Emergency physician gender and head computed tomography orders for older adults who have fallen

OBJECTIVE

Physicians vary in their computed tomography (CT) scan usage. It remains unclear how physician gender relates to clinical practice or patient outcomes. The aim of this study was to assess the association between physician gender and decision to order head CT scans for older emergency patients who had fallen.

METHODS

This was a secondary analysis of a prospective observational cohort study conducted in 11 hospital emergency departments (EDs) in Canada and the United States. The primary study enrolled patients who were 65 years and older who presented to the ED after a fall. The analysis evaluated treating physician gender adjusted for multiple clinical variables. Primary analysis used a hierarchical logistic regression model to evaluate the association between treating physician gender and the patient receiving a head CT scan. Secondary analysis reported the adjusted odds ratio (OR) for diagnosing intracranial bleeding by physician gender.

RESULTS

There were 3663 patients and 256 physicians included in the primary analysis. In the adjusted analysis, women physicians were no more likely to order a head CT than men (OR 1.26, 95% confidence interval 0.98-1.61). In the secondary analysis of 2294 patients who received a head CT, physician gender was not associated with finding a clinically important intracranial bleed.

CONCLUSIONS

There was no significant association between physician gender and ordering head CT scans for older emergency patients who had fallen. For patients where CT scans were ordered, there was no significant relationship between physician gender and the diagnosis of clinically important intracranial bleeding.

Framework to optimize fixed-length micro-CT systems for propagation-based phase-contrast imaging

A laboratory X-ray imaging system with a setup that closely resembles commercial micro-CT systems with a fixed source-to-detector distance of ∼90 cm is investigated for single distance propagation-based phase-contrast imaging and computed tomography (CT). The system had a constant source-to-detector distance, and the sample positions were optimized. Initially, a PTFE wire was imaged, both in 2D and 3D, to characterize fringe contrast and spatial resolution for different X-ray source settings and source-to-sample distances. The results were compared to calculated values based on theoretical models and to simulated (wave-optics based) results, with good agreement being found. The optimization of the imaging system is discussed. CT scans of two biological samples, a tissue-engineered esophageal scaffold and a rat heart, were then acquired at the optimum parameters, demonstrating that significant image quality improvements can be obtained with widely available components placed inside fixed-length cabinets through proper optimization of propagation-based phase-contrast.

Simulated outcomes for durotomy repair in minimally invasive spine surgery

Minimally invasive spine surgery (MISS) is increasingly performed using endoscopic and microscopic visualization, and the captured video can be used for surgical education and development of predictive artificial intelligence (AI) models. Video datasets depicting adverse event management are also valuable, as predictive models not exposed to adverse events may exhibit poor performance when these occur. Given that no dedicated spine surgery video datasets for AI model development are publicly available, we introduce Simulated Outcomes for Durotomy Repair in Minimally Invasive Spine Surgery (SOSpine). A validated MISS cadaveric dural repair simulator was used to educate neurosurgery residents, and surgical microscope video recordings were paired with outcome data. Objects including durotomy, needle, grasper, needle driver, and nerve hook were then annotated. Altogether, SOSpine contains 15,698 frames with 53,238 annotations and associated durotomy repair outcomes. For validation, an AI model was fine-tuned on SOSpine video and detected surgical instruments with a mean average precision of 0.77. In summary, SOSpine depicts spine surgeons managing a common complication, providing opportunities to develop surgical AI models.

The Lumbosacral Fractional Curve vs Maximum Coronal Cobb Angle in Adult Spinal Deformity Patients with Coronal Malalignment: Which Matters More?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

In patients undergoing adult spinal deformity (ASD) surgery we sought to: 1) report preoperative and postoperative lumbosacral fractional (LSF) curve and maximum coronal Cobb angles and 2) determine their impact on radiographic, clinical, and patient-reported outcomes (PROs).

METHODS

A single-institution cohort study was undertaken. The LSF curve was the cobb angle between the sacrum and most tilted lower lumbar vertebra. Coronal/sagittal vertical axis (CVA/SVA) were collected. Patients were compared between 4 groups: 1) Neutral Alignment (NA); 2) coronal malalignment only (CM); 3) Sagittal malalignment only (SM); and 4) Combined-Coronal-Sagittal-Malalignment (CCSM). Outcomes including postoperative CM, postoperative coronal vertical axis, complications, readmissions, reoperation, and PROs.

