Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Acute Medicine: How will we grow? - An analysis of organisational capabilities for quality improvement, research & education from SAMBA 2021

BACKGROUND

Education, research, and Quality Improvement (QI) are key enablers for high quality care. We aimed to map the capability of Acute Medical Units (AMUs) to facilitate excellence in these areas.

METHODS

AMUs were surveyed in an organisational questionnaire within the Society for Acute Medicine Benchmarking Audit 2021.

RESULTS

143 units participated. 80 units had a QI lead, 24 had a research lead and 99 had a medical education lead. 15 units had all three leadership roles. Most QI work considered service structure rather than changes in processes or care outcomes.

CONCLUSION

The organisational capability of AMUs in the strategic areas considered is variable. Improving leadership and disseminating learning could help build a strategic foundation for acute medicine to grow.

Society for Acute Medicine's Patients: Learning from Experience Report (SAM-PLER) A service evaluation of patient reported experience in Acute Medicine - establishing the feasibility of a quality improvement collaborative

Patient reported experience measures (PREMS) are a key part of measured quality. There is no tool currently used in the UK in Acute Medicine. On the 8th of September 2022 10 units based in England, Scotland and Wales collected data for the validated PREM, alongside the EQ-5D and variables from the Society for Acute Medicine's Benchmarking Audit (SAMBA) dataset. 365 patients were screened, 200 were included (55%): 159 patients from AMUs and 41 from SDEC units. Overall experience of patients was rated 8.5/10, patients rated their experience of safety, trust and listening highly. Collection of PREMS was feasible. Further research is required to link experience to clinical outcome and explore tools that capture experience of patients with altered mental status.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Society for Acute Medicine Benchmarking Audit 2021 (SAMBA21): assessing national performance of acute medicine services

INTRODUCTION

The Society for Acute Medicine Benchmarking Audit 2021 (SAMBA21) took place on 17th June 2021, providing the first assessment of performance against the Society for Acute Medicine's Clinical Quality Indicators (CQIs) within acute medical units since the start of the COVID-19 pandemic.

METHODS

All acute hospitals in the UK were invited to participate. Data were collected on unit structure, and for patients admitted to acute medicine services over a 24-hour period, with follow-up at 7 days.

RESULTS

158 units participated in SAMBA21, from 156 hospitals. 8973 patients were included. The number of admissions per unit had increased compared to SAMBA19 (Sign test p<0.005). An early warning score was recorded within 30 minutes of hospital arrival in 77.4% of patients. 87.4% of unplanned admissions were seen by a tier 1 clinician within 4 hours of arrival. Overall, the medical team performed the initial clinician assessment for 36.4% of unplanned medical admissions. More than a third of medical admissions had their initial assessment in Same Day Emergency Care (SDEC) in 25.4% of hospitals. 62.1% of unplanned admissions were seen by two other clinical decision makers prior to consultant review. Of those unplanned admissions requiring consultant review, 67.8% were seen within the target time. More than a third of unplanned admissions were discharged the same day in 41.8% of units.

CONCLUSION

Performance against the CQIs for acute medicine was maintained in comparison to previous rounds of SAMBA, despite increased admissions. There remains considerable variation in unit structure and performance within acute medical services.

Length of stay in Acute Medical Admissions: Analysis from the Society for Acute Medicine Benchmarking Audit

INTRODUCTION

Medical admissions to hospital represent a diverse range of patients, from those managed on ambulatory pathways through Same Day Emergency Care (SDEC) services, to those requiring prolonged inpatient admission. An understanding of current patterns of admission through acute medicine services and patient factors associated with longer hospital admission is needed to guide service planning and improvement.

METHODS

Data from the Society for Acute Medicine Benchmarking Audit (SAMBA) 2021 were analysed. Patients admitted to acute medicine services during a 24-hour period on 17th June 2021 were included, with data recording patient demographics, frailty score, acuity and follow-up of outcomes after seven days.

