Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Gender and motor competence affects perceived likelihood and importance of physical activity outcomes among 14 year olds

BACKGROUND

Perceptions of the effects of physical activity could facilitate or deter future participation. This study explored the differences between gender and motor competence at 14 years of age in the perceptions of likelihood and importance of physical activity outcomes.

METHOD

The sample comprised 1582 14-year-old adolescents (769 girls) from the Western Australian Pregnancy Cohort (Raine) Study. Four motor competence groups were formed from a standardized Neuromuscular Developmental Index score (McCarron 1997). Perceptions of the likelihood and the importance of 15 physical activity outcomes were measured by a questionnaire developed for the NSW Schools Fitness and Physical Activity Survey (Booth et al. 1997). Gender (two) × motor competence (four) analyses of variance and Tukey post hoc were conducted on outcome scores (P < 0.02) using SPSS version 17.

RESULTS

Gender differences were found in the perceived likelihood and importance of physical activity outcomes within competition, social friendships and injury domains. Motor competence was significant in the perceived likelihood of physical health (P < 0.001), psychosocial (P < 0.009) and competition (P < 0.002) outcomes, with lower perceptions by the least competent groups. Significantly lower importance was perceived for academic outcomes for 14 year olds categorized with low compared with high motor competence (P < 0.005). Regardless of motor competence and gender, the same health and fun outcomes were ranked the highest in likelihood and the highest in importance.

CONCLUSION

Although level of motor competence at 14 years affected the perceived likelihood of health, social and fun outcomes from future participation in physical activity, adolescents highly valued these outcomes, whereas gender affected competition and winning, outcomes that were less valued. Physical activity that promotes these key and valued outcomes may encourage young people's ongoing involvement in physical activity, especially for those at risk of low participation.

Sources of sport confidence, imagery type and performance among competitive athletes: the mediating role of sports confidence

AIM

This study explored the mediating role of sport confidence upon (1) sources of sport confidence-performance relationship and (2) imagery-performance relationship.

METHODS

Participants were 157 competitive athletes who completed state measures of confidence level/sources, imagery type and performance within one hour after competition.

RESULTS

Among the current sample, confirmatory factor analysis revealed appropriate support for the nine-factor SSCQ and the five-factor SIQ. Mediational analysis revealed that sport confidence had a mediating influence upon the achievement source of confidence-performance relationship. In addition, both cognitive and motivational imagery types were found to be important sources of confidence, as sport confidence mediated imagery type- performance relationship.

CONCLUSION

Findings indicated that athletes who construed confidence from their own achievements and report multiple images on a more frequent basis are likely to benefit from enhanced levels of state sport confidence and subsequent performance.

Calreticulin-independent regulation of the platelet integrin αIIbβ3by the KVGFFKR αIIb-cytoplasmic motif

The platelet integrin alphaIIbbeta3 alters conformation in response to platelet activation and ligand binding, although the molecular mechanisms involved are not known. We previously showed that a lipid modified peptide, corresponding to the membrane proximal 989KVGFFKR995 portion of the alphaIIb cytoplasmic tail, independently activates platelet alphaIIbbeta3. Calreticulin (CRT) is a potential integrin regulatory protein based on its interaction with the highly conserved alpha-integrin sequence KxGFFKR. We therefore examined the possible interaction of calreticulin and alphaIIbbeta3 in human platelets. We demonstrate that calreticulin in platelets is localised to the granulomere. In contrast, the known integrin-binding protein talin accumulates at the periphery of spreading platelets and colocalises with alphaIIbbeta3 during the process of adhesion. An interaction between calreticulin and alphaIIbbeta3 could not be demonstrated using co-immunoprecipitation techniques under various platelet activation states, even in the presence of covalent chemical crosslinkers. Thus, calreticulin does not functionally interact with the major integrin in human platelets. In order to identify proteins that interact with the integrin KVGFFKR motif we then used a peptide 'pull-down' assay from platelet lysates with biotinylated peptides and demonstrate that only the alphaIIb and beta3 subunits selectively and individually interact with this sequence. This interaction is divalent cation-dependent, has high-affinity, and occurs both with purified alphaIIbbeta3 complex and with electroeluted alpha and beta subunits. Thus, our data show that the conserved integrin KVGFFKR domain interacts primarily with the alpha and beta cytoplasmic tails and not with CRT in human platelets.

