Generalizability of predictive models for Clostridioides difficile infection, severity and recurrence at an urban safety-net hospital

INTRODUCTION

Predictive models for Clostridioides difficile infection can identify high-risk patients and aid clinicians in preventing infection. Issues of generalizability regarding current predictive models have been acknowledged but, to the authors' knowledge, have never been quantified.

METHODS

C. difficile infection, severity and recurrence predictive models were created using multi-variate logistic regression through case-control sampling from an urban safety-net hospital. Models were validated using five-fold cross-validation, and inverse probability weights (IPW) based on two different catchment area definitions were used to improve external validity. Akaike Information Criterion (AIC), area under the receiver operating characteristic curve (AUROC), and sensitivity and specificity with bootstrapped confidence intervals (CI) were used to assess and compare model fit and performance.

RESULTS

Changes in performance before and after weighting were small across all models, although differences were more apparent after weighting the recurrence model (AUROC values of 0.78, 0.76 and 0.71 for the unweighted and two weighted models, respectively). Overall, the infection model performed the best (AUROC 0.82, 95% CI 0.78-0.85), followed by the recurrence model (AUROC 0.78, 95% CI 0.69-0.86) and then the severity model (AUROC 0.70, 95% CI 0.63-0.78).

CONCLUSIONS

The performance of the models after weighting did not change drastically, suggesting that the models predicting C. difficile infection, severity and recurrence may not be impacted by patient selection factors. However, other researchers may wish to consider addressing these catchment forces using IPW.

Antiracist training programs for mental health professionals: A scoping review

Racism has been shown to be directly deleterious to the mental health care received by minoritized peoples. In response, some mental health institutions have pledged to provide antiracist mental health care, which includes training mental health care professionals in this approach. This scoping review aimed to synthesize the existing published material on antiracist training programs among mental health care professionals. To identify studies, a comprehensive search strategy was developed and executed by a research librarian in October 2022 across seven databases (APA PsycInfo, Education Source, Embase, ERIC, MEDLINE, CINAHL, and Web of Science). Subject headings and keywords relating to antiracist training as well as to mental health professionals were used and combined. There were 7186 studies generated by the initial search and 377 by the update search, 30 were retained and included. Findings revealed four main antiracist competencies to develop in mental health professionals: importance of understanding the cultural, social, and historical context at the root of the mental health problems; developing awareness of individual biases, self-identity and privilege; recognizing oppressive and racism-sustaining behaviors in mental health care settings; and, employing antiracist competencies in therapy. Professionals who have taken trainings having the main components have developed skills on the interconnectedness between racialized groups' mental health and the cultural, religious, social, historical, economic, and political issues surrounding race, necessary for successful clinical practice and for providing anti-racist mental health care. This scoping review presents a summary of the essential antiracist competencies drawn from the literature which must be applied in a mental health care setting, to improve help seeking behaviors, and reduce distrust in mental health care professionals and settings.

A Systematic Review of Black People Coping With Racism: Approaches, Analysis, and Empowerment

This article reviews the current research literature concerning Black people in Western societies to better understand how they regulate their emotions when coping with racism, which coping strategies they use, and which strategies are functional for well-being. A systematic review of the literature was conducted, and 26 studies were identified on the basis of a comprehensive search of multiple databases and reference sections of relevant articles. Studies were quantitative and qualitative, and all articles located were from the United States or Canada. Findings demonstrate that Black people tend to cope with racism through social support (friends, family, support groups), religion (prayer, church, spirituality), avoidance (attempting to avoid stressors), and problem-focused coping (confronting the situation directly). Findings suggest gender differences in coping strategies. We also explore the relationship between coping with physical versus emotional pain and contrast functional versus dysfunctional coping approaches, underscoring the importance of encouraging personal empowerment to promote psychological well-being. Findings may help inform mental-health interventions. Limitations include the high number of American-based samples and exclusion of other Black ethnic and national groups, which is an important area for further exploration.

Lifetime Trauma Exposure and Posttraumatic Stress Disorder Among African Americans and Black Caribbeans by Sex and Ethnicity

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a debilitating disorder requiring timely diagnosis and treatment, with special attention needed for Black populations in the U.S. Yet, stakeholders often fail to recognize Black communities' heterogeneous ethnic composition, thus not allowing diverse sociocultural realities to inform PTSD interventions. This study aims to characterize sex and ethnic differences in lifetime trauma exposure, lifetime PTSD diagnosis and symptoms, and help-seeking among the African Americans and Black Caribbeans in the U.S.

METHOD

This study relied on data from the National Survey of American Life 2001-2003 (NSAL) to investigate the lifetime exposure to traumatic events and prevalence of a clinical PTSD diagnosis based on the DSM-IV among African American (n = 3,570) and Black Caribbean (n = 1,623) adults. 44.5% of respondents were men and 55.5% were women. Logistic regression was utilized to investigate the impact of traumatic events on PTSD.