RESULTS

8101 unplanned medical admissions were included, from 156 hospitals. 31.6% were discharged without overnight admission; the median hospital performance was 30.1% (IQR 19.3-39.3%). 22.1% of patients remained in hospital for more than 7 days. Those remaining in hospital for more than 48 hours and for more than seven days were more likely to be aged over 70, to be frail, or to have a NEWS2 of 3 or more on arrival to hospital.

CONCLUSION

The proportion of acute medical attendances receiving overnight admission varies between hospitals. Length of stay is impacted by patient factors and illness acuity. Strategies to reduce inpatient service pressures must ensure effective care for older patients and those with frailty.

Perceptions of anonymised data use and awareness of the NHS data opt-out amongst patients, carers and healthcare staff

BACKGROUND

England operates a National Data Opt-Out (NDOO) for the secondary use of confidential health data for research and planning. We hypothesised that public awareness and support for the secondary use of health data and the NDOO would vary by participant demography and healthcare experience. We explored patient/public awareness and perceptions of secondary data use, grouping potential researchers into National Health Service (NHS), academia or commercial. We assessed awareness of the NDOO system amongst patients, carers, healthcare staff and the public. We co-developed recommendations to consider when sharing unconsented health data for research.

METHODS

A patient and public engagement program, co-created and including patient and public workshops, questionnaires and discussion groups regarding anonymised health data use.

RESULTS

There were 350 participants in total. Central concerns for health data use included unauthorised data re-use, the potential for discrimination and data sharing without patient benefit. 94% of respondents were happy for their data to be used for NHS research, 85% for academic research and 68% by health companies, but less than 50% for non-healthcare companies and opinions varied with demography and participant group. Questionnaires showed that knowledge of the NDOO was low, with 32% of all respondents, 53% of all NHS staff and 29% of all patients aware of the NDOO. Recommendations to guide unconsented secondary health data use included that health data use should benefit patients; data sharing decisions should involve patients/public. That data should remain in close proximity to health services with the principles of data minimisation applied. Further, that there should be transparency in secondary health data use, including publicly available lists of projects, summaries and benefits. Finally, organisations involved in data access decisions should participate in programmes to increase knowledge of the NDOO, to ensure public members were making informed choices about their own data.

CONCLUSION

The majority of participants in this study reported that the use of healthcare data for secondary purposes was acceptable when accessed by NHS. Academic and health-focused companies. However, awareness was limited, including of the NDOO. Further development of publicly-agreed recommendations for secondary health data use may improve both awareness and confidence in secondary health data use.

The changing characteristics of COVID-19 presentations. A regional comparison of SARS-CoV-2 hospitalised patients during the first and second wave

BACKGROUND

This study assesses COVID-19 hospitalised patient demography and outcomes during wave 1 and wave 2, prior to new variants of the virus.

METHODS

All patients with a positive SARS-CoV-2 swab between 10th March 2020 and 5th July 2020 (wave 1) and 1st September 2020 and 16th November 2020 (wave 2) admitted to University Hospitals Birmingham NHS Foundation Trust were included (n=4856), followed for 28 days.

RESULTS

Wave 2 patients were younger, more ethnically diverse, had less co-morbidities and disease presentation was milder on presentation. After matching for these factors, mortality was reduced, but without differences in intensive care admissions.

CONCLUSION

Prior to new SARS-CoV-2 variants, outcomes for hospitalised patients with COVID-19 were improving but with similar intensive care needs.

