Exposure to the troubles in Northern Ireland, memory functioning, and social activity engagement: results from NICOLA

We investigated the potential impact of a cohort traumatic exposure, the Troubles in Northern Ireland, on memory functioning in later life, and the potential moderating effect of social activity engagement. Using data from 6571 participants aged 60 + in the Northern Ireland Cohort for the Longitudinal Study of Ageing (NICOLA) cohort, we used a structural equation modelling framework to explore associations between traumatic exposure during the Troubles and memory functioning. As expected, social activity engagement was positively associated with memory functioning, β = .102. Traumatic exposure was also positively associated with memory functioning, β = .053. This association was stronger at low levels of social activity engagement; among those with higher levels, there was little association, interaction β = - 0.054. The positive association between traumatic exposure during the Troubles and memory functioning was not moderated by the age at which the exposures occurred (based on analysis of a subsample with available data), interaction β = - 0.015. We conclude that superior memory functioning was associated with higher levels of traumatic exposure during the Troubles, particularly among those with lower levels of social activity engagement, and regardless of the age at which the exposures occurred. Future longitudinal analyses are required to build on these results, which potentially have implications for life-course epidemiology, in relation to critical periods for traumatising experiences.

Building On The Gains Of The ACA: Federal Proposals To Improve Coverage And Affordability

The Affordable Care Act (ACA) significantly improved health insurance coverage in the US, but too many Americans remain under- or uninsured. This article examines federal strategies under consideration that build on the ACA to extend comprehensive coverage to all low-income Americans and increase coverage affordability for middle-income Americans. For low-income Americans these policy options include extending the enhanced match rate offered to states that expanded eligibility for Medicaid in the early years of the ACA to states that have not yet expanded Medicaid and increasing Marketplace cost-sharing subsidies. To address the issue of affordability for middle-income Americans, this article considers options for lowering premiums (for example, extending tax credits to people with incomes above the current eligibility threshold, increasing the generosity of tax credits for those currently eligible, and making reinsurance permanent), lowering cost sharing (such as tying premium tax credits to the second-lowest-cost gold plan rather than the equivalent silver plan and extending federal assistance for cost sharing to people with incomes above the current threshold), and establishing a public option.

Risk of tuberculosis reactivation during interleukin-17 inhibitor therapy for psoriasis: a systematic review

Immunosuppressive therapies, effective in treating inflammatory disorders such as psoriasis, increase the risk of serious infections, such as tuberculosis (TB). For example, tumour necrosis factor (TNF)-alpha inhibitors significantly increase the risk of TB reactivation in patients with latent TB infection (LTBI), which has led clinicians to routinely test for TB prior to initiation of these medications. This protocol has since extended to other, newer immunomodulatory therapies for psoriasis, such as interleukin (IL)-17 inhibitors, including secukinumab, ixekizumab and brodalumab. We conducted a systematic review to examine whether there is any evidence that IL-17 inhibitor therapy for psoriasis increases the risk of TB reactivation. Using PubMed and EMBASE, our literature search resulted in 139 total articles. After manually reviewing each article for the discussion of IL-17 inhibitors for psoriasis, with data originating from clinical trials, and assessment for incidence of TB reactivation, 23 articles met the full inclusion criteria for our review. Overall, we found no cases of TB reactivation in patients treated with IL-17 inhibitors for psoriasis. This suggests that IL-17 inhibitors may be safely used in psoriasis patients with LTBI who receive appropriate LTBI treatment. However, long-term real-world studies are warranted to further evaluate this risk.

Pan-TRK Immunohistochemistry: A Useful Diagnostic Adjunct For Secretory Carcinoma of the Breast

Secretory carcinoma is a special-type breast carcinoma underpinned by a recurrent t(12;15)(p13;q25) translocation resulting in ETV6-NTRK3 gene fusion. Immunohistochemistry (IHC) using a pan-TRK antibody has been recently shown to help identify NTRK rearrangements in other tumor types. The purpose of this study was to assess the diagnostic utility of pan-TRK IHC in secretory carcinoma of the breast. Pan-TRK IHC was performed using a rabbit monoclonal antibody on whole sections of 24 breast secretory carcinomas and tissue microarray sections of other breast carcinoma types (n=203) and histologic mimics (n=15). Cases were assessed for staining intensity and localization. The 24 patients with secretory carcinoma had a median age of 44 years and a median tumor size of 1.0 cm. ETV6 fluorescence in situ hybridization was positive in all cases tested (n=20). Twenty-three cases (95.8%) showed staining with pan-TRK, which was exclusively nuclear in 19, primarily nuclear with weak cytoplasmic staining in 3, and primarily cytoplasmic with focal nuclear staining in 1. The nuclear staining was diffuse in 17 and at least focally strong in 17. The only pan-TRK negative case was a core biopsy with limited tumor. Among the 203 nonsecretory carcinomas, 21 (10.3%) showed focal, weak nuclear staining in <5% of tumor cells and 1 (0.5%) showed focal membranous staining. All histologic mimics were negative. In conclusion, diffuse and/or at least focally strong nuclear pan-TRK staining is a sensitive and specific marker for secretory carcinoma of the breast.