Severe Plasmodium falciparum malaria is associated with circulating ultra-large von Willebrand multimers and ADAMTS13 inhibition

Plasmodium falciparum infection results in adhesion of infected erythrocytes to blood vessel endothelium, and acute endothelial cell activation, together with sequestration of platelets and leucocytes. We have previously shown that patients with severe infection or fulminant cerebral malaria have significantly increased circulatory levels of the adhesive glycoprotein von Willebrand factor (VWF) and its propeptide, both of which are indices of endothelial cell activation. In this prospective study of patients from Ghana with severe (n = 20) and cerebral (n = 13) P. falciparum malaria, we demonstrate that increased plasma VWF antigen (VWF:Ag) level is associated with disproportionately increased VWF function. VWF collagen binding (VWF:CB) was significantly increased in patients with cerebral malaria and severe malaria (medians 7.6 and 7.0 IU/ml versus 1.9 IU/ml; p<0.005). This increased VWF:CB correlated with the presence of abnormal ultra-large VWF multimers in patient rather than control plasmas. Concomitant with the increase in VWF:Ag and VWF:CB was a significant persistent reduction in the activity of the VWF-specific cleaving protease ADAMTS13 (approximately 55% of normal; p<0.005). Mixing studies were performed using P. falciparum patient plasma and normal pooled plasma, in the presence or absence of exogenous recombinant ADAMTS13. These studies demonstrated that in malarial plasma, ADAMTS13 function was persistently inhibited in a time-dependent manner. Furthermore, this inhibitory effect was not associated with the presence of known inhibitors of ADAMTS13 enzymatic function (interleukin-6, free haemoglobin, factor VIII or thrombospondin-1). These novel findings suggest that severe P. falciparum infection is associated with acute endothelial cell activation, abnormal circulating ULVWF multimers, and a significant reduction in plasma ADAMTS13 function which is mediated at least in part by an unidentified inhibitor.

Compartmentalization regulates the interaction between the platelet integrin alpha IIb beta 3 and ICln

The volume-regulating protein, ICln, interacts with the conserved KxGFFKR alpha-integrin signature motif. ICln is an abundant protein (4455 +/- 650 molecules/platelet) found exclusively in the soluble cytosolic fraction of unactivated platelets. In contrast, its binding partner, the platelet integrin alpha(IIb)beta(3), is present in detergent-insoluble fractions associated with membrane and cytoskeleton subcellular localizations. This study investigated factors that regulate the interaction of ICln with alpha(IIb)beta(3) during platelet activation. His-tagged recombinant ICln bound equally to purified alpha(IIb)beta(3) and to integrin from resting or activated platelets. Binding was not affected by direct integrin activation with Mn(++) or by inhibitors of integrin occupancy (abciximab, RGD). However, the capacity for interaction between integrin and recombinant ICln was slowly downregulated following prolonged platelet activation for >300 s. In parallel, ICln redistributed to membrane and cytoskeletal platelet subcellular fractions. The time-course of this redistribution preceded the downregulation of integrin binding capacity and suggests that only a short window of opportunity exists for ICln interaction with alpha(IIb)beta(3) to occur. Thus, although ICln has the inherent capacity to bind to alpha(IIb)beta(3) regardless of its activation state, it can only do so following platelet activation. Activation-dependent subcellular redistribution of ICln represents a novel, temporally-regulated mechanism for control of integrin function in platelets.

Predictors of outcome after temporal lobectomy for refractory temporal lobe epilepsy

OBJECTIVE

To identify predictors of outcome after epilepsy surgery in patients with temporal lobe epilepsy (TLE).

METHODS

Seventy-six patients with normal magnetic resonance imaging (MRI) or hippocampal sclerosis on MRI who underwent anterior temporal lobe resections were included. Outcome 2 years after surgery was classified as good (Engel I and II) or poor (Engel III and IV). Gender, age at onset and duration of epilepsy, history of febrile convulsions, auras, right- or left-sided TLE, memory ipsilateral to seizure onset (Wada test), hippocampal asymmetry (HA) and T2 relaxation time, amygdala, temporal lobe and hemispheral volume were tested for associations with outcome.

RESULTS

Sixty-seven percent had a good outcome. Of all parameters tested, only a history of febrile convulsions and HA on quantitative MRI were significantly associated with a good seizure outcome. The absence of these parameters did not exclude a good outcome, but only five of 18 patients (28%) without HA and without a history of febrile convulsions had a good outcome.

CONCLUSION

Febrile convulsions and HA were predictors of outcome after epilepsy surgery in TLE. Subtle volume loss in amygdala, temporal lobe or hemispheres and the memory ipsilateral to the side of resection were not associated with outcome.