RESULTS

A total of 243 patients underwent ASD surgery with mean total instrumented levels of 13.5. Mean LSF curve was 12.1±9.9°(0.2-62.3) and mean max Cobb angle was 43.0±26.5° (0.0-134.3). The largest mean LSF curves were seen in patients with CM (14.6°) and CCSM (13.1°) compared to NA (12.1°) and SM (9.5°) (p=0.100). A higher LSF curve was seen in patients with fusion to the sacrum and instrumentation to the pelvis (p=0.009), and a higher LSF curve was associated with more TLIFs (p=0.031). Postoperatively, more TLIFs were associated with greater amount of LSF curve correction (p<0.001). Comparing the LSF and the max Cob angle among Qiu types, the highest mean max Cobb angle was in Qiu Type B patients (p=0.025), whereas the highest mean LSF curve was in Qiu Type C patients (p=0.037). Moreover, 82.7% of patients had a LSF curve opposite the max Cobb angle. The LSF curve was larger than the max Cobb angle in 22/243 (9.1%) patients, and most of these 22 patients were Qiu Type A (59.1%). Regarding correction, the max Cobb angle achieved more correction than the LSF curve, judged by the percent improved from preop (54.5% Cobb vs. 46.5% LSF, p=0.025) in patients with max cobb>20° and LSF curve >5°. The LSF curve underwent greater correction in Qiu Type C patients (9.2°) compared to Type A (5.7°) and Type B (5.1°) (p=0.023); however, the max Cobb angle was similarly corrected among Qiu Types: Type A 21.8°, Type B 24.6°, and Type C 25.4° (p=0.602). Minimal differences were seen comparing the preop/postop/change in LSF curve and max Cobb angle regarding postop CM, postop CVA, complications, readmissions, reoperation, and PROs.

CONCLUSIONS

The LSF curve was highest in patients with CM, CCSM, and Qiu Type C curves. Most patients had a LSF curve opposite the max Cobb angle. The max Cobb angle was more often corrected than the LSF curve. The LSF curve underwent greater correction among Qiu Type C patients, whereas the max Cobb angle was similarly corrected among all Qiu Types. No clear trend was seen regarding postoperative complications and PROs between the LSF curve and max Cobb angle.

Vertebral Aneurysmal Bone Cyst Mimicking Osteosarcoma: Case Report and Review of the Literature

Aneurysmal bone cysts are benign osseous lesions containing blood-filled cavities separated by walls of connective tissue. They can be difficult to identify clinically due to similarities in presentation, imaging, and histology with other pathologies. Specifically, it is important to distinguish these benign lesions from malignant processes, as both surgical and medical management differ. We present the case of a 21-year-old patient who presented with impaired motor and sensory function in his lower extremities. Radiologic findings were concerning for an invasive neoplasm, and the intraoperative frozen section supported this conclusion. However, an additional histological investigation was confirmatory for a diagnosis of an aneurysmal bone cyst. The patient underwent corpectomy, laminectomy, and a posterior spinal fusion, and regained motor and sensory function shortly thereafter. This report details the importance of considering aneurysmal bone cysts in the differential of infiltrative bone lesions, despite their benign nature, as medical and surgical management can vary greatly.

Two- versus multi-rod constructs for adult spinal deformity: A systematic review and Random-effects and Bayesian meta-analysis

BACKGROUND

Surgical approaches in adult spinal deformity are associated with high rates of adverse events including hardware failure and rod fracture. Recently, some reports have emerged comparing multiple-rod constructs with 2-rod constructs suggesting potential benefits with the former. However, these have been limited by variability in observed outcomes, which have limited the change of paradigm in adult spinal deformity surgery.

OBJECTIVE

To compare the rate of rod fracture, pseudoarthrosis, proximal junctional kyphosis and re-operation between 2-RC and M-RC.

METHODS

MEDLINE/Pubmed, Web of Science and Embase were searched without language restrictions for relevant articles from inception until October 2021. All observational cohort studies assessing patients with ADS undergoing 3-column osteotomy and comparing 2-RC with M-RC procedures on pseudarthrosis, rod fracture, kyphosis or reoperation were included. Data were independently extracted by 2 authors. Random-effects and Bayesian meta-analysis were used.

RESULTS

Six primary studies met inclusion criteria, yielding a total of 448 participants, with 223 receiving 2-RC and 225 M-RC. The random-effects meta-analysis pointed to a significantly lower risk of rod fracture associated with M-RC (RR = 0.43, 95 %CI = 0.28-0.66), with moderate heterogeneity being observed (I² = 20 %, p = 0.28). The random-effects meta-analysis pointed to a lower risk of pseudoarthrosis with M-RC than with 2-RC (RR = 0.49, CI = 0.28-0.84, to a lower rate of re-operation with M-RC than with 2-RC (RR = 0.52, CI = 0.28-0.97) and to a similar rate of proximal junctional kyphosis between 2-RC and M-RC patients (RR = 0.91, CI = 0.60-1.39). Low heterogeneity was observed for studies comparing pseudoarthrosis (I² = 9 %, p = 0.35), re-operation (I² = 0 %, p = 0.41) and proximal junctional kyphosis (I² = 0 %, p = 0.85).

DISCUSSION

These findings suggest that multiple rod-fracture constructs are associated with lower rates of rod fracture, re-operation rates, pseudoarthrosis but not proximal junctional kyphosis. Future studies should address the impact of other modulators of heterogeneity such as body mass index, metal alloys and length of the constructs.

Point of Care Ultrasound Literature Primer: Key Papers on Focused Assessment With Sonography in Trauma (FAST) and Extended FAST

Objective

The objective of this study is to identify the top five most influential papers published on focused assessment with sonography in trauma (FAST) and the top five most influential papers on the extended FAST (E-FAST) in adult patients.