Promoting lifestyle behaviour change and well-being in hospital patients: a pilot study of an evidence-based psychological intervention

BACKGROUND

Lifestyle risk behaviours show an inverse social gradient, clustering in vulnerable groups. We designed and piloted an intervention to address barriers to lifestyle behaviour change among hospital patients.

METHODS

We designed our intervention using effective components of behaviour change interventions informed by psychological theory. Delivered by a health psychologist based at the Royal Free London NHS Foundation Trust, the 4-week intervention included detailed baseline assessment, personalized goal setting, psychological skills development, motivation support and referral to community services. Primary outcomes were feasibility and patient acceptability. We also evaluated changes to health and well-being.

RESULTS

From 1 July 2013 to 31 September 2014, 686 patients were referred, 338 (49.3%) attended a first appointment and 172 (25.1%) completed follow-up. Furthermore, 72.1% of attenders were female with the median age 55 years and poor self-reported baseline health. After 4 weeks, self-efficacy, health and well-being scores significantly improved: 63% of lifestyle goals and 89% of health management goals were fully achieved; 58% of referrals to community lifestyle behaviour change services and 79% of referrals to other services (e.g. Citizen's Advice Bureau) were accepted; 99% were satisfied/very satisfied with the service.

CONCLUSIONS

Our hospital-based intervention was feasible, acceptable and showed preliminary health and well-being gains.

Frequency of abnormal fecal biomarkers in irritable bowel syndrome

PRIMARY STUDY OBJECTIVE

Determine the frequency of abnormal fecal biomarker test results in patients with 13 irritable bowel syndrome (IBS)-related ICD-9 (International Statistical Classification of Diseases and Related Health Problems) codes.

STUDY DESIGN

Quantitative review of de-identified records from patients in whom IBS was a possible diagnosis.

METHODS

Records were selected for analysis if they included any of 13 IBS-related diagnostic codes and laboratory test results of fecal testing for all biomarkers of interest. Data collection was restricted to one 12-month period. Frequency distributions were calculated to identify rates of abnormal results for each biomarker within the total number of tests conducted in the eligible population.

RESULTS

Two thousand, two hundred fifty-six records were included in the study, of which 1867 (82.8%) included at least one abnormal value. Quantitative stool culture for beneficial bacteria (Lactobacillus and Bifidobacterium) indicated low growth suggestive of intestinal dysbiosis in 73.1% of records, followed by abnormally elevated eosinophil protein X (suggestive of food allergy) in 14.3%, elevated calprotectin (suggestive of inflammation) in 12.1%, detection of parasites in 7.5%, and low pancreatic elastase (suggestive of exocrine pancreatic insufficiency) in 7.1%.

CONCLUSIONS

Abnormal fecal biomarkers are prevalent in patients with diagnoses suggestive of IBS. Abnormal fecal biomarker testing, if confirmed in additional independent clinical trials, could substantially reduce the economic costs associated with diagnosis and management of IBS.

Novel Testing Enhances Irritable Bowel Syndrome Medical Management: The IMMINENT Study

Primary Study Objective:

To evaluate the economic utility of a fecal biomarker panel structured to suggest alternative, treatable diagnoses in patients with symptoms of irritable bowel syndrome (IBS) by quantifying, comparing, and contrasting health service costs between tested and non-tested patients.

Study Design:

Retrospective, matched cohort study comparing direct medical costs for IBS patients undergoing fecal biomarker testing with those of matched control subjects.

Methods:

We examined de-identified medical and pharmacy claims of a large American pharmacy benefit manager to identify plan members who underwent panel testing, were eligible for covered benefits for at least 180 days prior to the test date, and had data available for 30, 90, and 365 days after that date. We used propensity score matching to develop population-based control cohorts for each tested cohort, comprised of records with IBS-related diagnoses but for which panel testing was not performed. Primary outcome measures were diagnostic and medical services costs as determined from claims data.

Results:

Two hundred nine records from tested subjects met inclusion criteria. The only significant baseline differences between groups were laboratory costs, which were significantly higher in each tested cohort. At each follow-up time point, total medical and gastrointestinal procedural costs were significantly higher in non-tested cohorts. Within tested cohorts, costs declined significantly from baseline, while costs rose significantly in non-tested control cohorts; these differences were also significant between groups at each time point.

Conclusions:

Structured fecal biomarker panel testing was associated with significantly lower medical and gastrointestinal procedural costs in this study of patients with IBS symptoms.

Workshop on predictive science of the immunogenicity aspects of particles in biopharmaceutical products

Particles in protein therapeutics and concerns for a potential correlation with product immunogenicity are increasingly becoming the focus of recent publications and scientific forums. The consensus of academic, industrial, and regulatory scientists is that this area is not well understood and will require in-depth research because of the potential impact on the product safety and efficacy. This commentary presents a summary of the 1-day workshop entitled "Predictive Science of the Immunogenicity Aspects of Particles in Biopharmaceutical Products," which discussed the current state of analytical resources for quantitation and characterization of protein aggregates and potential paths for developing predictive preclinical tools.