RESULTS

Several ethnic and sex differences in exposure to potentially traumatic events were identified. African American respondents were more likely to experience spousal abuse and toxin exposure than their Black Caribbean counterparts. Black Caribbeans reported higher lifetime exposure to muggings, natural disasters, harsh parental discipline, being a civilian living in terror and/or being a refugee than African American respondents. Specific to sex, Black men reported more events of combat, a peacekeeper/relief worker, being mugged, toxin exposure, seeing atrocities, and/or injuring someone. Black women were more likely to have been rape/sexual assault and/or intimate partner violence victims. The assaultive violence trauma type was most predictive of lifetime PTSD diagnosis among Black Americans. African American women were more likely to report PTSD symptoms than men, with almost no significant differences in Black Caribbean men and women. Approximately half of Black Americans sought help for their worst traumatic event, commonly engaging family/friends, psychiatrists, and mental health professionals. Further, there were almost no ethnic and sex differences related to professional and non-professional help sought.

CONCLUSION

Future PTSD-related research should aim to characterize the heterogenous experiences of potentially traumatic events within different Black communities. Clinicians working with Black clients should strive to understand the limitations within their tools/interventions in meeting the needs of diverse groups.

"Time Variable Earth Gravity Field Models From the First Spaceborne Laser Ranging Interferometer"

The Gravity Recovery and Climate Experiment Follow-On (GRACE-FO), launched May 22, 2018 and collecting science data since June 2018, is extending the 15-year data record of Earth mass change established by its predecessor GRACE mission (2002-2017). The GRACE-FO satellites carry onboard a novel technology demonstration instrument for intersatellite ranging, the Laser Ranging Interferometer (LRI), in addition to the microwave interferometer (MWI) carried on GRACE. The LRI has out-performed its in-orbit performance requirements both in terms of accuracy as well as the duration of tracking. Here, we compare and validate LRI-based gravity solutions for January 2019 to September 2020 against the MWI solutions. The comparison between the two sets of gravity solutions shows great similarities in general and nearly perfect consistency at a large hydrologic basin spatial scale (100,000 km² and above), commonly viewed as the spatial resolution established by GRACE. The comparison in the spectral domain shows differences at the higher degrees of the spectrum, with lower error in the zonal and near zonal terms for the LRI solutions. We conclude that the LRI observations can be used to recover time-varying gravity signals to at least the level of accuracy established by the MWI-based solutions. This is a promising finding, especially when considering the benefits of using the LRI over the MWI, such as the great stability of the instrument and the low occurrence of instrument reboot events.

Historical Housing Discrimination, Indicators of Disinvestment, and Breast Cancer Outcomes Nearly a Century Later

Purpose: We investigated associations between 1930's era records of mortgage lending discrimination (i.e., “redlining”), a present-day indicator of disinvestment (i.e., residential physical disorder), and tumor clinicopathologic features (stage, grade, subtype) and survival among women diagnosed with breast cancer in New Jersey. Methods: Historical, Home Owners' Loan Corporation (HOLC) data were recently geocoded from the University of Richmond's Digital Scholarship Lab. Risk grades of ‘A'/‘Best', ‘B'/‘Still Desirable', ‘C'/‘Definitely Declining', and ‘D'/‘Hazardous' – available for six metropolitan areas of New Jersey – were collapsed into C/D (‘redlined') and A/B (‘not redlined') for analyses. Sociodemographics (age, race, ethnicity, geocoded residential address, date of diagnosis), tumor features (stage at diagnosis, grade, subtype), and vital status (cause and date of death) were ascertained from the New Jersey State Cancer Registry for all primary, histologically-confirmed, invasive breast cancer cases diagnosed between 2008 and 2017, among female residents of a HOLC-graded area, who were ≥ 20 years at diagnosis (N = 11,980). Residential physical disorder was estimated based on residential address at diagnosis using spatial prediction models of virtually audited Google Street View scenes of 6,132 locations. Logistic regression models of tumor features and accelerated failure time models of survival time to BrCa-specific death (follow-up through 2019) were built to investigate associations with redlining and physical disorder, while controlling for covariates. Results: There were 1,215 BrCa-specific deaths, a median follow-up time of 5.1 years, and a 5-year survival of 89.6%. Living in a historically redlined neighborhood was associated with higher odds of late-stage and high-grade tumors. Living in a non-redlined neighborhood was associated with a 47.5% (95% CI: 20.1, 79.8) longer survival time in low physical disorder areas. This survival benefit decreased as physical disorder increased. Conclusions: Historical racial housing discrimination might interact with present-day measures of disinvestment to influence BrCa survival. Future studies should collect more comprehensive data including potential confounders and residential history.