Methods

An expert panel was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. These experts are ultrasound fellowship-trained or equivalent, are involved with point-of-care ultrasound (POCUS) research and scholarship, and are leaders in both the POCUS program at their local site and within the national Canadian POCUS community. This 14-member expert group used a modified Delphi process consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers for FAST and E-FAST.

Results

The expert panel identified 56 relevant papers on FAST and 40 relevant papers on E-FAST. After completing all three rounds of the modified Delphi process, the authors identified the top five most influential papers on FAST and the top five most influential papers on E-FAST.

Conclusion

We have developed a reading list of the top five influential papers for FAST and E-FAST that will benefit residents, fellows, and clinicians who are interested in using POCUS in an evidence-informed manner.

COVID-19, commuter territories and the e-bike boom

The appearance and integration of e-bikes in public space is a source of much debate worldwide. This paper offers insights to these debates by reflecting on how Deleuze and Guattari's concept of assemblage as territory helps us to understand the uptake of e-bike commuter cycling during the Covid-19 pandemic through empirical material from a study conducted in Sydney, Australia. Here we conceptualise commuter journeys in terms of processes of deterritorialisation and reterritorialisation; experienced through the affective territories generated by e-bikes. The disclosure of commuter cycling sensations generated by the pandemic disruptions to commuter routines provided an important lens through which to understand the uptake of e-bikes. The paper concludes by showing the utility of the concept of territory as a means of theorising changes to everyday mobility practices.

A laboratory-based, low-energy, multi-modal x-ray microscope with user-defined resolution

We report on the development of a low-energy x-ray phase-based microscope using intensity-modulation masks for single-shot retrieval of three contrast channels: transmission, refraction, and ultra-small-angle scattering or dark field. The retrieval method is based on beam tracking, an incoherent and phase-based imaging approach. We demonstrate that the spatial resolution of this imaging system does not depend on focal spot size nor detector pixel pitch, as opposed to conventional and propagation-based x-ray imaging, and it is only dependent on the mask aperture size. This result enables the development of a multi-resolution microscope where multi-scale samples can be explored on different length scales by adjusting only the mask aperture size, without other modifications. Additionally, we show an extended capability of the system to resolve periodic structures below the resolution limit imposed by the mask apertures, which potentially extends dark-field imaging beyond its conventional use.

The effect of a variable focal spot size on the contrast channels retrieved in edge-illumination X-ray phase contrast imaging

Multi-modal X-ray imaging allows the extraction of phase and dark-field (or “Ultra-small Angle Scatter”) images alongside conventional attenuation ones. Recently, scan-based systems using conventional sources that can simultaneously output the above three images on relatively large-size objects have been developed by various groups. One limitation is the need for some degree of spatial coherence, achieved either through the use of microfocal sources, or by placing an absorption grating in front of an extended source. Both these solutions limit the amount of flux available for imaging, with the latter also leading to a more complex setup with additional alignment requirements. Edge-illumination partly overcomes this as it was proven to work with focal spots of up to 100 micron. While high-flux, 100 micron focal spot sources do exist, their comparatively large footprint and high cost can be obstacles to widespread translation. A simple solution consists in placing a single slit in front of a large focal spot source. We used a tunable slit to study the system performance at various effective focal spot sizes, by extracting transmission, phase and dark-field images of the same specimens for a range of slit widths. We show that consistent, repeatable results are obtained for varying X-ray statistics and effective focal spot sizes. As the slit width is increased, the expected reduction in the raw differential phase peaks is observed, compensated for in the retrieval process by a broadened sensitivity function. This leads to the same values being correctly retrieved, but with a slightly larger error bar i.e. a reduction in phase sensitivity. Concurrently, a slight increase in the dark-field signal is also observed.

The reactivated bike: Self-reported cycling activity during the 2020 COVID-19 pandemic in Australia

In western societies, the 2020 COVID-19 pandemic restrictions created a boom in cycling activity and business. This article reports findings from an Australia-wide survey that invited responses from those who changed their cycling behaviour during the pandemic lockdowns. The survey premise was that the pandemic lockdowns in each state presented the conditions of a 'natural experiment' to test whether the reduction in automobile traffic affected how cyclists reported experiencing the cycling environment. The survey was in the field from 3 August to 16 September 2020 with purposive sampling. A total of 699 respondents participated, with 444 complete surveys. Key questions we seek to address include: Did cycling activity increase during the pandemic shutdowns? How did cyclists from under-represented groups experience the pandemic lockdowns? The findings are twofold. First, cycling activity increased among most respondents during pandemic lockdowns for exercise and wellbeing, but not for transport. Our survey reports that for respondents the pandemic lockdowns did not result in an uptake of active transport, despite the appearance of 'pop-up' cycle lanes. Second, the reduced traffic of the pandemic shutdown period created a particular opportunity for women to ride bikes. The key policy implication is that cities in Australia should be designed for more relaxed modalities of mobility if the goal is to increase rates of active travel and cycling activity.