Abstract 2111: Characterization of current and novel biomarkers of bladder cancer

Bladder cancer is one of the most common cancers in industrialized countries. It is reported that 3.51 billion dollars are spent each year on bladder cancer treatment making it the most expensive cancer to treat on a per patient basis. Approximately 80% of bladder cancer patients have at least one reported recurrence thereby prompting meticulous lifetime screening and surveillance by health care professionals. Therefore, careful evaluation of our institution's current fluorescent in situ hybridization surveillance tools in addition to investigation of novel biomarkers is imperative. Our investigation of novel biomarkers focused on apoptosis regulating genes which are often unbalanced in cancerous tissues. Our institution recently adopted BioView, an automated FISH capture/analysis system, to replace the manual protocol. Validation and assessment of the automated system for fluorescent in situ hybridization (FISH) interpretation to detect urothelial cancer was determined using patient cases to evaluate concordance, overall positivity, interpretative time spent, sensitivity, and specificity. To evaluate novel biomarkers, mRNA from patient samples was reversed transcribed to cDNA then utilized for biomarker quantification by RT-PCR. In addition, immunohistochemistry was performed on the most promising gene to further confirm its clinical usefulness. The automated BioView capture/ detection system does prove to be more time efficient and accurate when addressing all parameters described. In evaluation of novel biomarkers, API5, BIRC3, BIRC4, SURVIVIN, and BFAR provided the most promising data with sensitivity and specificity percentages all ranging from 83% to 97%. From this study of bladder cancer markers, we focused on API5 and its role in bladder cancer initiation and progression. API5 is strongly expressed early in tumorigenesis. Our data confirm that the automated FISH capture/detection system improves laboratory efficiency and accuracy. Furthermore, our data indicate that apoptotic regulators are promising biomarkers for clinical use. In addition, API5 is expressed early in tumorigenesis, which makes it an ideal early diagnostic marker. We have noticed increase in the level of API5 protein associated with tumor grade and stage which also suggest that API5 might be a potential prognostic marker for bladder cancer. In conclusion, detection of apoptosis regulating genes is a promising diagnostic and prognostic approach to aid our screening and surveillance tools.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2111. doi:1538-7445.AM2012-2111

Abstract 159: Prognostic and diagnostic significance of microRNA in bladder cancer

Purpose: Recently the role of microRNA (miRNA) in the development and progression of cancer including genitourinary tumors, and lymphomas to name a few have illustrated specific miRNA's to be dysregulated. Consequently miRNA's are currently being investigated as potential diagnostic and prognostic markers in neoplastic diseases. Because miRNA's are highly conserved they are promising as a potential biomarker that may be acquired by non-invasive means. This study investigated the presence of miR-21, miR-17-5p, miR-155, miR-26, miR-126, and miR-182 in bladder cancer tumor and tumor normal tissue specimens. We further investigated the presence of miR-21, miR-17-5p and miR-155 in urine sediment of bladder cancer patients.

Materials and Methods: quantitative Real time (RT-PCR) analysis was utilized for the detection of the precursors of miR-21, miR-17-5p, miR-155, miR-26, miR-126, and miR-182 in 23 RNA samples obtained from with bladder cancer tissue specimens. The relative expression values were compared to pooled matched non-tumor tissue. The presence of precursors of miRNA miR-21, miR-17-5p and miR-155 were also tested in 104 urine specimens from patients with active disease following positive cystoscopy (n=57) and patients previously diagnosed and treated for bladder cancer (n=34) with negative cystoscopic examination, patients with non-bladder cancer urological disease (n=6) and 7 healthy volunteers.

Results: The precursors of the oncogenic miRNA miR-21, miR-155, and miR-26 were up-regulated in the early grades and stages of the disease and the levels of expression are maintained in high grades and late disease stage. Interestingly, high levels of miR-17-5p were detected in higher grades and stages of bladder cancer and correlated with poor long term survival. Our data also indicated that the miR-126 is down-regulated in bladder cancer specimens compared to the non-tumor tissues. Our preliminary data have also shown that high levels of the precursors of miR-21, miR-17-5p and miR-155 can be detected in urine sediment collected from patients with active disease in higher levels compared to cytoscopy negative patients, patients with non-malignant urological diseases and healthy controls.

Conclusion: Our data have shown that miRNA detection in tissue and urine specimens in patients with bladder cancer has a promising prognostic and diagnostic significance and this preliminary data warranting further investigation to look at miRNA's as potential biomarkers. Illustrating the presence of miRNA in urine sediment of bladder cancer patients may prove useful in noninvasive evaluation of bladder cancer.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 159. doi:10.1158/1538-7445.AM2011-159

An inactivated cell-culture vaccine against yellow fever

BACKGROUND

Yellow fever is a lethal viral hemorrhagic fever occurring in Africa and South America. A highly effective live vaccine (17D) is widely used for travelers to and residents of areas in which yellow fever is endemic, but the vaccine can cause serious adverse events, including viscerotropic disease, which is associated with a high rate of death. A safer, nonreplicating vaccine is needed.