Evaluation as Disintegrant, Acetone-dehydrated Pre-Gelatinized Starch of Arthocarpus altilis Fruits in Oral paracetamol Tablets

Introduction: Modifying natural polymers have imparted desirable properties making them suitable as pharmaceutical additives. Aim: This research work was to prepare pre-gelatinized breadfruit starch using acetone to reduce drying time and energy expended. The modified starch was evaluated as a disintegrant in paracetamol oral compacts. Methods: Starch from unripe mature bread fruit was pre-gelatinized, precipitated with acetone to reduce drying time. Native and pre-gelatinized starches were characterized for micromeritics, compatibility studies with test drug using Fourier Transform Infra-Red (FT-IR) and water interaction properties (viscosity, swelling power and hydration capacity). Paracetamol granules formed by wet granulation were compacted incorporating starches as disintegrant intragranularly, extragranularly and combining both methods. Disintegration and dissolution studies done. Results: Pre-gelatinization did not alter the native starch chemically and their pH were within pharmaceutical limits. The disintegration efficiency ratio (DER) for the P2 and P3 (tablet batches with pre-gelatinized starches) compared favourably with that of corn starch. Also, the dissolution kinetics of the breadfruit starches followed the Hixson Crowel’s model while that of reference corn starch was best described by the Higuchi kinetic model. Conclusion: Breadfruit starch is edible and the properties of its pre-gelatinized form as a disintegrant compares favourably with corn starch BP. It could be an good alternative as pharmaceutical excipient.

Health professional mobility and the Global Code of Practice: joint EUROSTAT/OECD/WHO survey data

Background

This study assesses the impact and continuing relevance of the Code of Practice on the International Recruitment of Health Personnel in the WHO Europe region by analysing trends over time in intra- and inter-regional health worker mobility.

Methods

Data from the joint EUROSTAT/OECD/WHO questionnaire are analysed to determine 1) the proportion of foreign-born and foreign-trained doctors and nurses working in WHO Europe Member States, 2) trends in health workforce mobility over time by country of origin and destination, and 3) how the Global Code has impacted mobility patterns.

Results

The size of the foreign-trained health workforce in Europe varies widely, with foreign-trained doctors comprising over a quarter of the workforce in Norway, Switzerland and the UK, but below 2% in Estonia and Serbia. While annual in-flows across the region have been stable since 2009, the share of foreign-trained doctors and nurses have both increased by over 30%. Mobility between The Commonwealth of Independent States has remained steady, but an increase in East-West and South-North migration is observed, driven by European Union expansion in 2004 and the economic crisis. Migration of health workers into Europe from developing countries covered by the Code has fluctuated, with increased numbers seen from some origin countries (e.g. Nigeria, Pakistan). Some Western countries remain reliant on a foreign-trained health workforce. This contributes to a high outward flow of health professionals from other European countries and creates challenges for sustainable workforce development.

Conclusions

The Global Code remains highly relevant, but other factors have more impact on migration flows, such as free movement in the EU. Health workforce mobility data can be improved to support a 'whole of workforce' approach to policy and planning by including more professional groups, and by adding qualitative indicators, e.g. individual perceptions and intention to leave.

Panel: Care4Care: what is it about the migrant care workforce and how to improve inclusion?

A round table comprising three panelists will discuss the topic from different perspectives. Gabrielle Jacob, WHO: The WHO Global Code of Practice on the International Recruitment of Health Personnel. How far have we come, where are we now and what’s next?Natasha Azzopardi-Muscat, EUPHA President: The role of public health in raising awareness on the contribution of migrant workers to health systemsScott L Greer, European Observatory on Health Systems and Policies: Governance4Care of the migrant care workforce: what matters?

Iron retention in iron-fortified rice and use of iron-fortified rice to treat women with iron deficiency: A pilot study

Objectives

1. Evaluate the effect of washing and cooking iron-fortified rice on iron retention and bioavailability. 2. Evaluate the effect of iron-fortified rice on women with iron deficiency anemia

Methods

1. Iron-fortified rice (18 mg/100 g as FeSO₄) was cooked in Baton Rouge, Louisiana (C), rinsed and cooked (RC), fried and cooked (FC), cooked with extra water (CW), or soaked and cooked with extra water (SCW), and iron retention was determined. 2. Rice samples were cooked in Kampala, Uganda in a lab (C-Uganda) and households using traditional cooking method (TC-Uganda) and iron retention were determined. 3. Seventeen women with iron deficiency (low iron and/or low ferritin) anemia were randomized to 100 g/d of rice (two cooked 0.75 cup servings) for two weeks containing 18 mg/d iron (supplemented) or 0.5 mg/d iron (un-supplemented). Hemoglobin and hematocrit were evaluated at baseline and 2 weeks with other measures of iron metabolism.

