The Impact of COVID-19 Vaccinations on Emergency Department Presentations

Objective

The aim of the present study was to describe the burden of patients presenting to the ED with symptoms occurring after receiving a COVID‐19 vaccination.

Methods

This was a retrospective cohort study performed over a 4‐month period across two EDs. Participants were eligible for inclusion if it was documented in the ED triage record that their ED attendance was associated with the receipt of a COVID‐19 vaccination. Data regarding the type of vaccine (Comirnaty or ChAdOx1) were subsequently extracted from their electronic medical record. Primary outcome was ED length of stay (LOS) and secondary outcomes included requests for imaging and ED disposition destination.

Results

During the study period of 22 February 2021 to 21 June 2021, 632 patients were identified for inclusion in the present study, of which 543 (85.9%) had received the ChAdOx1 vaccination. The highest proportion of COVID‐19 vaccine‐related attendances occurred in June 2021 and accounted for 21 (8%) of 262 total daily ED attendances. Patients who had an ED presentation related to ChAdOx1 had a longer median ED LOS (253 vs 180 min, P < 0.001) compared to Comirnaty and a higher proportion had haematology tests and imaging requested in the ED. Most patients (n = 588, 88.8%) were discharged home from the ED.

Conclusion

There was a notable proportion of ED attendances related to recent COVID‐19 vaccination administration, many of which were associated with lengthy ED stays and had multiple investigations. In the majority of cases, the patients were able to be discharged home from the ED.

Glomangioma: rare case of a painful lump in the upper lip

Glomus tumours in the lip are extremely rare with only 13 cases, including this one, recorded in the English language that we know of. We report a 45-year-old woman with a firm, mildly painful lump in her upper lip. Excisional biopsy examination and histopathological analysis showed it to be a subtype of glomus tumour called a glomangioma.

Neurological soft signs are associated with APOE genotype, age and cognitive performance

Neurodegeneration is associated with increased frequency of neurological soft signs (NSS). We designed the present study to investigate the association between NSS and subjective memory complaints, cognitive function and apolipoprotein E genotype in a community-dwelling sample of volunteers participating in an ongoing longitudinal program investigating predictors of cognitive decline. NSS were found to be associated with apolipoprotein E (APOE) epsilon4 genotype (p = 0.015), age (p = 0.012) and poor cognitive performance, as assessed by the Mini Mental State Examination (p = 0.053). There was no significant difference between subjects with and without memory complaints in relation to the frequency of NSS (p = 0.130). The association with age and the APOE epsilon4 genotype suggests that the systematic investigation of NSS may contribute to identify subjects at risk of clinically significant cognitive decline in later life.

Influence of postural anxiety on postural reactions to multi-directional surface rotations

Previous studies have shown significant effects of increased postural anxiety in healthy young individuals when standing quietly or performing voluntary postural tasks. However, little is known about the influence of anxiety on reactive postural control. The present study examined how increased postural anxiety influenced postural reactions to unexpected surface rotations in multiple directions. Ten healthy young adults (mean age: 25.5 yr, range: 22-27 yr) were required to recover from unexpected rotations of the support surface (7.5 degrees amplitude, 50 degrees/s velocity) delivered in six different directions while standing in a low postural threat (surface height: 60 cm above ground) or high postural threat (surface height: 160 cm above ground) condition. Electromyographic data from 12 different postural leg, hip, and trunk muscles was collected simultaneously. Full body kinematic data were also used to determine total body center of mass (COM) and segment displacements. Four distinct changes were observed with increased postural anxiety: increased amplitude in balance-correcting responses (120-220 ms) in all leg, trunk, and arm muscles; decreased onset latency of deltoid responses; reduced magnitude of COM displacement; and reduced angular displacement of leg, pelvis, and trunk. These observations suggest that changes in dynamic postural responses with increased anxiety are mediated by alterations in neuro-muscular control mechanisms and thus may contribute significantly to the pathophysiology of balance deficits associated with aging or neurological disease.