Applying a COVID Virtual Ward model, assessing patient outcomes and staff workload

A COVID virtual ward (CVW) is recommended by NHS England, but 'usual care' outcomes have not been reported. A retrospective study of all adults with COVID-19 attending Queen Elizabeth Hospital Birmingham between 01/06/2020-31/01/2021, assessed against CVW criteria and followed for 28 days. Of 2301 COVID-19 patients, 571(25%) would have met CVW criteria. Of these, 325(57%) were discharged after review and 246(43%) admitted. Of admitted patients who met CVW criteria, 81% required hospital-supported therapies; 11% died. Of the 325 discharged, 13% re-presented, 9% with COVID-related symptoms, 2% required intensive care admission, and one died (0.3%). In this comparison, discharging patients without a CVW did not lead to more re-presentations, re-admissions, ITU escalations or deaths compared to published outcomes for hospitals with a CVW.

Acute care service performance during winter: report from the winter SAMBA 2020 national audit of acute care

The Winter Society for Acute Medicine Benchmarking Audit (SAMBA) provides the first comparison of performance within acute medicine against clinical quality indicators during winter, a time of increased pressure and demand on acute services. 105 hospitals participated in Winter SAMBA, collecting data over 24-hours on 30th January 2020. 5626 patients were included. Participating units saw a median of 48 patients (range 13-131). Comparison between Winter SAMBA and SAMBA19 found less patients had an early warning score within 30 minutes during winter (74.3% vs 78.9%) and less were seen by a clinical decision maker within four hours (84.9% vs 87.9%). Unplanned admissions represented a higher proportion of workload (92.5% vs 90.1%). Patients were more likely to have a NEWS2 score of 3 or higher (30.1% vs 25.7%). Performance is poorer in winter, and patients are more unwell, needing prompt treatment. Services should ensure high quality care can be maintained through times of increased pressure, including winter.

Society for Acute Medicine Benchmarking Audit 2019 (SAMBA19): Trends in Acute Medical Care

INTRODUCTION

The eighth Society for Acute Medicine Benchmarking Audit (SAMBA19) took place on Thursday 27th June 2019. SAMBA gives a broad picture of acute medical care in the UK and allows individual units to compare their performance against their peers.

METHOD

All UK hospitals were invited to participate. Unit and patient level were collected. Data were analysed against published Clinical Quality indicators (CQI) and standards. This was the biggest SAMBA to date, with data from 7170 patients across 142 units in 140 hospitals.

RESULTS

84.5% of patients had an Early Warning Score measured within 30 minutes of arrival in hospital (SAMBA18 84.1%), 90.4% of patients were seen by a competent clinical decision maker within four hours of arrival in hospital (SAMBA18 91.4 %) and 68.6% of patients were seen by a consultant within the timeframe standard (SAMBA18 62.7%). Ambulatory Emergency Care is provided in 99.3% of hospitals. 61.8% of patients are initially seen in the Emergency Department (ED). Since SAMBA18 death rates and planned discharge rates, while the use of NEWS2 increased from 2.5% to 59.2% of hospitals.

CONCLUSION

SAMBA19 highlighted the evolving complexity of acute medical pathways for patients. The challenge now is to increase sample frequency, assess the impact of SAMBA open a broader debate to define optimal CQIs.

Acute, non-COVID related medical admissions during the first wave of COVID-19: A retrospective comparison of changing patterns of disease

COVID-19 may have altered the case-mix of non-COVID acute medical admissions. Retrospective analysis of acute medical admissions to University Hospitals Birmingham NHS Foundation Trust, showed that medical admissions decreased in April 2020 compared to April 2019. The proportion of young adults, non-cardiac chest pain, musculoskeletal conditions and self-discharges decreased. The proportion of admissions due to alcohol misuse, psychiatric conditions, overdoses and falls increased. There were a higher number of patients admitted to ICU and greater inpatient mortality but not once COVID diagnoses were excluded. There was a significant change in hospitalised case-mix with conditions potentially reflecting social isolation increasing and diagnoses which rarely require hospital treatment, reducing. This analysis will help inform service planning.

Serum lipase for assessment of pancreatic trauma

PURPOSE

Pancreatic enzymes are routinely measured during reception of trauma patients to assess for pancreatic injury despite conflicting evidence on their utility. The aim of this study was to investigate the utility of routine initial serum lipase measurement for the diagnosis of acute pancreatic trauma.