METHODS

In a double-blind, placebo-controlled, dose-escalation, phase 1 study of 60 healthy subjects between 18 and 49 years of age, we investigated the safety and immunogenicity of XRX-001 purified whole-virus, β-propiolactone-inactivated yellow fever vaccine produced in Vero cell cultures and adsorbed to aluminum hydroxide (alum) adjuvant. On two visits 21 days apart, subjects received intramuscular injections of vaccine that contained 0.48 μg or 4.8 μg of antigen. Levels of neutralizing antibodies were measured at baseline and on days 21, 31, and 42.

RESULTS

The vaccine induced the development of neutralizing antibodies in 100% of subjects receiving 4.8 μg of antigen in each injection and in 88% of subjects receiving 0.48 μg of antigen in each injection. Antibody levels increased by day 10 after the second injection, at which time levels were significantly higher with the 4.8-μg formulation than with the 0.48-μg formulation (geometric mean titer, 146 vs. 39; P<0.001). Three adverse events occurred at a higher incidence in the two vaccine groups than in the placebo group: mild pain, tenderness, and (much less frequently) itching at the injection site. One case of urticaria was observed on day 3 after the second dose of 4.8 μg of vaccine.

CONCLUSIONS

A two-dose regimen of the XRX-001 vaccine, containing inactivated yellow fever antigen with an alum adjuvant, induced neutralizing antibodies in a high percentage of subjects. XRX-001 has the potential to be a safer alternative to live attenuated 17D vaccine. (Funded by Xcellerex; ClinicalTrials.gov number, NCT00995865.).

Removal of N-terminal blocking groups from proteins

Two enzymatic methods commonly used in N-terminal sequence analysis of blocked proteins are presented: one uses pyroglutamate aminopeptidase for N(α)-pyrrolidone carboxyl-proteins in solution or blotted onto a membrane, and the other uses acylaminoacyl-peptide hydrolase for N(α)-acyl-proteins blocked with other acyl groups. A Support Protocol describes a colorimetric assay for pyroglutamate aminopeptidase activity. Sequencing with acylaminoacyl-peptide hydrolase must include fragmentation of the protein before unblocking, so procedures are provided for chemically blocking newly generated peptides with either succinic anhydride or phenylisothiocyanate/performic acid. The hydrolase is then applied to the total mixture of peptides, only one of which, the acylated N-terminal peptide, should be a substrate for hydrolase. After incubation, the mixture of peptides is subjected to sequence analysis.

The Drosophila protein palmitoylome: characterizing palmitoyl-thioesterases and DHHC palmitoyl-transferases

Palmitoylation is the post-translational addition of a palmitate moiety to a cysteine residue through a covalent thioester bond. The addition and removal of this modification is controlled by both palmitoyl acyl-transferases and thioesterases. Using bioinformatic analysis, we identified 22 DHHC family palmitoyl acyl-transferase homologs in the Drosophila genome. We used in situ hybridization,RT-PCR, and published FlyAtlas microarray data to characterize the expression patterns of all 22 fly homologs. Our results indicate that all are expressed genes, but several, including CG1407, CG4676, CG5620, CG6017/dHIP14, CG6618, CG6627 and CG17257 appear to be enriched in neural tissues suggesting that they are important for neural function. Furthermore, we have found that several may be expressed in a sex-specific manner with adult male specific expression of CG4483 and CG17195. Using tagged versions of the DHHC genes, we demonstrate that fly DHHC proteins are primarily located in either the Golgi Apparatus or Endoplasmic Reticulum in S2 cells, except for CG1407, which was found on the plasma membrane. We also characterized the subcellular localization and expression of the three known thioesterases: Palmitoyl-protein Thioesterase 1 (Ppt1), Palmitoyl-protein Thioesterase 2 (Ppt2)and Acyl-protein Thioesterase 1 (APT1). Our results indicate that Ppt1 and Ppt2 are the major lysosomal thioesterases while APT1 is the likely cytoplasmic thioesterase. Finally, in vivo rescue experiments show that Ppt2 expression cannot rescue the neural inclusion phenotypes associated with loss of Ppt1, further supporting distinct functions and substrates for these two thioesterases. These results will serve as the basis for a more complete understanding of the protein palmitoylome's normal cellular functions in the fly and will lead to further insights into the molecular etiology of diseases associated with the mis-regulation of palmitoylation.

Inactivated yellow fever 17D vaccine: development and nonclinical safety, immunogenicity and protective activity

In the last 10 years new concerns have arisen about safety of the live, attenuated yellow fever (YF) 17D vaccine, in particular viscerotropic adverse events, which have a case-fatality rate of 64%. A non-replicating cell culture-based vaccine would not cause these adverse events, and potentially could be used in persons with precautions or contraindications to use of the live vaccine, including age <9 months and >60 years, egg allergy, immune suppression, and pregnancy. We developed a whole virion vaccine from the 17D strain inactivated with beta-propiolactone, and adsorbed to aluminum hydroxide. The inactivated vaccine was highly immunogenic in mice, hamsters, and cynomolgus macaques. After a single dose in hamsters and macaques, neutralizing antibody titers were similar to those elicited by the live 17D vaccine (YF-VAX, Sanofi Pasteur). After two doses of inactivated vaccine, neutralizing antibody titers in hamsters were significantly higher than after a single dose of YF-VAX [geometric mean titer (GMT) 20,480 vs. 1940, respectively (P<0.001, ANOVA)]. Hamsters given a single dose or two doses of inactivated vaccine or a single dose of YF-VAX were fully protected against hepatitis, viremia, weight loss and death after challenge with YF virus (Jimenez strain). A clinical trial of the inactivated vaccine (XRX-001) has been initiated.