Fast, non-iterative algorithm for quantitative integration of X-ray differential phase-contrast images

X-ray phase contrast imaging is gaining importance as an imaging tool. However, it is common for X-ray phase detection techniques to be sensitive to the derivatives of the phase. Therefore, the integration of differential phase images is a fundamental step both to access quantitative pixel content and for further analysis such as segmentation. The integration of noisy data leads to artefacts with a severe impact on image quality and on its quantitative content. In this work, an integration method based on the Wiener filter is presented and tested using simulated and real data obtained with the edge illumination differential X-ray phase imaging method. The method is shown to provide high image quality while preserving the quantitative pixel content of the integrated image. In addition, it requires a short computational time making it suitable for large datasets.

Treatment of bypass wastewater using potassium ferrate(VI): assessing the role of mixing

In-plant wastewater treatment strategies to deal with bypass wastewater in excess of plant capacity are critical in securing sustainable wastewater management. To address this issue, potassium ferrate(VI), which is a dual disinfectant and coagulant, is assessed in this study as the sole chemical applied to enhance the primary treatment of bypass wastewater. The effect of rapid mixing speed is investigated for the first time along with potassium ferrate(VI) dosage by means of central composite design and response surface methodology. Escherichia coli (E. Coli), Faecal Coliform (FC), Total Suspended Solids (TSS), and Orthophosphates ( P O 4 3 - ) were considered as the process responses. All responses other than P O 4 3 - showed good agreement between the observed and modelled values. While there was no point of maximum or minimum response for both E. Coli and FC, whose removals were found to increase with the increase of both the mixing intensity and potassium ferrate(VI) dosages, TSS removal exhibited optimal responses. The effluent quality achieved by potassium ferrate(VI), as an independent treatment, can be sufficient for certain types of unrestricted and restricted irrigation reuse purposes suggested by World Health Organisation (WHO) reuse guidelines.

Clinical Perspectives in Brain Metastasis

Brain metastases (BMs) are responsible for decline in neurological function, reduction in overall quality of life, and mortality from recurrent or untreatable lesions. Advances in diagnostics and imaging have led to increased detection of central nervous system (CNS) metastases in patients with progressive cancers. Improved control of extracranial systemic disease, and the limited ability of current therapeutics to cross the blood-brain barrier (BBB) also contribute to the increase in incidence of brain metastases, as tumor cells seek refuge in the brain. Surgery, chemotherapy, and/or radiation (whole-brain radiation therapy and stereotactic radiation surgery [WBRT/SRS]) are a clinically established treatment paradigm for patients with brain metastases. With the advent of genetic and molecular characterization of tumors and their immune microenvironment, clinical trials seek to include targeted drugs into the therapeutic regimen for eligible patients. Several challenges, like treatment of multiple CNS lesions, superior uptake of chemotherapy into the brain, and trials with multidisciplinary approaches, are now being clinically addressed.

Simplified retrieval method for Edge Illumination X-ray phase contrast imaging allowing multi-modal imaging with fewer input frames

We present data from an implementation of Edge Illumination (EI) that uses a detector aperture designed for increasing dynamic range, suitable for clinically relevant X-ray energies and demonstrated here using synchrotron radiation. By utilising a sufficiently large crosstalk between pixels, this implementation enables single-scan imaging for phase and absorption, and double-scan for phase, absorption and dark field imaging. The presence of the detector mask enables a direct comparison between conventional EI and beam tracking (BT), which we conduct through Monte Carlo and analytical modelling in the case of a single-scan being used for the retrieval of all three contrasts. In the present case, where the X-ray beam width is comparable to the pixel size, we provide an analysis on best-positioning of the beam on the detector for accurate signal retrieval. Further, we demonstrate an application of this method by distinguishing different concentrations of microbubbles via their dark field signals at high energy using an EI system.

Soluble chemical oxygen demand removal from bypass wastewater using iron electrocoagulation

In-plant wastewater treatment strategies to handle bypass wastewater exceeding design capacity are insufficiently investigated in the scientific literature notwithstanding their importance in ensuring sustainable wastewater management. In this study, the effectiveness of iron electrocoagulation was investigated, for the first time, to enhance primary treatment capability in removing soluble chemical oxygen demand (sCOD) from bypass wastewater. In addition, the appropriate assumptions and experimental protocols for the application of adsorption isotherm models, widely used to describe the electrocoagulation process, were discussed in light of experimental results. Under neutral pH conditions, the bypass wastewater treatment was performed to test the effects of three preselected variables (electrolysis duration, current density, and temperature) on sCOD removal. Using a 15 mA/cm² current density, an average 52% sCOD removal efficiency was achieved after 15 min at 23 °C while approximately 40 min were needed to attain comparable removal efficiency at 8 °C. sCOD removals of 74% and 87% were achieved after 40 min treatment using a 22 mA/cm² current density at 8 °C and 23 °C, respectively. Experimental results and theory show that adsorption equilibrium was not reached in the electrocoagulation cell; consequently, variable-order-kinetic (VOK) models derived from Langmuir and Langmuir-Freundlich adsorption expressions were adapted to describe the process. These models were modified to account for the de facto estimation of ferric hydroxide (adsorbent) mass that accounts for the conversion of ferrous ion to particulate end products. The Langmuir-based VOK model was found to better describe sCOD removal under all the operating conditions tested and showed the sCOD removal mechanism to be consistent with chemisorption. This research shows the promising ability of iron electrocoagulation to achieve superior removal of sCOD as compared to established and emerging standalone bypass wastewater treatment technologies.