MATERIALS AND METHODS

Lipase measurements were introduced as part of the trauma pathology panel and requested on all patients who presented to an adult major trauma service and met trauma call-out criteria. Clinical records of these patients were extracted from the trauma registry and retrospectively reviewed. The performance of an initial serum lipase level measured on presentation to detect pancreatic trauma was determined.

RESULTS

There were 2,580 patients included in the study, with 17 patients diagnosed with pancreatic trauma. An elevated lipase was recorded in 390 patients. Statistically significant associations were observed for elevated lipase in patients with pancreatic trauma, head injury, acute alcohol ingestion and massive blood transfusion. As a test for pancreatic trauma, an abnormal serum lipase result had a specificity of 85.3 % (95 % CI 83.8-86.6), sensitivity of 76.5 % (95 % CI 49.8-92.2), positive predictive value of 3.3 % (95 % CI 1.8-5.8) and negative predictive value of 99.8 % (95 % CI 99.4-99.9). Higher cut-offs of serum lipase did not result in better performance.

CONCLUSIONS

A normal serum lipase result can be a useful adjunct to exclude pancreatic injury. A positive lipase result, regardless of the cut-off used, was not reliably associated with pancreatic trauma, and should not be used to guide further assessment.

Continuous Propagation of Trichosporon cutaneum in Cheese Whey

Trichosporon cutaneum, a nonfermenting yeast, was used to convert cheese whey lactose into microbial cell material. The doubling time for this organism in a laboratory-scale continuous propagator was 2 hr in a whey medium fortified with ammonium sulfate and corn steep liquor. Cellular growth and efficiency of conversion of lactose to cell material was higher than with Saccharomyces fragilis. When grown in whey, the nitrogen content of T. cutaneum was 3.5% and the distribution of amino acids per gram of cell protein was similar to that of commercial food yeasts.

Breeding and longevity in captive Australian sea lions Neophoca cinerea at zoos and aquaria in Australia: 1965-2003

Australian sea lions (Neophoca cinerea) are known to have been kept in aquaria and zoos in Australia since 1965. During that time at least 41 births were recorded, of which 19 were in Adelaide, 15 at Adelaide Zoo and 4 at Marineland of South Australia. The mean interval between successive births in Adelaide was 538.9 � 9.5 days (18.0 months; n = 10) and the mean assumed pregnancy period, including embryonic diapause, was 536.0 � 11.4 days (17.9 months; n = 9). The mean interval between parturition and presumed successful mating was 8.4 � 1.6 days (n = 5). Births occurred in all months except January, June, August and December. Figures for New South Wales and Queensland establishments are too small and scattered over time for any pregnancy periods or birth intervals to be determined. Likewise, latitudinal differences, if any, were not evident, because of the paucity of data from these more northerly places. One female at the Adelaide Zoo produced 8 pups between 1986 and 1997; she is still alive after 22 years in captivity. The youngest known-age (captive-born) female was 4 years, 8 months old when she gave birth to her first pup; and the oldest female in captivity to give birth to a pup was aged approximately 21 years, 8 months. The longest recorded captive period for a female was more than 25 years by 31 December 2003, and for a male it was 21 years, 11 months. A captive-bred female was still alive after 18 years, 2 months, 24 days; another such female died aged 18 years, 2 months, 18 days. These life spans appear to be similar to those that meagre data suggest for tagged N. cinerea in the wild.