Nicotinamide Reverses Neurological and Neurovascular Deficits in Streptozotocin Diabetic Rats

In diabetes, activation of the nuclear enzyme poly(ADP-ribose) polymerase (PARP) is an important effector of oxidative-nitrosative injury, which contributes to the development of experimental diabetic peripheral neuropathy (DPN). However, the potential toxicity of complete PARP inhibition necessitates the utilization of weaker PARP inhibitors with additional therapeutic properties. Nicotinamide (vitamin B3) is a weak PARP inhibitor, antioxidant, and calcium modulator and can improve energy status and inhibit cell death in ischemic tissues. We report the dose-dependent effects of nicotinamide in an established model of early DPN. Control and streptozotocin-diabetic rats were treated with 200 to 400 mg/kg/day nicotinamide (i.p.) for 2 weeks after 2 weeks of untreated diabetes. Sciatic endoneurial nutritive blood flow was measured by microelectrode polarography and hydrogen clearance, and sciatic motor and hind-limb digital sensory nerve conduction velocities and thermal and mechanical algesia were measured by standard electrophysiological and behavioral tests. Malondialdehyde plus 4-hydroxyalkenal concentration in the sciatic nerve and amino acid-(4)-hydroxynonenal adduct and poly(ADP-ribosyl)ated protein expression in human Schwann cells were assessed by a colorimetric method with N-methyl-2-phenyl indole and Western blot analysis, respectively. Nicotinamide corrected increased sciatic nerve lipid peroxidation in concert with nerve perfusion deficits and dose-dependently attenuated nerve conduction slowing, as well as mechanical and thermal hyperalgesia. Nicotinamide (25 mM) prevented high (30 mM) glucose-induced overexpression of amino acid-(4)-hydroxynonenal adducts and poly(ADP-ribosyl)ated proteins in human Schwann cells. In conclusion, nicotinamide deserves consideration as an attractive, nontoxic therapy for the treatment of DPN.

Neurological soft signs and dermatoglyphic anomalies in twins with schizophrenia

Schizophrenia is associated with altered neural development. We assessed neurological soft signs (NSS) and dermatoglyphic anomalies (total a-b ridge count (TABRC) and total finger ridge count) in 15 pairs of twins concordant and discordant for schizophrenia. Within-pair differences in both NSS and TABRC scores were significantly greater in discordant compared to concordant monozygotic pairs. There was no significant difference in NSS and TABRC scores between subjects with schizophrenia and their co-twins without the illness. However, monozygotic discordant twins with schizophrenia had higher ABRCs on their right hands compared to their co-twins without the illness. These findings suggest that an unidentified environmental event acting between weeks 6 and 15 of gestation affects the development of monozygotic twins who go on to develop schizophrenia but does not have a corresponding effect on their co-twins who do not develop the illness. The effect of such an event on dermatoglyphic profiles appears lateralised to the right hand in affected twins.

ICln, a Novel Integrin αIIbβ3-Associated Protein, Functionally Regulates Platelet Activation

A critical role for the conserved alpha-integrin cytoplasmic motif, KVGFFKR, is recognized in the regulation of activation of the platelet integrin alpha(IIb)beta(3). To understand the molecular mechanisms of this regulation, we sought to determine the nature of the protein interactions with this cytoplasmic motif. We used a tagged synthetic peptide, biotin-KVGFFKR, to probe a high density protein expression array (37,200 recombinant human proteins) for high affinity interactions. A number of potential integrin-binding proteins were identified. One such protein, a chloride channel regulatory protein, ICln, was characterized further because its affinity for the integrin peptide was highest as was its expression in platelets. We verified the presence of ICln in human platelets by PCR, Western blots, immunohistochemistry, and its co-association with alpha(IIb)beta(3) by surface plasmon resonance. The affinity of this interaction was 82.2 +/- 24.4 nm in a cell free assay. ICln co-immunoprecipitates with alpha(IIb)beta(3) in platelet lysates demonstrating that this interaction is physiologically relevant. Furthermore, immobilized KVGFFKR peptides, but not control KAAAAAR peptides, specifically extract ICln from platelet lysates. Acyclovir (100 microm to 5 mm), a pharmacological inhibitor of the ICln chloride channel, specifically inhibits integrin activation (PAC-1 expression) and platelet aggregation without affecting CD62 P expression confirming a specific role for ICln in integrin activation. In parallel, a cell-permeable peptide corresponding to the potential integrin-recognition domain on ICln (AKFEEE, 10-100 microm) also inhibits platelet function. Thus, we have identified, verified, and characterized a novel functional interaction between the platelet integrin and ICln, in the platelet membrane.