The role of mixing in potassium ferrate(VI) consumption kinetics and disinfection of bypass wastewater

Bypass wastewaters need an appropriate auxiliary treatment to address their broad range of chemical and bacterial characteristics. The dual capacity of potassium ferrate(VI) as disinfectant/oxidant and coagulant may be useful in a sustainable process retrofit to provide adequate treatment to such wastewaters. However, the engineering aspects of potassium ferrate(VI) based technology to retrofit within existing coagulation-flocculation-sedimentation basins have not been studied. This study investigated, for the first time, the role of rapid mixing on the rate of potassium ferrate(VI) decay and disinfection in bypass wastewaters from extreme wet weather flow events. First-order, second-order, and double exponential models were fit to the potassium ferrate(VI) consumption data, and the double exponential model was able to represent the potassium ferrate(VI) decay in all conditions with a high coefficient of determination and low mean square error. In addition, Chick-Watson and Hom models were tested in this study, and both fit the E. coli disinfection results. The rates of potassium ferrate(VI) consumption and disinfection derived from the models were higher using 500-1000 rpm rapid mixing speeds than they were when magnetic stirrer mixing was used for the same initial dosage and wastewater sample. There was no significant increase in the potassium ferrate(VI) consumption or disinfection rates with the increase of the rapid mixing speeds from 500 to 1000 rpm which revealed that the reactions were kinetically controlled. The coagulation capability of potassium ferrate(VI) enhanced the sedimentation ability and contributed almost the same as the chemical disinfection capability to the overall E. coli removal. This study suggests that potassium ferrate(VI) can be implemented in existing facilities that mix coagulants to enhance primary sedimentation, yet potassium ferrate(VI) can provide both disinfection and coagulation at lower mixing speeds.

Proliferative Index in Pediatric Pilocytic Astrocytoma by Region of Origin and Prediction of Clinical Behavior

BACKGROUND/AIMS

Pilocytic astrocytomas are common pediatric tumors. Molecular profiles vary with location of origin. Comparisons of proliferation have not been reported. We sought to identify differences in growth by region and whether these predict clinical behavior.

METHODS

A retrospective review of all patients undergoing surgery for a pilocytic astrocytoma at Children's Hospital LA from 2003 to 2015 was completed. Tumor location, determined by imaging, was stratified into infratentorial, supratentorial, or optic pathway. Proliferation was measured by Ki-67 immunostaining. A p value of 0.05 was deemed significant.

RESULTS

77 patients were identified. 51 had posterior fossa tumors, 12 had supratentorial tumors, and 14 had optic pathway tumors. Mean Ki-67 score was 3.67, 4.09, and 3.83%, respectively (p = 0.82). Ki-67 of ≥4% trended towards recurrence (p = 0.11), incomplete resection (p = 0.15), and younger age at presentation (p = 0.04). Ki-67 was weakly correlated with shorter survival after surgery (r = -0.103, p = 0.41). Partial resection strongest predicted recurrence (p < 0.001; OR = 13.0).

CONCLUSION

Proliferative index does not change by location. Higher cell proliferation was seen in younger patients and associated with shorter time to and a higher risk of recurrence. Further study is needed to identify predictors for clinical behavior. Importance of Study: This study provides a detailed analysis of the proliferative indices of tumors arising from characteristic locations within the brain. With recent advances in our understanding of the differences in molecular and genetic profiles despite similar histologic diagnoses, we felt that it was important to review whether there were unique components of tumor behavior that could be identified. In turn, we sought to determine whether tumor behavior could be used to predict the clinical course. This knowledge is important, given that not every tumor may undergo complete surgical resection, and that some lesions may require more aggressive upfront adjuvant therapy or be closely monitored for recurrence.

Pulmonary Embolism Testing Among Emergency Department Patients Who Are Pulmonary Embolism Rule-out Criteria Negative

OBJECTIVE

Previous studies have demonstrated that rates of pulmonary embolism (PE) testing have increased without a concomitant decrease in PE-related mortality. The Pulmonary Embolism Rule-out Criteria (PERC) intend to reduce testing for PE in the emergency department (ED) by identifying low-risk patients ("PERC-negative") who do not require D-dimer, computed tomography pulmonary angiogram (CTPA), or ventilation/perfusion (VQ) scan for PE. This study assesses PE testing rates among PERC-negative patients presenting to an urban academic ED.

METHODS

We prospectively enrolled a convenience sample of ED patients with chest pain and/or shortness of breath presenting between June 2010 and December 2015. We recorded baseline variables at the time of ED presentation, information on testing performed in the ED, and the diagnosis of acute PE during the ED visit. We classified patients as PERC-positive or PERC-negative utilizing baseline variables and clinical characteristics.