APOE-epsilon4 and APOE -491A polymorphisms in individuals with subjective memory loss

The accurate clinical diagnosis of Alzheimer's disease can only be made with a high degree of certainty in specialized centres. The identification of predictive or diagnostic genetic factors may improve accuracy of disease prediction or diagnosis. One major genetic risk factor, the epsilon4 allele of the apolipoprotein E gene, is universally recognised. We have recently shown that the A allele of the apolipoprotein E, -491A/T promoter polymorphism is also an important risk factor for Alzheimer's disease in an Australian population. We designed the present study to investigate the association between apolipoprotein E genotype, -491A/T polymorphism, plasma apoE levels and the subjective experience of memory decline among 98 subjects and 49 age, gender and education-matched normal controls. An increased frequency of the epsilon4 allele of apolipoprotein E was significantly associated with the 'memory complainers' group (OR = 2.35, P = 0.02) as was the A allele of the -491A/T polymorphism (OR = 2, P = 0.02). Among all subjects, only seven individuals were homozygous for both of these alleles, and six of these seven individuals belonged to the 'memory complainers' group. This sub-group also had relatively elevated plasma apolipoprotein E levels (P < 0.01) and tended to score lower on the Mini-Mental State Examination (MMSE) and Cambridge Cognition Test. These data suggest that the epsilon4 allele of apolipoprotein E and the -491A allele are over-represented among individuals who complain of memory difficulties. Follow-up studies should clarify whether these genotypes and phenotypes are useful in the prediction and/or diagnosis of Alzheimer's disease.

Association between presenilin-1 Glu318Gly mutation and familial Alzheimer's disease in the Australian population

Mutations in the presenilin-1 (PS-1) gene on chromosome 14 account for the majority of early-onset familial Alzheimer's disease (FAD) cases. To date, more than 90 mutations have been identified and, while most of these mutations are completely penetrant, the Glu318Gly mutation has been suggested to be partially penetrant. These findings indicate that it may play a similar role to apolipoprotein E (APOE)-epsilon4 by acting as a genetic risk factor for AD. In the current study, a total of 682 subjects were tested to assess the frequency of the Glu318Gly mutation in AD in the Australian population. The Glu318Gly mutation was identified in six sporadic late-onset AD patients, four FAD patients (unrelated) and in nine control subjects. The frequency of this mutation was highest in the familial AD group (8.7%) and lowest in control subjects (2.2%). When the mutation frequencies were compared, we found a statistically significant difference between the latter two groups (Fisher's exact test, P < 0.05). The genotype frequency of the Glu318Gly mutation in all AD cases and controls in the Australian population was 2.8%. This frequency is comparable to that observed for the Dutch population (3.2%), but not for the Finnish population (6.8% and 6.0%) or the Spanish population (5.3%). These findings show that the frequency of the Glu318Gly mutation is increased in FAD patients, suggesting a potential role as a genetic risk factor contributing to the pathogenesis of familial AD.

Genetic diversity of Ocimum gratissimum L. based on volatile oil constituents, flavonoids and RAPD markers

Morphological, chemical and genetic differences of 12 tree basil (Ocimum gratissimum L.) accessions were studied to determine whether volatile oils and flavonoids can be used as taxonomical markers and to examine the relationship between RAPDs to these chemical markers. Eugenol, thymol, and geraniol were the major volatile oil constituents found in Ocimum gratissimum. Xantomicrol and cirsimaritin were the major external flavones. The accessions morphologically described as O. gratissimum var. gratissimum contained eugenol as the major volatile oil constituent, and cirsimaritin as the major flavone. Ocimum gratissimum var. macrophyllum accessions contained thymol as the major volatile oil constituent, and xantomicrol as the major flavone. A distinct essential oil and flavone chemotype (producing geraniol and a mixture of the flavones cirsimaritin, isothymusin, xanthomicrol, and luteolin) was found in an accession genetically more distant from the other two groups when analyzed by molecular markers. The accessions could be divided based on volatile oil constituents into six groups: (1) thymol: alpha-copaene (ot24, ot25, ot26, and ot28); (2) eugenol:spathulenol (ot17, ot63, and ot52); (3) thymol:p-cymene (ot65); (4) eugenol:gamma-muurolene (ot27 and ot29); (5) eugenol:thymol: spathulenol (ot85); and (6) geraniol (ot84). Cluster analysis of RAPD markers showed that there are three groups that are distinct genetically and highly correlated (r=0.814) to volatile oil constituents.