Oxidative neuropathology and putative chemical entities for Alzheimer's disease: neuroprotective effects of salen-manganese catalytic anti-oxidants

Considerable evidence exists that the brains of individuals with Alzheimer's disease are subject to elevated levels of oxidative stress, particularly in regions exhibiting pathological damage. A major contributor to this oxidative stress appears to be the inflammatory process. Activation of rodent microglial cells by LPS or beta-amyloid peptide results in a marked up-regulation of inducible nitric oxide synthase (iNOS) and corresponding nitric oxide (NO) production. Elevated levels of iNOS are also observed in the brains of Alzheimer patients. The reaction of NO with superoxide leads to the generation of the highly reactive and damaging peroxynitrite free radical species. Peroxynitrite appears to play a key role in the generation of an oxidative stress in the Alzheimer brain as evidenced by widespread nitrotyrosine immunoreactivity. We have employed SIN-1 as a peroxynitrite generating system in cell cultures in order to characterize the effects of this free radical on neurons. SIN-1 treatment of primary rat hippocampal neurons in culture results in neurotoxicity by a necrosis mechanism according to electron microscopic criteria. One approach to limiting peroxynitrite mediated damage is to limit superoxide production. An approach we have evaluated is treatment with salen manganese compounds, a class of catalytic antioxidant compounds which behave as superoxide dismutase (SOD)/catalase mimetics to detoxify superoxide. A number of such salen manganese compounds, including EUK-8 and EUK-134, can markedly protect primary rat cortical neurons from hydrogen peroxide mediated oxidative stress. Such salen manganese compounds can similarly afford marked neuroprotection to an oxidative stress imposed by SIN-1, potentially attributable at least in part to their inherent SOD activity. The salen manganese SOD/catalase mimetics represent a promising class of catalytic antioxidant for attenuating oxidative stress.

High mutation detection rate in the COL4A5 collagen gene in suspected Alport syndrome using PCR and direct DNA sequencing

Approximately 85% of patients with Alport syndrome (hereditary nephritis) have been estimated to have mutations in the X chromosomal COL4A5 collagen gene; the remaining cases are autosomal with mutations in the COL4A3 or COL4A4 genes located on chromosome 2. In the present work, the promoter sequence and previously unknown intron sequences flanking exons 2 and 37 of COL4A5 were determined. Furthermore, intron sequences flanking the other 49 exons were expanded from 35 to 190 to facilitate mutation analysis of the gene. Using this information, all 51 exons and the promoter region were PCR-amplified and sequenced from DNA of 50 randomly chosen patients with suspected Alport syndrome. Mutations were found in 41 patients, giving a mutation detection rate of 82%. Retrospective analysis of clinical data revealed that two of the cases might be autosomal. Although it could not be determined whether the remaining seven cases (14%) were autosomal or X chromosome-linked, it is likely that some of them were autosomal. It is concluded that PCR amplification and direct DNA sequencing of the promoter and exons is currently the best procedure to detect mutations in COL4A5 in Alport syndrome.

Replacement of the DR alpha chain with the E alpha chain enhances presentation of Mycoplasma arthritidis superantigen by the human class II DR molecule

Mycoplasma arthritidis mitogen (MAM) is produced by an organism which can cause chronic proliferative arthritis in rodents. MAM possesses a typical superantigenic activity; it has the ability to activate a large panel of T cells which express specific V beta segments of the T-cell receptor. The presentation of MAM to T cells by antigen-presenting cells is mediated primarily through its binding to the major histocompatibility complex (MHC) class II E alpha chain in mice and the DR alpha chain in humans. However, MAM is much less active for human peripheral blood lymphocytes than for mouse splenocytes. It was suggested that a difference in MAM binding affinity between human and mouse class II molecules may account for their different MAM activities. To examine this possibility, we generated a panel of B-cell transfectants whose DR molecule is composed of either the DR alpha or the E alpha chain paired with a DR3 beta chain. The ability of these transfectants to present MAM to human peripheral T cells was analyzed. Our data show that transfectants expressing E alpha DR beta chimeric molecules have higher MAM-presenting activity than transfectants expressing wild-type DR alpha DR beta molecules, while the latter have higher activity in stimulating DR3-alloreactive T cells. Since both types of transfectants present MAM to T cells expressing the same T-cell receptor V beta gene families, the higher MAM-presenting activity of the E alpha transfectant is not due to its ability to interact with a different set of T cells. Furthermore, both the E alpha 1 and E alpha 2 domains contribute to this increased affinity for MAM binding. Taken together, our data suggest that there may be multiple MAM binding sites on the E alpha and DR alpha chains and residues unique to the E alpha chain may provide additional affinity for MAM.