RESULTS

Of the 3,024 study patients, 54.8% (95% confidence interval = 53%-56.5%) were female and the mean age was 51.7 (51.1-52.3) years. A total of 17.5% (16.2%-18.9%) of study patients were PERC-negative and 33.7% (32%-35.4%) of all patients underwent testing for PE. A total of 25.5% (22%-29.4%) of PERC-negative patients had PE testing compared to 35.4% (33.6%-37.3%) of PERC-positive patients (p < 0.001). A total of 7.2% (5.3%-9.7%) of PERC-negative patients had advanced imaging without a D-dimer compared to 19.2% (17.8%-20.8%) of PERC-positive patients (p < 0.001). In multivariate analysis, factors associated with PE testing in PERC-negative patients included age, white non-Hispanic race/ethnicity, pleuritic chest pain, and a complaint of both chest pain and shortness of breath. Two PERC-negative patients (0.4%) were diagnosed with an acute PE in the ED compared to 2.2% of PERC-positive patients (p = 0.008). The overall testing yield for PE was 1.6% (0.4%-9.2%) among PERC-negative patients versus 6.3% (4.9%-8.1%) among PERC-positive patients (p = 0.017).

CONCLUSION

In an academic ED, a significant proportion of PERC-negative patients underwent testing for PE, including CT or VQ scan without D-dimer risk stratification. Future areas of research may include evaluating factors that lead clinicians to pursue PE testing in PERC-negative patients and implementing clinical pathways to minimize practice variability among these patients.

Improving Patient Safety in Clinical Oncology: Applying Lessons From Normal Accident Theory

Concerns for patient safety persist in clinical oncology. Within several nonmedical areas (eg, aviation, nuclear power), concepts from Normal Accident Theory (NAT), a framework for analyzing failure potential within and between systems, have been successfully applied to better understand system performance and improve system safety. Clinical oncology practice is interprofessional and interdisciplinary, and our therapies often have narrow therapeutic windows. Thus, many of our processes are, in NAT terms, interactively complex and tightly coupled within and across systems and are therefore prone to unexpected behaviors that can result in substantial patient harm. To improve safety at the University of North Carolina, we have applied the concepts of NAT to our practice to better understand our systems' behavior and adopted strategies to reduce complexity and coupling. Furthermore, recognizing that we cannot eliminate all risks, we have stressed safety mindfulness among our staff to further promote safety. Many specific examples are provided herein. The lessons from NAT are translatable to clinical oncology and may help to promote safety.

Management of in-flight medical emergencies: are senior medical students prepared to respond to this community need?

Introduction

In-flight medical emergencies on commercial aircraft are common in both domestic and international flights. We hypothesized that fourth-year medical students feel inadequately prepared to lend assistance during in-flight medical emergencies. This multicenter study of two U.S. medical schools obtains a baseline assessment of knowledge and confidence in managing in-flight medical emergencies.

Methods

A 25-question survey was administered to fourth-year medical students at two United States medical schools. Questions included baseline knowledge of in-flight medicine (10 questions) and perceived ability to respond to in-flight medical emergencies.

Results

229 participants completed the survey (75% response rate). The average score on the fund of knowledge questions was 64%. Responses to the 5-point Likert scale questions indicated that, on average, students did not feel confident or competent responding to an in-flight medical emergency. Participants on average also disagreed with statements that they had adequate understanding of supplies, flight crew training, and ground-based management.

Conclusion

This multicenter survey indicates that fourth-year medical students do not feel adequately prepared to respond to in-flight medical emergencies and may have sub-optimal knowledge. This study provides an initial step in identifying a deficiency in current medical education.

Opportunities for improving pLDH-based malaria diagnostic tests

BACKGROUND

Monoclonal antibodies to Plasmodium lactate dehydrogenase (pLDH) have been previously used to format immunochromatographic tests for the diagnosis of malaria. Using pLDH as an antigen has several advantages as a sensitive measure of the presence of parasites within patient blood samples. However, variable results in terms of specificity and sensitivity among different commercially available diagnostic kits have been reported and it has not been clear from these studies whether the performance of an individual test is due simply to how it is engineered or whether it is due to the biochemical nature of the pLDH-antibody reaction itself.

METHODS

A series of systematic studies to determine how various pLDH monoclonal antibodies work in combination was undertaken. Different combinations of anti-pLDH monoclonal antibodies were used in a rapid-test immunochromatographic assay format to determine parameters of sensitivity and specificity with regard to individual Plasmodium species.

RESULTS

Dramatic differences were found in both species specificity and overall sensitivity depending on which antibody is used on the immunochromatographic strip and which is used on the colorimetric colloidal-gold used for visual detection.

DISCUSSION

The results demonstrate the feasibility of different test formats for the detection and speciation of malarial infections. In addition, the data will enable the development of a universal rapid test algorithm that may potentially provide a cost-effective strategy to diagnose and manage patients in a wide range of clinical settings.

CONCLUSION

These data emphasize that using different anti-pLDH antibody combinations offers a tractable way to optimize immunochromatographic pLDH tests.