C-terminal sequence analysis

Carboxy-terminal (C-terminal) sequence analysis is used for direct confirmation of the C-terminal sequence of native and expressed proteins, for detection and characterization of protein processing at the C-terminus, for identification of post-translational proteolytic cleavages, and for obtaining partial sequence information on N-terminally blocked protein samples in order to facilitate design of oligonucleotide probes for gene cloning. This unit describes an automated chemical method and a manual enzymatic (carboxypeptidase digestion) method for determining C-terminal sequence information. Carboxypeptidase digestion requires only a standard amino acid analysis method.

Removal of N-terminal blocking groups from proteins

Two enzymatic methods commonly used in N-terminal sequence analysis of blocked proteins are presented in this unit; one uses pyroglutamate aminopeptidase for N(alpha)-pyrrolidone carboxyl-proteins in solution or blotted onto a membrane, and the other uses acylaminoacyl-peptide hydrolase for N(alpha)-acyl-proteins blocked with other acyl groups. A Support Protocol describes a colorimetric assay for pyroglutamate aminopeptidase activity. Sequencing with acylaminoacyl-peptide hydrolase must include fragmentation of the protein before unblocking can be carried out, so procedures are provided for chemically blocking newly generated peptides with either succinic anhydride or phenylisothiocyanate/performic acid. The hydrolase is then applied to the total mixture of peptides, only one of which, the acylated N-terminal peptide, should be a substrate for hydrolase. After incubation, the mixture of peptides is subjected to sequence analysis. Protocols are also provided for unblocking N-terminally blocked proteins using acid-catalyzed hydrolysis or methanolysis, hydrazinolysis, and beta-elimination after acid-catalyzed N-O shift. Alternate protocols describe chemical removal of acetyl and longer-chain alkanoyl groups, as well as formyl groups to open the cyclic imide of pyrrolidone carboxylate.

Tumor necrosis factor-alpha haplotype is strongly associated with bone mineral density in patients with Crohn's disease

BACKGROUND AND AIM

There is limited consensus on the major variables that determine bone integrity and bone loss in patients with Crohn's disease. Twin and family studies in the general population indicate that up to 85% of variance in bone mineral density is inherited. The aim was to determine the prevalence of bone loss and both molecular and clinical risk factors for bone loss in a large Crohn's disease population.

METHODS

This was a cross-sectional study of 304 patients with Crohn's disease attending the Inflammatory Bowel Disease unit at Royal Brisbane and Women's Hospital, Queensland. The results of bone density testing were ascertained directly and by a mailed questionnaire. Bone mineral density data were combined with clinical information and correlated with single nucleotide polymorphisms within the tumor necrosis factor-alpha (TNF-alpha), interleukin-10, and NOD2/CARD15 genes.

RESULTS

Of 304 Crohn's disease patients, 101 had undergone previous bone density testing. Forty-five patients (45%) had been diagnosed with osteopenia and 18 (18%) were osteoporotic. After multivariate analysis, both the TNF-alpha GT haplotype and the -857 CC genotype showed strong associations with bone mineral density overall (P = 0.003 and P = 0.002, respectively). Body mass index (P = 0.01) and previous bowel resection in female patients (P = 0.03) were predictive of a higher spine bone density, while body mass index (P = 0.003) and the effect of years since first bowel resection (P = 0.02) remained independent predictors of proximal femur bone mineral density. There were no other significant associations observed.

CONCLUSIONS

This study has identified a novel protective association between a TNF-alpha haplotype and bone mineral density in Crohn's disease. It confirms the important influence of body mass index and intestinal resection on bone loss in this population.

A systematic literature review to investigate if we identify those patients who can cope with anterior cruciate ligament deficiency

Rupture of the anterior cruciate ligament (ACL) results in increased tibiofemoral laxity in the knee, thereby ultimately resulting in knee instability and dysfunction. However, ACL rupture does not automatically infer functional impairment and instability as confirmed by the ACL deficient (ACLD) coper, who can resume pre-morbid activity levels. Alternatively, an authentic ACLD non-coper is unable to return to pre-injury levels of activity due to repeated incidents of giving-way. Little is known as to the contributory factors, which allows copers dynamic stability and render non-copers functionally impaired. This systematic literature review aims to examine the evidence presented by relevant trials in order to identify measurement tools, which could differentiate ACLD copers and non-copers. A literature search found nine trials; four adhered to the inclusion criteria of this review. Consensus was achieved within the studies that laxity measurements and IKDC ratings are incapable of distinguishing the functional status of the ACLD patient. Alternatively, Lysholm, KOS-Sport, KOS-ADL and Global Knee Function Rating Scores were regarded as capable of discriminating between ACLD copers and non-copers. Disagreement existed as to the efficacy of the Quadriceps Index and the single leg hop in categorising the ACLD patient according to function level. It was concluded that no single measurement tool is sufficient in determining the functional status of the ACLD individual. Consequently, a collaboration of tests is recommended, specifically incorporating the KOS-Sport, Global Knee Function Rating, hop tests and Quadriceps Index.