Using the Rasch measurement model to investigate the construct of motor ability in young children

This paper reports the use of a Rasch measurement model, the Extended Logistic Model of Rasch (Andrich, 1988), to explore the construct of a general motor ability in young children. Data were collected from 332 five and six year old children performing 24 motor skills, including run, hop, balance and ball skills. The data were categorised based on threshold estimates provided by the measurement model. Gender differences in performances on items were hypothesised to contribute to initial item and person misfit for the total sample. The data for boys and for girls were separated and independently analysed resulting in improved item and person fit. Two different, unidimensional scales for boys and for girls were created.

MPer1 and mper2 are essential for normal resetting of the circadian clock

Mammalian Per1 and Per2 genes are involved in the mechanism of the circadian clock and are inducible by light. A light pulse can evoke a change in the onset of wheel-running activity in mice by shifting the onset of activity to earlier times (phase advance) or later times (phase delays) thereby advancing or delaying the clock (clock resetting). To assess the role of mouse Per (mPer) genes in circadian clock resetting, mice carrying mutant mPer1 or mPer2 genes were tested for responses to a light pulse at ZT 14 and ZT 22, respectively. The authors found that mPer1 mutants did not advance and mPer2 mutants did not delay the clock. They conclude that the mammalian Per genes are not only light-responsive components of the circadian oscillator but also are involved in resetting of the circadian clock.

Creating performance categories from continuous motor skill data using a Rasch measurement model

This paper reports the use of the Extended Logistic Model (ELM) of Rasch (Andrich, 1988), based on Item Response Theory, to validate the reduction of continuous motor skill data to categories of performance. The data were gathered from the performances of 5 and 6 year old children on 24 fundamental movement skills and involved different measurement units such as seconds, centimetres, scores and counts. In order to compare results across all skills the data were collapsed into discrete sets of categories. Several alternative cut-off locations based on normative data were considered. A feature of the ELM is that it can account for correct scoring of the response categories, but only if the threshold estimates derived from the data by the measurement model are correctly ordered in a hierarchical fashion, from lowest to highest. Should this be the case, a valid scoring function has been established. In this study, the data were successfully reduced to three categories based on the 15th and 85th percentile allowing further analysis to proceed.

Stability and change in children's skill

This paper explores age-related performance variability, both within trials and between sessions, in repetitive hopping. The mean, the standard deviation (SD), and the coefficient of variation (CV) of several timing and ground-reaction-force variables of hopping were analysed by repeated-measures ANOVA for age-related effects across test sessions and foot used. Forty-five subjects in five age groups (3-4 years, 4-5 years, 6-7 years, 8-9 years, or Adult) performed self-paced, one-footed hopping on three occasions within one week. As was expected, the results showed main effects for Age in all force and time variables, with the exception of CV of medio-lateral force. No significant main effects for Feet were revealed. However, significant Feet x Session interactions were found in flight-time measures, with higher flight-time SD and lower CV for the non-preferred foot in Session 1, a reversal in Session 2, and a negligible difference in Session 3. Across sessions, decreased SD and CV for both vertical and medio-lateral force and shorter flight time indicated more efficient hopping. Overall, it was concluded that SD and CV measures were more sensitive measures of children's performance across repeated sessions than were mean scores and that the order of testing the limbs is an important consideration in experimental protocols when lateralized tasks are measured.

Audit of cost and clinical outcome of cataract surgery

An audit of routine cataract surgery in our hospital was carried out by examining records of 340 adult patients who underwent such surgery during October 1990. The category of intended accommodation (day case or inpatient), operative details, post-operative course and management were recorded, along with the outcome measures of visual acuity (unaided and corrected) and refractive error (spherical equivalent and cylinder). The costs of treatment, including post-operative management, were calculated for each patient. The results indicate that day case surgery under local anaesthesia was the most cost-effective method of cataract surgery, with no detrimental effect on clinical outcome.

Kinaesthetic abilities of clumsy children

Kinaesthesis was examined in 80 clumsy and 80 control children aged between six and nine years. Seven tasks were administered which required passive and active movements in both kinaesthetic and kinaesthetic-visual modes. Clumsy children performed inferiorly on three tasks which involved passive or active demands. A range of tasks appears to be necessary to identify kinaesthetic dysfunction.

Movement laterality and its relationship to hemispheric specialization

Hypothesized relationships between asymmetric brain processes and movement-related asymmetries are reviewed. Theories that attribute asymmetric preference and performance to hemisphere dominance have been superseded by more complex ideas: motor-specific and more global hemispheric specializations are considered to influence movement organization. Environmentally conditioned preferences and their relationship to preferential asymmetric movements are also addressed. The literature suggests that laterality may be dynamic, because task requirements have been shown to override asymmetric brain influences. This observation of the nature of laterality may result in a more flexible approach to the reeducation of preference and performance in brain-injured patients.