Results

1. Iron retention, from highest to lowest, was (C), (RC), (FC), (C-Uganda), (CW), (SCW) and (TC-Uganda). 2. Seventeen women were randomized and 15 completed the study (hemoglobin 10.6 ± 1.6 g, hematocrit 33.7 ± 4.1%), 9 in the iron-fortified rice group and 6 in the un-fortified rice group. The iron-fortified group had a greater increase in hemoglobin (0.82 g, p = 0.0035) and Hematocrit (1.83%, p = 0.0248) with directional differences in other measures of iron metabolism favoring the iron-fortified group.

Conclusions

Iron-fortified rice increased hemoglobin and hematocrit in women with iron-deficient anemia. Iron deficiency and anemia are widespread in Southeast Asia and Africa and undermine development in these regions.

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Iron deficiency is prevalent engendering poor health and cognitive development.

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Iron deficiency can be treated effectively with iron fortification.

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Iron rinses in a rice-based diet have leached reducing fortification.

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An iron rinse resistant leaching during cooking is described.

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The leach-resistant iron rinse improved iron deficiency anemia in a clinical trial.

Precise experimental investigation of eigenmodes in a planar ion crystal

The accurate characterization of eigenmodes and eigenfrequencies of two-dimensional ion crystals provides the foundation for the use of such structures for quantum simulation purposes. We present a combined experimental and theoretical study of two-dimensional ion crystals. We demonstrate that standard pseudopotential theory accurately predicts the positions of the ions and the location of structural transitions between different crystal configurations. However, pseudopotential theory is insufficient to determine eigenfrequencies of the two-dimensional ion crystals accurately but shows significant deviations from the experimental data obtained from resolved sideband spectroscopy. Agreement at the level of 2.5×10(-3) is found with the full time-dependent Coulomb theory using the Floquet-Lyapunov approach and the effect is understood from the dynamics of two-dimensional ion crystals in the Paul trap. The results represent initial steps towards an exploitation of these structures for quantum simulation schemes.

Single-ion heat engine at maximum power

We propose an experimental scheme to realize a nanoheat engine with a single ion. An Otto cycle may be implemented by confining the ion in a linear Paul trap with tapered geometry and coupling it to engineered laser reservoirs. The quantum efficiency at maximum power is analytically determined in various regimes. Moreover, Monte Carlo simulations of the engine are performed that demonstrate its feasibility and its ability to operate at a maximum efficiency of 30% under realistic conditions.

Symptomatic and quality of life response to tolterodine in subgroups of men with overactive bladder symptoms and presumed non-obstructive benign prostatic hyperplasia

OBJECTIVES

To investigate the symptomatic and quality of life (QoL) response to treatment with tolterodine extended release (ER) in subgroups of male patients with Overactive Bladder Syndrome (OAB) and LUTS suggestive of non-obstructive benign prostatic hyperplasia (BPH) according to age, symptom severity, diabetes mellitus status, and concomitant treatment for LUTS.

METHODS

Patients treated with tolterodine ER 4 mg/day for OAB symptoms, alone or added to unsuccessful alpha-blocker treatment of > or =6 weeks duration, and presumed non-obstructive BPH (Q (max) > or = 15 ml/s) were observed for 12 weeks in a non-interventional study. Patients completed the International Prostate Symptom Score (IPSS) and Overactive Bladder Questionnaire (OAB-q) at baseline and after 12 weeks.

RESULTS

52.4% of 741 patients were aged < or =65 years; 4, 64, and 32% had mild, moderate, and severe symptoms, respectively, according to IPSS; 14% had diabetes mellitus, and in 42% tolterodine was added to alpha blockers. In the various subgroups, mean IPSS total scores improved by 2.8-11.1 points, IPSS QoL scores by 1.8-2.4 points, and all OAB-q subscores by more than 14 points. Only IPSS and OAB-q baseline scores had a relevant impact on changes during treatment, benefits were greatest in patients with more severe symptoms and bother.

CONCLUSIONS

In men with symptoms of OAB and LUTS suggestive of non-obstructive BPH of all IPSS severity classes, aged < or =65 years or above, with or without concomitant diabetes or alpha-blockers, symptoms and QoL improved markedly during treatment with tolterodine ER.