Lack of LFA1 mediated signals promotes generation of memory precursor effector CD8 T cells during LCMV infection (83.19)

Multiphoton intravital microscopy (MP-IVM) studies have revealed that T cell priming encompasses a prolonged phase of stable interactions between T cell and Dendritic cells (DCs). Although believed to promote T cell activation, the role of prolonged T-DC interactions remains poorly understood. Here we dissect the contribution of LFA1 mediated adhesion/signaling in two settings: in mediating P14 T cell interactions with GP33-39 peptide pulsed DCs and modulating the differentiation of P14 T cells after an LCMV infection. First, we show that the lack of LFA1 on P14 T cells significantly decreases the T-DC interaction time measured by MP-IVM. Second adoptive transfer of physiological numbers of P14 LFA1 -/- T cells into WT recipients generated reduced effector cell numbers at day 8 after LCMV i.p. infection, when compared to P14 LFA1+/+ T cells. Moreover, P14 LFA1-/- T cells were poor cytokine producers and showed a significant increase in the frequency of IL7Rhigh KLRG1low memory precursor effector cells. In summary, our results suggest that prolonged T-DC interactions mediated by LFA1 promote generation of short lived effector cells. In contrast, short lived T-DC interactions promote the generation of memory precursor effector cells.

Toxicity identification fractionation of environmental estrogens in waste water and sludge using gas and liquid chromatography coupled to mass spectrometry and recombinant yeast assay

We developed a toxicity identification fractionation (TIF) procedure to determine estrogenic compounds in wastewaters and sludge. The procedure consisted in fractionation of samples through a C(18) solid-phase extraction cartridge, in which Fraction I contained nonylphenol (NP) and its mono (NPEO(1)) and diethoxylate (NPEO(2)) and the markers of faecal exposure, Fraction II contained bisphenol A (BPA) and synthetic and natural hormones, and Fraction III contained the hormone conjugates. These three fractions were analyzed in parallel using gas or liquid chromatography coupled to mass spectrometry and recombinant yeast assay (RYA). Water samples collected daily throughout a whole week contained from 0.45 to 7.22 microg L(-1) of NP > NPEO(1) > NPEO(2) and were responsible for the estrogenicity of these samples. Fractions II and III were not estrogenic and that was due to the low ng L(-1) level of hormones and hormone conjugates found, respectively. The biological treatment sewage treatment plant (STP) was capable to eliminate from 52 to 100% of the compounds, with bisphenol A being the least removed. Only alkylphenols were accumulated in sludge with concentrations from 8.69 to 26.3 mg kg(-1) dw of NPEO(1) > NPEO(2) > NP. The integrated procedure herein proposed can be used as a screening method to evaluate estrogenic compounds in STPs and to survey faecal elimination.

An assessment of estrogenic organic contaminants in Canadian wastewaters

A suite of 30 primarily estrogenic organic wastewater contaminants was measured in several influent/effluent wastewater samples from four municipal wastewater treatment plants and effluents from one bleached kraft pulp mill (BKME) using an ultra-trace analytical method based on gas chromatography-high resolution mass spectroscopy (GC-HRMS). In vitro recombinant yeast assay detection of the estrogenic equivalent (EEq) on whole and solid phase extracted (SPE) and fractionated wastewater was also performed. 19-norethindrone was the most frequently detected and abundant (26-224 ng/L) of all the synthetic estrogens/progesterones in the influent samples. 17alpha-ethinylestradiol was the more frequently detected synthetic estrogen/progesterone in the effluents occurring at or below 5 ng/L with some sporadic occurrences of up to 178 ng/L. The greatest levels of steroidal estrogens in municipal effluents were E1>E2>E3 which were all <20 ng/L. Nonylphenol and di(2-ethylhexyl) phthalate were found to be the highest non-steroidal synthetic compounds surveyed in both municipal influent and effluent samples, both occurring at 6-7 microg/L in municipal effluents. BKME contained relatively large amounts of the plant sterol stigmasterol (4 microg/L) but low amounts of fecal sterols, and steroidal estrogens (E2 only at 6 ng/L) when compared to the municipal effluents. In vitro EEq in the wastewater surveyed ranged from 9-106 ng E2/L and ranked from municipal influent>municipal effluent approximately BKME, with most of the estrogenicity fractionating in the 100% methanol SPE fraction followed by a secondary amount in the diethyl ether (for municipal) or methyl-tert butyl ether (for BKME) SPE fractions. Most correlations between chemical and in vitro estrogenic equivalency were weak (p>0.05 in most cases). Unexpected inverse correlations between in vitro estrogenic activity and concentrations of the estrogenic contaminant bisphenol A were found which likely contributed to the weakness of these correlations. A modified toxicity identification and evaluation procedure was continued with the SPE extracts from the more potent 100% methanol SPE fractions of municipal effluent. High performance liquid chromatography band elution retention times, based on in vitro estrogen detection, indicated that steroidal estrogens such as E2 were responsible for most of the estrogenicity of the samples. Subsequent collection and GC-MS analysis of active bands did not confirm the presence of steroidal estrogens, but expanded the possibility of phthalate esters (i.e. dibutyl phthalate) and natural sterols (i.e. beta-sitosterol) contributing to the overall estrogenic load.