Clinical characteristics of individuals with subjective memory loss in Western Australia: results from a cross-sectional survey

Subjective memory complaint is common in later life. Its relationship to future risk of dementia is unclear, although many reports have found a positive association. We designed the present cross-sectional survey to investigate the clinical features associated with subjective memory impairment. One hundred and eight volunteers and 38 non-complainers acting as age-matched controls were recruited. Eleven subjects with memory complaints were excluded because of prior stroke or low MMSE score. The CAMCOG was used to measure cognition; complainers had significantly lower scores (p<0.001). Univariate analysis showed that complainers had greater prevalence of depression, anxiety, insomnia, psychotic phenomenon, difficulties with ADL and word-finding difficulties. The frequency distribution of the apolipoprotein E epsilon4 allele was similar for both groups (p=0.469). Logistic regression analysis indicated that CAMCOG scores (p=0.002) and word-finding difficulty (p=0.002) were independently associated with memory complaints. These results show that memory complainers have worse cognitive performance than non-complainers and support the findings of other studies that suggest that subjective memory loss may be a reliable indicator of cognitive decline.

Alcohol: matters of life and death

Most of us enjoy alcohol and drink moderately, but some 7 million people in Britain drink more than the old ‘safe’ levels of alcohol — 21 and 14 units a week for men and women respectively. This represents one in eight of the population, or one in six if you exclude children under 15 years of age, difficult to justify these days given the amount of drinking by young children.

Reflections on alcohol and the young

Young people's exposure to alcohol in Britain is a major cause of concern to alcohol workers, yet little impact has been made on the problem despite extensive research and numerous recommendations for tackling it. To some extent, this is due to permissive public attitudes and the general lack of knowledge among the public and professionals of the dangers of alcohol misuse, but lack of leadership by government and targetting of alcohol at the young by the drinks industry must take some of the blame. Particular issues of relevance to young people are excessive drinking in pregnancy, which may affect the fetus, alcoholic parents, drinking among 11-15 year olds, and heavy consumption by older adolescents. The pressure that these put on social and health services (and the expense) is considerable. Rather than concentrating resources on treating the damage, greater emphasis should be placed on prevention and detection, for example recognizing risk factors -- immaturity, poor educational performance, antisocial behaviour, mental heath problems and dysfunctional families -- which lead to harm. This will require better education about alcohol for child specialists, teachers, social workers, the police, the legal professions, and others who have to deal with young people. Self-help groups among the young could help spread the message of sensible drinking among their peers. In addition, the number of alcohol agencies in the community which support parents and young people, at present woefully inadequate, need to be increased as a matter of urgency.

The -491AA polymorphism in the APOE gene is associated with increased plasma apoE levels in Alzheimer's disease

Recent evidence suggests that a polymorphism in the regulatory region of the apolipoprotein E gene (APOE) is associated with an increased risk for developing Alzheimer's disease (AD) independent of that conveyed by the epsilon4 allele of APOE. Previous work by our group indicated that plasma apolipoprotein E (apoE) levels were elevated in AD, raising the possibility that the -491 genotype might modify AD risk by increasing expression of the APOE gene. In a total of 638 individuals the -491AA genotype was significantly associated with AD (P < 0.005) while the TT genotype was associated with controls (P < 0.005). In 138 individuals the AA genotype showed significantly higher plasma apoE levels, independent of epsilon4 and AD status (P < 0.01) as well as within control and AD groups (P < 0.05). Within the AD group the AA genotype showed increased apoE levels when compared to AA controls (P < 0.0001). These results suggest that the -491 AA genotype is associated with increased plasma apoE levels, providing a potential basis for elucidating how that genotype increases the risk for developing AD.