High diversity and rapid changeover of expressed var genes during the acute phase of Plasmodium falciparum infections in human volunteers

Plasmodium falciparum erythrocyte membrane protein 1 (PfEMP1) proteins expressed on the surface of P. falciparum-infected erythrocytes undergo antigenic variation by switching the gene expressed within a repertoire of approximately 50 var genes per haploid genome. The switching of PfEMP1 plays an important role in the survival and pathogenesis of the parasite. To understand how a parasite switches its var gene expression in human infections, we investigated the composition and change of var gene transcripts during the acute phase of well-defined laboratory-induced P. falciparum infections in naive human hosts. Multiple var transcripts, with the same dominant transcript, were identified in samples collected after three to four asexual-parasite cycles in two volunteers infected with cloned 3D7 P. falciparum via mosquito bites. A major change in composition and frequency of var gene transcripts was observed between the culture used to infect the mosquitoes and the parasites recovered from the infected volunteers. A further change was seen when infected blood from a mosquito-infected volunteer was either passaged to other volunteers or cultured in vitro. The diversity of var transcripts did not increase with time. The results suggest that the switch of var gene expression is reinitiated after mosquito transmission and that var genes may rapidly switch from the first gene expressed after liver stage, but subsequent switching occurs at a much lower rate.

Complications related to carpal tunnel release

Complications of operative carpal tunnel release continue to occur in the clinical practice of hand surgery. Anatomic localization of nerve injury has been reviewed in the area of the palmar cutaneous nerve, the median motor branch, and in the combined sensory/motor median nerve itself. Diagnosis and appropriate treatment plans have been reviewed to facilitate early appropriate treatment which usually diminishes disability. General complications have also been discussed including recurrent scar formation which is probably the most commonly encountered complication following carpal tunnel release. Possible neurovascular complications involving the development of reflex sympathetic dystrophy have received some attention in this presentation in order to alert the clinical surgeon to the possibility of this entity providing further disability to an already injured median nerve.

Analytical laboratory quality: Part I. General quality practices

Once a biotechnology product reaches the final stages of development, the types of quality practices required in the laboratories performing the analytical testing are clearly defined in the applicable regulations. Long before this stage, though, there are innumerable tests and studies conducted in biomolecular facilities that provide critical information upon which product development decisions are made. While sound scientific practices will guide the management of the best of these laboratories, there are several additional operational elements that can significantly enhance the utility of the data to commercial clients. Such laboratory quality practices can also provide considerable benefit to the facility itself, engendering higher confidence in the day-to-day operations within the laboratory. Most of these practices can be simply implemented with pens, notebooks, and diligence.

Oral tolerance: elucidation of mechanisms and application to treatment of autoimmune diseases

Oral tolerance is the phenomenon of systemic, antigen specific, immunological hyporesponsiveness that results from oral administration of a protein. The mechanism by which tolerance is generated depends on the amount of antigen administered; low doses favor induction of regulatory T cells while higher doses favor clonal deletion and anergy. The regulatory T cells induced by low doses of oral antigen are triggered by the same antigen to secrete cytokines that suppress, in an antigen nonspecific manner, inflammation in the microenvironment where the triggering antigen is located. This makes possible the targeted delivery of antiinflammatory cytokines to a specific tissue without the requirement for identifying the antigen causing the inflammation. This attribute makes active suppression an attractive mechanism for developing therapies for autoimmune diseases. Orally administered autoantigens have been shown to suppress a wide variety of experimental autoimmune diseases and have recently been applied to the treatment of human autoimmune diseases with promising early results.

The built environment as a component of quality care: understanding and including the patient's perspective

BACKGROUND

Although there has been little systematic assessment of how the built environment of health care facilities affects the quality of care, the built environment is a major element of structure of care--one of three facets of quality. Yet in contrast to the growing trend of using consumer perceptions of both processes and outcomes of care in QI activities, quality assessments of the structure of care do not currently rely on patient feedback. PURPOSE OF PROJECT: During the initial phase of a multiphase project, nine focus groups were conducted in 1997 to identify the salient dimensions of experience from the patient's perspective. The content of these focus groups guided the development of assessment tools in the second phase of the project, which began in February 1998.

FINDINGS

Participants in three focus groups that were held in each of three settings--ambulatory care, acute care, and long term care--described in detail a variety of reactions to the built environment. Analysis revealed eight consistent themes in what patients and family member consumers look for in the built environment of health care. In all three settings, they want an environment, for example, that facilitates a connection to staff and caregivers, is conducive to a sense of well-being, and facilitates a connection to the outside world.

DISCUSSION

Data derived from the focus group research has guided the development of quantitative survey and assessment tools. For each setting, patient-centered checklists and questionnaires are designed to help institutions set priorities for the improvement of facility design from the patient's perspective.