Hydration does not prevent orthostatic hypercoagulability

Prolonged standing activates the coagulation cascade by the activation of endothelial cells, and probably the haemoconcentration effect contributes to this "orthostatic hypercoagulability". It was the objective of this study to assess whether rehydration (haemodilution) prevents or attenuates orthostatic induced thrombin formation. Twelve healthy young subjects were studied during two separate visits. Haematocrit (Hct), total plasma protein, coagulation profile tests, including endothelial activation related factors, and protein C global pathway were studied at rest supine, and while standing at 15 and 30 minutes (min). During the second visit the study was repeated after intravenous 1.5 liter 0.9% saline. While in supine posture, intravenous rehydration resulted in Hct reduction of 14.2 +/- 2% (haemodilution), a decrease of 11.5 +/- 1.3% in total protein, as well as a significant dilutional effect on most of the coagulation parameters. Still standing for 30 min, with and without rehydration caused a comparable increase in tissue factor by 49.83 +/- 13.6%, and 35.34 +/- 8.55% (p>0.05), respectively and in von Willebrand factor (vWF) 9.5 +/- 2.4% and 13.59 +/- 2.17% (p>0.05), respectively. At 30 min standing, after intravenous rehydration, factor V and VIII activities, and fibrinogen rose by 22 +/- 1.9%, 31.2 +/- 6.2%, 9.15 +/- 2.64%, (p<0.002 for all), respectively. Prothrombin fragments 1+2 elevated by 84.84 +/- 15.3% (p<0.001). Comparable results were obtained with and without the rehydration. Additionally, protein C assay results decreased by 19.4 +/-1.7% and 17.5 +/- 2.6%, with and without fluids (p<0.05 for both). In healthy subjects, intravenous prophylactic rehydration with normal saline resulted in a haemodilution of all the coagulation parameters, but did neither attenuate nor prevent the orthostatic hypercoagulability.

CA 19-9 to differentiate benign and malignant masses in chronic pancreatitis: is there any benefit?

BACKGROUND

The role of the tumor marker CA 19-9 in differentiating benign from malignant masses in chronic pancreatitis has not been extensively studied.

AIM

This study aims at assessing the accuracy of CA 19-9 in differentiating inflammatory head masses in chronic pancreatitis from superimposed carcinomas on chronic pancreatitis.

METHODS

The data of 84 consecutive patients who had mass lesions in chronic pancreatitis were analyzed to determine the sensitivity, specificity and predictive values at cut-off values of 37, 100, 200 and 300 U/mL. Receiver operating characteristic (ROC) curves were used to assess the sensitivity and specificity.

RESULTS

There were 50 benign masses and 34 malignancies. The overall sensitivity and specificity of CA 19-9 for cancer was 68% and 70%, respectively. There was a higher positivity of CA 19-9 in cancers than in benign masses (23/34; 68% versus 15/50; 30%, P<0.01) with cut-off values of 37 U/mL. Higher positivity rates were obtained in cancers using other cut-off values such as 100, 200 and 300 U/mL. Values over 300 U/mL were 100% specific for malignancy, but occurred in only 5 (of whom had distant metastases) of 34 patients.

CONCLUSION

CA 19-9 level in excess of 300 U/mL in mass lesions in chronic pancreatitis was always indicative of malignancy.

Variations in care for operable breast cancer and outcomes between rural and metropolitan centers in Australia

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Background: The causes of variation in breast cancer survival remain uncertain. Care provided to women with breast cancer may vary in relation to both the care setting and characteristics of the clinicians. Methods: To compare the outcomes of management of breast cancer treated in rural and metropolitan centers, a prospective audit of breast cancer in a region of Australia was undertaken. Over a nine-year observation period 2102 women with invasive breast cancer underwent potentially curative surgery. Treatments received, including systemic adjuvant therapy, were compared to contemporary guideline-based indicators. Breast cancer specific mortality was analyzed using Cox proportional hazards models. Results: Overall agreement of received treatment with the indicators was high. Women treated within rural centers were, however, much less likely to receive post operative radiotherapy after breast conserving surgery (86.4% vs. 97.0%; p<0.001). The overall recurrence rate, including distant metastases, for all women was 11.6%. Local or regional recurrence was more frequent in rural centers compared with metropolitan centers (4.1% versus 2.1%; p=0.05). Breast cancer mortality was increased in women with large tumors, high grade disease, and positive axillary lymph nodes. Non-compliance with treatment guidelines was associated with a trend towards increased breast cancer mortality (HR=1.55; p=0.056). After adjustment for these factors and patient age, undergoing surgery in rural centers was associated with increased breast cancer mortality (HR=1.84; p<0.001). Although women treated in rural centers were older, their cancer stage and tumour characteristics were similar to those of women treated in metropolitan centers. Non-cancer related mortality was elevated in women treated in rural centers compared with women travelling to a city for surgery (HR=2.08; p=0.005). Conclusions: Increased non-cancer related mortality in rural treated women suggests increased medical co-morbidity in this group, which may have influenced treatment choices and outcomes. Low rates of adjuvant radiotherapy were noted for women treated in rural centers. In addition, clinically significant differences in outcome, including breast cancer mortality, were observed.

No significant financial relationships to disclose.

