are concerned that they do not facilitate the building of shared mental models that the literature such as that on highly reliable organisations has shown is important.