Wound care for persons with diabetes

This article addresses local wound care in people with diabetes mellitus. An approach is proposed that uses wound depth and color to determine the goals of local wound treatment. Principles of cleansing, debridement, and the use of moisture retentive dressings are discussed. Infection, a significant problem in the diabetic patient, is addressed as an essential part of local wound care in these patients.

Managing diabetic foot ulcers

This article discusses optimal care for a diabetic foot wound including use of a protocol with standards for assessment, treatment, and prevention. Patient and family education is also pivotal to the plan's success.

Wound infection: a nurse's perspective

There is clinical uncertainty about the involvement of bacteria in open wounds. Frequently asked questions are: Is this wound infected? Should I culture the wound? How should I clean the wound? Do I need to use sterile technique when I perform local wound care? Using available science and common sense, a practical approach is proposed to answer these questions.

Comparing claims data and self-reported data with the medical record for Pap smear rates

The objective of this study was to assess and compare the relative accuracy of claims data and patient self-reported information with medical records for Pap smear rates. A retrospective analysis of information obtained from administrative claims files, patient medical records, and a telephone survey was performed of 400 women age 19 through 75 years who were randomly selected for participation in the study. The data were obtained from a large multispecialty group practice in Minneapolis, Minnesota for the study years 1991 through 1993. Information from administrative claims regarding Pap smear status corresponded highly with information in the medical record (sensitivity 95% or higher; specificity 95% or higher; kappa 0.896 or better). Self-reported information from the telephone survey did not correspond well with medical record information nor with results in administrative claims.

Energy expenditure during walking by children who have proximal femoral focal deficiency

The energy expended during walking by sixteen children who had proximal femoral focal deficiency was measured to compare the outcomes after Syme amputation (seven subjects) with those after Van Nes rotational osteotomy (nine subjects). Multivariate regression analysis revealed that the subjects who had had a Van Nes procedure had a mean oxygen cost (energy per unit of body mass expended per distance walked) that was 0.12 milliliter per kilogram of body mass per meter lower than that of the subjects who had had a Syme amputation (p = 0.001). The subjects who had had a Van Nes procedure tended to walk faster (p = 0.07). A significant decrease in the oxygen cost as a function of increasing age was observed for both groups (p < 0.0001, r2= 0.79). We believe that the reduced energy expenditure associated with the Van Nes rotational osteotomy is one of several factors to consider when deciding which operation should be done for children who have proximal femoral focal deficiency.

Taking health status into account when setting capitation rates: a comparison of risk-adjustment methods

OBJECTIVE

To compare performance of different health status measures for risk-adjusting capitation rates.

DESIGN

Cross-sectional study. Health status measures derived from 1 year were used to predict resources for that year and the next.

SETTING

Group-network health maintenance organization in Minnesota.

PARTICIPANTS

Sample of 18- to 64-year-old (n=3825) and elderly (aged > or = 65 years; n=1955) members enrolled in a network-model health maintenance organization in Minnesota.

MAIN OUTCOME MEASURES

Total expenditures in the year concurrent with the health status survey (July 1991 through June 1992) and total expenditures in the year following the survey (July 1992 through June 1993).

RESULTS

Capitation adjustment based on demographic measures performed least well. Both self-reported health status measures and diagnoses predicted future expenditures twice as well as demographics. When predicting costs for groups of patients rather than individuals, the demographic model worked well for average groups but tended to overpredict healthier groups and underpredict sicker groups. Ambulatory Care Groups based on diagnoses performed better than self-reported health status both in the retrospective models and across healthier and sicker groups.

CONCLUSIONS

Without risk adjustment, capitation rates are likely to overpay or underpay physicians for certain patient groups. It is possible to improve prediction using health status measures for risk adjustment. When selection bias is suspected and administrative data are available, we recommend a risk-adjustment method based on diagnostic information. If diagnostic data are not available, we recommend a system based on simple self-reported measures, such as chronic conditions, rather than complex functional status measures.

Physical therapy to improve functioning of older people in residential care facilities

BACKGROUND AND PURPOSE

The purpose of this study was to determine the effectiveness of an individualized physical therapy mobility training program on the gait, balance, and functional performance of elderly individuals living in residential care facilities.

SUBJECTS

Twenty-seven elderly individuals with impaired balance and difficulty performing at least one functional activity participated in the study. The subjects ranged in age from 71 to 97 years (mean = 87.1, SD = 6.7).

METHODS

Balance and gait speed were assessed at baseline and following physical therapy that consisted of exercises to improve specific functional limitations. Outcomes were reassessed 1 month following completion of the physical therapy.

RESULTS

Gait and balance outcomes were analyzed using a one-way repeated-measures analysis of variance. Improvement was obtained in balance, which was maintained at 1 month follow-up. Gait speed did not improve to a level of statistical significance.

CONCLUSION AND DISCUSSION

After physical therapy, subjects improved in balance and functional performance. An improvement in gait speed may require a longer duration of treatment.