Phase I study results of nanomolecular liposomal annamycin in refractory ALL

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Background: There continues to be no effective second-line therapy for refractory AML or ALL and the cure rate with current therapy has not significantly improved in decades. The first-line therapy for adult AML has remained the same 7 + 3 that it was a generation ago. Annamycin was specifically synthesized to overcome MDR and to have little to no cardiac toxicity when given as a nanomolecular liposomal entity. Methods: We performed a phase I multi-center, open-label, MTD study of nanomolecular liposomal annamycin in patients with refractory ALL. The secondary objective was to study the MDR-1 encoded P-1u70 glycoprotein expression in correlation with CD34 expression and MDR-1 MRP mRNA levels in refractory ALL patients before and after receiving liposomal annamycin. Results: Thirty patients were enrolled on the study. The MTD was determined to be 150 mg/m2/day for 3 days. Eight of the patients completed 1 cycle of the 3 days of treatment. Of these 8 subjects, 5 (62%) had an efficacy signal. All 5 completely cleared circulating blasts. Three subjects also cleared bone marrow blasts. Of these 3, 1 went on to a successful bone marrow transplant. The other 2 had tumor lysis syndrome and unfortunately expired. Other than the tumor lysis syndromes, there was only 1 SAE definitely related to the study drug which was a grade 3 mucositis but there were also 3 other SAEs of grade 3 or 4 mucositis probably related to the study drug which comprised the MTD determination. There were no reports of cardiac toxicity. Conclusions: Nanomolecular liposomal annamycin appears to be effective through its innate resistance to MDR even as a single agent in refractory adult ALL. We are now testing it in a phase I study in children and young adults with refractory ALL or AML.

[Table: see text]

The effect of rotational malalignment on X-rays of the wrist

This study evaluates the effect of rotational malposition of the wrist on measured radiographic parameters of the distal radius and carpus. Ten wrists from five healthy volunteers were imaged in varying degrees of rotation. The wrists were placed in a custom, calibrated jig and images were taken in 5 degrees increments to a maximum pronation and supination of 20 degrees . The results demonstrate the following: a steady decrease in the scapholunate and radioscaphoid angles with extremes of supination; an increase in palmar tilt with supination and a decrease in palmar tilt with pronation. The palmar tilt varied from -4 degrees to 15 degrees and the scapholunate angle ranged from 48 degrees to 29 degrees at the extremes of rotation. These results demonstrate how malrotation in X-ray positioning can have a significant effect on the apparent alignment of the distal radius and carpal bones. Measurements taken from poor X-rays typically fall outside the normal range and could adversely effect treatment decisions.

Safety and efficacy of tolterodine extended release in men with overactive bladder symptoms and presumed non-obstructive benign prostatic hyperplasia

Patients with presumed non-obstructive BPH (Q (max )>or= 15 ml/s) treated with tolterodine ER 4 mg/day for OAB symptoms, alone or added to unsuccessful alpha-blocker treatment of >or=6 weeks duration, were observed for 12 weeks in a non-interventional study to generate real-life efficacy and safety data. Patients completed the IPSS, the OAB-q and a 2-day micturition diary at baseline and 12 weeks. PVR was determined sonographically. Seven hundred and forty one patients were analysed. Mean PVR did not increase (25.4 +/- 26.5 vs. 29.3 +/- 30.9 ml at baseline). AUR requiring catheterization occurred in two patients, acute UTI in four patients. Median IPSS total scores decreased from 17 to 10, IPSS QoL scores from 4 to 2, OAB-q symptom bother scores from 50.0 to 22.5 and OAB-q HRQL scores increased from 59.2 to 81.6. In men with OAB symptoms and presumed non-obstructive BPH, tolterodine ER provided considerable symptomatic and QoL improvements with a low risk of AUR, acute UTI, or increased PVR.

Intussusception due to ileal metastases from renal cell carcinoma

Small bowel secondaries from renal cell carcinoma are rare. Patients usually present with features of intestinal obstruction or GI bleeding. Management should be aggressive since metastasectomy can improve the quality of life and survival.

Multidisciplinary approach in the long-term management of intrahepatic stones: Indian experience

BACKGROUND

Intrahepatic stones, though common in East Asia, are uncommon in India. There is paucity of data from India regarding the treatment and long-term outcome of patients with intrahepatic stones.

METHODS

We retrospectively analyzed medical records of 35 patients with intrahepatic stones who had been treated surgically. Endoscopic biliary drainage had been used in patients who presented with acute cholangitis. Intraoperative stone clearance was confirmed by choledochoscopy and intraoperative cholangiography. Outcome of surgery, frequency and subsequent management of recurrent intrahepatic stones, and factors associated with stone recurrence and cholangitis were analyzed.

RESULTS

Twenty-one (60%) patients had bilobar disease. Eight patients underwent hepatectomy and 16 hepatico-jejunostomy with access loop; 12 of these were jejuno-duodenal anastomoses. Postoperative morbidity was observed in 10 patients (29%). Recurrence of stones occurred in 12 patients (34%) and cholangitis in 9 patients (26%). Presence of bilobar disease and associated biliary strictures were associated with recurrent cholangitis (p< 0.05). Two patients (6%) required re-operation for recurrent cholangitis. Complete removal of recurrent stones using conventional endoscope was possible through jejuno-duodenostomy in all 5 cases who had this type of access loop construction.