A reciprocal allosteric mechanism for efficient transfer of labile intermediates between active sites in CAD, the mammalian pyrimidine-biosynthetic multienzyme polypeptide

Carbamoyl phosphate is the product of carbamoyl phosphate synthetase (CPS II) activity and the substrate of the aspartate transcarbamoylase (ATCase) activity, each of which is found in CAD, a large 240-kDa multienzyme polypeptide in mammals that catalyses the first three steps in pyrimidine biosynthesis. In our study of the transfer of the labile intermediate between the two active sites, we have used assays that differentiate the synthesis of carbamoyl phosphate from the overall reaction of CPS II and ATCase that produces carbamoyl aspartate. We provided excess exogenous carbamoyl phosphate and monitored its access to the respective active sites through the production of carbamoyl phosphate and carbamoyl aspartate from radiolabelled bicarbonate. Three features indicate interactions between the folded CPS II and ATCase domains causing reciprocal conformational changes. First, even in the presence of approximately 1 mM unlabelled carbamoyl phosphate, when the aspartate concentration is high ATCase uses endogenous carbamoyl phosphate for the synthesis of radiolabelled carbamoyl aspartate. In contrast, the isolated CPS II forward reaction is inhibited by excess unlabelled carbamoyl phosphate. Secondly, the affinity of the ATCase for carbamoyl phosphate and aspartate is modulated when substrates bind to CPS II. Thirdly, the transition-state analogue phosphonacetyl-L-aspartate is a less efficient inhibitor of the ATCase when the substrates for CPS II are present. All these effects operate when CPS II is in the more active P state, which is induced by high concentrations of ATP and magnesium ions and when 5'-phosphoribosyl diphosphate (the allosteric activator) is present with low concentrations of ATP; these are conditions that would be met during active biosynthesis in the cell. We propose a phenomenon of reciprocal allostery that encourages the efficient transfer of the labile intermediate within the multienzyme polypeptide CAD. In this model, binding of aspartate to the active site of ATCase causes a conformational change at the active site of the liganded form of CPS II, which protects it from inhibition by its product, carbamoyl phosphate; reciprocally, the substrates for CPS II affect the active site of ATCase by increasing the affinity for its substrates, endogenous carbamoyl phosphate and aspartate, and thus impede access of exogenous carbamoyl phosphate or the transition-state analogue. Reciprocal allostery justifies the close association of the enzyme activities within the polypeptide and ensures that carbamoyl phosphate is efficiently synthesised and is dedicated to the second step of pyrimidine biosynthesis. These conditions fulfill those required for metabolic channeling in the cell.

Infraspecific taxonomy and essential oil chemotypes in sweet basil, Ocimum basilicum

Essential oil compositions of fresh and freeze-dried leaves were determined for 16 accessions of Ocimum basilicum belonging to different varieties to see whether they could be used as infraspecific taxonomic characters. One accession of O. x citriodorum was also studied. Some 30 monoterpenoids, sesquiterpenoids and phenylpropanoids were identified, the major components (more than 20% of the total essential oil composition in one or more accessions) being geranial and neral in O. x citriodorum, and linalool, methyl chavicol, eugenol, methyl eugenol and geraniol in O. basilicum. Based on a combination of the latter compounds, five major essential oil profiles could be distinguished in the accessions studied for O. basilicum. These profiles were largely the same for fresh and freeze-dried material of the same plant, although in the dried leaves, methyl chavicol and eugenol concentrations had generally declined in comparison to those of linalool. There appeared to be little correlation between essential oil patterns and varietal classification within O. basilicum. In view of the chemical heterogeneity of O. basilicum and its use as an essential oil-producing crop, culinary herb, medicinal plant and insect-controlling agent, in all of which chemicals play an important role, the infraspecific classification of this taxon should take chemical characters into consideration. A system for the classification of essential oil chemotypes in O. basilicum is proposed.