Helicopter retrieval of primary trauma patients by a paramedic helicopter service

All trauma cases flown over a 3.5 year period by the Metropolitan Helicopter Ambulance (MHA) from the accident scene to the Alfred Hospital were analysed. The MHA carries paramedics trained in advanced life support and is not under direct medical control. There were 254 patients (226 males, 28 females, mean age 34 years) of whom 242 had sustained blunt trauma. The mean distance from the accident scene to hospital was 28 nautical miles. The mean time from dispatch of the MHA to arrival at the Alfred was 82 min. The mean ground time at the scene was 32 min. Major trauma (an injury severity score (ISS) of 15 or more) was present in 62% of patients, and the mean ISS was 22.4. The major treatments at the accident scene by the paramedics were insertion of an intravenous (i.v.) cannula (242 cases), application of splints (197 cases), endotracheal intubation (35 patients) and needle thoracostomy to exclude tension pneumothorax (18 cases). There were 25 patients with a Glasgow Coma Score (GCS) less than 8 who were not intubated at the scene. Review of paramedic management identified four cases where prehospital care could have been improved but it is unlikely the final outcome would have changed: delay in transport (1 case), inadequate i.v. fluid resuscitation (2 cases) and delay in intubation (1 case). There was 1 case of undiagnosed tension pneumothorax that contributed to the patient's death and 1 case of non-intubation where the outcome may have been altered. Overall there were 38 deaths (14% mortality), which was not significantly different from the predicted mortality of 17%.(ABSTRACT TRUNCATED AT 250 WORDS)

Mutations in the codon for a conserved arginine-1563 in the COL4A5 collagen gene in Alport syndrome

We have screened 110 unrelated Alport syndrome kindreds for mutations in the exon 48 region of the COL4A5 collagen gene. Denaturing gradient gel electrophoresis (DGGE) of the PCR-amplified region of exon 48 revealed sequence variants in DNA from affected males and carriers of three unrelated kindreds. All three kindreds have classical Alport syndrome of the juvenile type. DNA-sequencing analyses demonstrated two different single base changes in the codon for arginine-1563 located in exon 48. In Utah kindred 2103, there was a substitution of C by T resulting in the change of the CGA codon for arginine to the translation stop codon TGA. In Utah kindred 2123 and in the Danish kindred A13, there was a C-->T mutation in the noncoding strand changing the same codon to CAA for glutamine. Both mutations were confirmed by allele-specific hybridization on PCR-amplified DNA from other family members.

Isolation of Kunjin virus from a patient with a naturally acquired infection

OBJECTIVE

To describe the first isolation of Kunjin virus from a patient with a natural infection.

CLINICAL FEATURES

A 48-year-old female egg collector presented with muscle weakness, fatigue and extreme lethargy three weeks after developing rigors, headache, photophobia and nausea. Kunjin virus was isolated from an acute phase serum sample.

INTERVENTION AND OUTCOME

The patient made a partial recovery after treatment for 10 days with Catovit (Boehringer Ingelheim), one tablet twice a day, and then declined further medical contact.

CONCLUSION

The isolation of Kunjin virus from this patient confirms previous serological observations which suggested that this mosquito-borne virus caused febrile episodes in humans accompanied, on occasion, by polyarthralgia or mild central nervous system signs and symptoms.

Content and effects of alcohol advertising: a reply to Strickland

Strickland's criticisms of Atkin and Block's study on alcohol advertising are refuted point by point with quotations from the original study and defense of the methodologies used.