CONCLUSION

Surgical treatment for intrahepatic stones depends on the site of involvement. Construction of a jejuno-duodenal access loop in patients with bilobar disease and intrahepatic strictures is helpful in facilitating postoperative stone clearance. A multidisciplinary approach is beneficial especially when the disease is bilobar and recurrent in type.

Are some cases of infected pancreatic necrosis treatable without intervention?

BACKGROUND

Infected pancreatic necrosis is considered an absolute indication for interventional management such as percutaneous drainage or surgery. The presence of retroperitoneal air is a sign of anaerobic sepsis.

METHOD

A retrospective review of case records of patients presenting with severe acute pancreatitis and pancreatic necrosis was performed to identify cases in whom conservative treatment was followed by a satisfactory outcome.

RESULTS

Four patients were identified over a 3-year period who had pancreatic necrosis and retroperitoneal air; they were treated with antibiotics and intensive care, and they improved without any interventional treatment.

CONCLUSIONS

Some patients with infected pancreatic necrosis are treatable medically. The clinical status of the patients may well be a more important factor governing the choice of the treatment approach than bacteriological findings of infection alone.

Port-site tuberculosis after laparoscopy: report of eight cases

In light of the explosive increase in laparoscopic surgery, there is concern about the effectiveness of sterilizing reusable laparoscopic instruments by immersion in 2% glutaraldehyde. This article describes the clinical features of eight patients who presented with biopsy-proven tuberculosis at the port-site unassociated with other clinical features of tuberculosis. Three of the eight patients had positive cultures for Mycobacterium tuberculosis. The port-site sinuses healed with antituberculous chemotherapy. There is conflicting information in the literature regarding the effectiveness of a 20-min instrument soak in 2% glutaraldehyde to clear M. tuberculosis. In light of the preceding information, the current practice of glutaraldehyde disinfection for reusable laparoscopes needs to be reexamined.

Case report: gastroduodenal intussusception of a gastrointestinal stromal tumour

Gastrointestinal stromal tumours (GISTs), previously termed leiomyomas and leiomyosarcomas are relatively common tumours of the gastrointestinal tract, most commonly found in the stomach. Most GISTs are asymptomatic but may cause abdominal pain or bleeding from ulceration of the overlying mucosa. A rare case of gastroduodenal intussusception of a large gastric stromal tumour, which presented with intermittent abdominal pain and gastric outlet obstruction, is reported. Pre-operative diagnosis was made on abdominal CT and confirmed at laparotomy. Pre-operative diagnostic difficulties and management are discussed.

Isolated duodeno-pancreatic involvement due to metastatic dysgerminoma ovary and its management by a modified pancreatico-duodenal resection

Dysgerminomas of the ovary rarely metastasize to abdominal viscera and when they do, the involvement is a part of a disseminated disease. A 30-year-old woman developed isolated duodenopancreatic dysgerminoma 14 years after salpingo-oophorectomy. The clinical picture was complicated by the presence of tuberculous lesions in the liver which mimicked metastatic disease. Surgical excision was carried out using a modified pancreatic head resection.

Laparoscopic cholecystectomy in acute cholecystitis

BACKGROUND

In the light of laparoscopic cholecystectomy increasingly applied to all forms of cholecystitis, this study aimed at evaluating the safety of laparoscopic cholecystectomy applied to all cases of acute cholecystitis, and at determining factors associated with the risk of conversion to open cholecystectomy.

METHODS

The clinical, biochemical, radiologic, and operative data from 124 consecutive cases of acute cholecystitis were analyzed retrospectively to determine the complications and morbidity after operation. The data were analyzed further by univariate and multivariate analysis to identify factors associated with conversion.

RESULTS

No major bile duct injury or mortality occurred. Bile leak from the stump of the cystic duct developed in four patients. These were managed successfully by endoscopic biliary stent placement. The mean duration of hospital stay was 3.8 days in the laparoscopic group and 8.2 days in the open group. Of the 124 patients (18.5%), 23 underwent conversion to open cholecystectomy. Univariate analysis identified the following factors as associated with conversion: common duct dilation greater than 7 mm observed on ultrasound, (p < 0.05), pericholecystic collection seen on ultrasound (p < 0.0001), emphysematous cholecystitis (p < 0.01), endoscopic retrograde cholangiopancreatographic evidence of Mirizzi syndrome (p < 0.05), and pericholecystic collection at operation (p < 0.0001). On multivariate analysis, only pericholecystic collection (p < 0.015) and gallbladder wall thickness greater than 5 mm (p < 0.013) were statistically significant.