Using wound debridement to help achieve the goals of care

The removal of devitalized tissue, particulate matter, or foreign materials from a wound, debridement, is often the first goal of wound care. Debridement can be accomplished surgically (instrument/sharp), chemically, mechanically or by means of autolysis. Each procedure has distinct advantages, disadvantages, indications for use and risks, and a combination of methods will often expedite the process while limiting the chance of complications. Depending on the method used as well as a variety of local and systemic factors, chronic wound debridement can take anywhere from a few days to more than a month. Even though wound debridement is often discussed separately, particularly when managing patients with chronic wounds, it should not be viewed in isolation. Rather, it is one aspect of total patient care. Measures to facilitate the healing process in general should be employed at all times, because debridement and wound healing can occur simultaneously.

Screening for balance and mobility impairment in elderly individuals living in residential care facilities

BACKGROUND AND PURPOSE

The rapid growth of the elderly population has resulted in a corresponding rise in the number of elderly individuals who experience disability during their lifetimes. The purpose of this study was to test the usefulness of four established clinical measures of balance, gait, and subjective perceptions of fear of falling as screening methods for referring community-dwelling elderly individuals living in residential care facilities for detailed physical therapy evaluation and possible intervention.

SUBJECTS

The subjects were a convenience sample of 53 elderly individuals living in two residential care facilities for the elderly.

METHODS

Subjects were tested on each of four clinical measures of balance and mobility. Their performance on these measures was compared with a physical therapist's brief evaluation of disability and appropriateness for more detailed evaluation. The usefulness of these tools as screening methods was determined by calculating sensitivity and specificity levels using the physical therapist's evaluation as a standard.

RESULTS

The sensitivity and specificity levels of the four clinical measures in their application as screening tests for referral to physical therapy were as follows: Berg Balance Scale, 84% and 78%; balance subscale of the Tinetti Performance-Oriented Mobility Assessment, 68% and 78%; gait speed, 80% and 89%; and Tinetti Fall Efficacy Scale, 59% and 82%. The combination of two tests, Berg Balance Scale and gait speed, yielded the highest sensitivity of 91% and the highest specificity of 70% when a subject tested positive on at least one test.

CONCLUSION AND DISCUSSION

These findings indicate the feasibility of developing screening methods for referring community-dwelling elderly individuals for a detailed physical therapy evaluation based on established clinical assessment measures, with a combination of tests measuring balance and gait demonstrating the most promising results.

Biotechnology core facilities: trends and update

A survey of 128 biotechnology core facilities has provided data on the finances, services, space requirements, and personnel. An average facility had four full-time personnel and 7.5 major instrument systems, and occupied 969 sq. ft. Average total income was $244,000/year, but annual user fee income was only $125,000. Typically, facilities required substantial institutional support or grants. Cost recovery (user fee income divided by total income) averaged 49%. During the last 5 years user fee income, total income, and cost recovery have increased. In-house charges for protein sequencing and peptide synthesis increased approximately 30%, while oligonucleotide synthesis charges decreased by 74%. The costs (charges corrected for subsidy from non-user fee income) for most services did not significantly change, except that oligonucleotide synthesis costs decreased by 25% in 1992. DNA synthesis had the highest throughout per month (116 samples), followed by amino acid analysis (86 samples) and DNA sequencing (67 samples). Other services averaged from 5 to 60 samples. DNA synthesis and purification were the services used by the greatest number of principal investigators. A number of services including DNA sequencing, mass spectrometry, capillary electrophoresis, RNA synthesis, electroblotting, and carbohydrate analysis have been introduced in the last 3 years. Although these services are characterized by high levels of methods development and non-user runs, they are offered by twice the percentage of facilities as in 1989, and are increasingly contributing to facility income.

Depressant insect selective neurotoxins from scorpion venom: chemistry, action, and gene cloning

The present study examines the similarity in the symptoms and binding properties between the depressant and excitatory insect-selective neurotoxins, derived from scorpion venom. A comparison of their primary structures and neuromuscular effects is presented. A new depressant toxin (LqhIT2) was purified from the venom of the scorpion Leiurus quinquestriatus hebraeus. The effects of this toxin on a prepupal housefly neuromuscular preparation mimic its effects on the intact insect, i.e, a brief period of repetitive bursts of regular junction potentials (JPs) is followed by reduced amplitude JPs ending with a block of the neuromuscular transmission. "Loose" patch clamp recordings indicate that the repetitive activity has a presynaptic origin (the motor nerve) and resembles the effect of the excitatory toxin AaIT. The final synaptic block is supposed to be the end result of neuronal membrane depolarization. Such an effect is not caused by an excitatory toxin, which induces long "trains" of repetitive firing. The amino acid sequences of three depressant toxins were determined by automatic Edman degradation indicating a high degree of sequence homology. This conservation differs from those of other groups of scorpion toxins. The opposing pharmacological effects of depressant toxins are discussed in light of the above neuromuscular effects and sequence analysis. A genetic approach in the study of the structure-function relationships of the depressant toxins was initiated by isolating cDNA clones encoding the LqhIT2 and BjIT2 toxins. Their sequence analysis revealed the precursor form of these toxins: A 21 amino acid residue signal peptide followed by a 61 amino acid region of the mature toxin, and three additional amino acids at the carboxy terminus.