CONCLUSIONS

Laparoscopic cholecystectomy for acute cholecystitis can be applied safely to all comers, offering the advantage of a shortened hospital stay. Pericholecystic collection, as observed on ultrasound, is associated with a high risk of conversion to open cholecystectomy.

Sequential modulation of cardiac autonomic control induced by cardiopulmonary and arterial baroreflex mechanisms

BACKGROUND

Nonhypotensive lower body negative pressure (LBNP) induces a reflex increase in forearm vascular resistance and muscle sympathetic neural discharge without affecting mean heart rate. We tested the hypothesis that a reflex change of the autonomic modulation of heartbeat might arise during low intensity LBNP without changes of mean heart rate.

METHODS AND RESULTS

Ten healthy volunteers underwent plasma catecholamine evaluation and a continuous recording of ECG, finger blood pressure, respiratory activity, and central venous pressure (CVP) during increasing levels of LBNP up to -40 mm Hg. Spectrum and cross-spectrum analyses assessed the changes in the spontaneous variability of R-R interval, respiration, systolic arterial pressure (SAP), and CVP and in the gain (alpha(LF)) of arterial baroreflex control of heart rate. Baroreceptor sensitivity was also evaluated by the SAP/R-R spontaneous sequences technique. LBNP began decreasing significantly: CVP at -10, R-R interval at -20, SAP at -40, and the indexes alpha(LF) and baroreceptor sensitivity at -30 and -20 mm Hg, compared with baseline conditions. Plasma norepinephrine increased significantly at -20 mm Hg. The normalized low-frequency component of R-R variability (LF(R-R)) progressively increased and was significantly higher than in the control condition at -15 mm Hg.

CONCLUSIONS

Nonhypotensive LBNP elicits a reflex increase of cardiac sympathetic modulation, as evaluated by LF(R-R), which precedes the changes in the hemodynamics and in the indexes of arterial baroreflex control.

The activity of CK2 in the extracts of COS-7 cells transfected with wild type and mutant subunits of protein kinase CK2

Protein kinase CK2 is ubiquitous in eukaryotes and is known to phosphorylate many protein substrates. The enzyme is normally a heterotetramer composed of catalytic (alpha and alpha') and regulatory (beta) subunits. The physiological regulation of the enzyme is still unknown but one of the factors that may play an important role in this regulation is the ratio of the catalytic and regulatory subunits present in cells. The possible existence of 'free' CK2 subunits, not forming part of the holoenzyme, may be relevant to the physiological function of the enzyme in substrate selection or in the interaction of the subunits with other partners. The objective of this work was to study in COS-7 cells the effects of transient expression of CK2 subunits and mutants of the catalytic subunit on the CK2 phosphorylating activity of the extracts of these cells. Using pCEFL vectors that introduce hemagglutinin (HA) or a heptapeptide (AU5) tags in the expressed proteins, COS-7 cells were transfected with alpha and beta subunits of Xenopus CK2, with the alpha' subunit of D. rerio, and with Xl CK2alphaA156, which although inactive can bind tightly to CK2beta, and with Xl CK2alphaE75E76, which is resistant to heparin and polyanion inhibition. The efficiency of transient transfection was of 10-20% of treated cells. Expression of CK2alpha or CK2alphaE75E76 in COS-7 cells caused an increase of 5-7-fold of the CK2 activity in the soluble cell extracts. If these catalytic subunits were cotransfected with CK2beta, the activity increased further to 15-20-fold of the controls. Transfection of CK2beta alone also increase the activity of the extracts about 2-fold. Transfection with the inactive CK2alphaA156 yielded extracts with CK2 activities not significantly different from those transfected with the empty vectors. However, co-transfection of CK2alpha or CK2alphaE75E76 with CK2alphaA156 caused a 60-70% decrease in the CK2 activity as compared to those of cells transfected with only the active CK2alpha subunits. These results can be interpreted as meaning that CK2alphaA156 is a dominant negative mutant that can compete with the other catalytic subunits for the CK2beta subunit. Addition of recombinant CK2beta to the assay system of extracts of cells transfected with catalytic subunits causes a very significant increase in their CK2 activity, demonstrating that CK2beta subunit is limiting in the extracts and that an excess of free CK2alpha has been produced in the transfected cells. Transfection of cells with CK2alphaE75E76 results in a CK2 activity of extracts that is 90% resistant to heparin demonstrating that a very large proportion of the CK2 activity is derived from the expression of the exogenous mutant. In both the in vivo and in vitro systems, the sensitivity of CK2alphaE75E76 to heparin increases considerably when it forms part of the holoenzyme CK2alpha2beta2.

Primary tuberculous stricture of the oesophagus mimicking carcinoma

A middle-aged woman presented with progressive dysphagia and weight loss was investigated. A stricture involving the lower third of oesophagus was identified but precise histology of the lesion could not be obtained even after multiple biopsies. The resected specimen showed histology consistent with oesophageal tuberculosis.