Partnership working between university researchers and self-advocacy organizations: 'A way forward for inclusion?'in England and 'Fine feathers make a fine bird'in Flanders

This article gives accounts of differing experiences of self-advocate partnerships in research with universities in England and Flanders. In England the partnership grew up within a local People First group built upon a personal working relationship with one support person. It is focused almost exclusively on empirical research and, because it is aimed at influencing policy and practice, questions of funding and control are to the fore. In Flanders the partnership is closely linked with the development of a national movement of self-advocates in which the university was a close ally. Research is important in both contexts but in Flanders the university is more clearly identified with the wider movement. Partnerships have their ups and downs but in both countries researchers with the label 'learning difficulties' wish to set their own agendas and place great importance on trust in their work with their support worker (England) or ally (Flanders).

Evaluation of the effects and interactions of mixing and oxygen transfer on the production of Fab’ antibody fragments in Escherichia coli fermentation with gas blending

Fermentations carried out at 450-L and 20-L scale to produce Fab' antibody fragments indicated a serious problem to control levels of dissolved oxygen in the broth due to the large oxygen demand at high cell densities. Dissolved oxygen tension (DOT) dropped to zero during the induction phase and it was hypothesised that this could limit product formation due to inadequate oxygen supply. A gas blending system at 20-L scale was employed to address this problem and a factorial 2(2) experimental design was executed to evaluate independently the effects and interaction of two main engineering factors: agitation rate and DOT level (both related to mixing and oxygen transfer in the broth) on Fab' yields. By comparison to the non-gas blending system, results in the gas blending system at same scale showed an increase in the production of Fab' by 77% independent of the DOT level when using an agitation rate of 500 rpm level and by 50% at an agitation rate of 1,000 rpm with 30% DOT. Product localisation in the cell periplasm of >90% was obtained in all fermentations. Results obtained encourage further studies at 450-L scale initially, to evaluate the potential of gas blending for the industrial production of Fab' antibody fragments.

Development of a rapid enzyme immunoassay for the detection of retinol-binding protein

BACKGROUND

Retinol-binding protein (RBP) was chosen as a surrogate marker for retinol because of the close correspondence between retinol and RBP.

OBJECTIVE

To meet the need for rapid, cost-effective determination of vitamin A status in populations, a quantitative enzyme immunoassay (EIA) for detection of RBP was developed.

DESIGN

The resulting RBP EIA, a competitive assay, uses RBP adsorbed to microtest strip wells to compete with RBP in serum. The assay takes approximately 40 min.

RESULTS

With a reference panel of sera, test accuracy was found to be within 4% of expected values through the calibrated range of 0.48-1.92 micro mol RBP/L (10-40 micro g RBP/mL). Intraassay and interassay variability averaged 6.7% and 8.9%, respectively. Specificity testing showed no interference from other serum proteins, prealbumin, rheumatoid factor, bilirubin, estrogen, or C-reactive protein. The RBP EIA provided linear results between 0.43 and 1.80 micro mol RBP/L (9 and 38 micro g RBP/mL). Preliminary laboratory evaluations indicated that the RBP EIA correlates well with radial immunodiffusion for RBP and with HPLC for retinol, the current reference standard. A field evaluation in a population at risk for vitamin A deficiency (VAD) resulted in close correlation between RBP EIA measures and retinol measures by HPLC (R(2) = 0.82).

CONCLUSIONS

The RBP EIA is as reliable in estimating VAD as is HPLC retinol. After successful validations, the test should enable public health authorities to rapidly monitor VAD and track vitamin A status in populations.

Acute hepatitis C virus seroconversion in a Scottish blood donor: HCV antigen is not comparable with HCV nucleic acid amplification technology screening

BACKGROUND AND OBJECTIVES

This study was conducted to analyse the usefulness of hepatitis C virus (HCV) core antigen tests for the confirmation of HCV infection in a donor presenting as nucleic acid amplification technology (NAT) positive but negative for antibodies to HCV (anti-HCV).

MATERIALS AND METHODS

Blood donations were screened, in parallel, for anti-HCV using the Abbott PRISM HCV Chemiluminescent immunoassay (ChLIA) and an 'in-house' HCV NAT (pools of up to 95 donations). An HCV NAT-positive antibody-negative donor was identified. Twelve follow-up samples were obtained and tested with various HCV antigen (including the recently marketed Trak-C second-generation assay) and HCV antibody assays.

RESULTS

The single HCV NAT-positive, antibody-negative donation was identified from 1 117 681 donations screened in the 4-year period, July 1999 to June 2003. The index donation was positive by Ortho HCV core antigen enzyme immunoassay (EIA) and Ortho Trak-C (second-generation HCV core antigen EIA). An archive sample, taken 127 days prior to the index donation, was negative for all HCV markers. Subsequent samples demonstrated a loss of reactivity in the Ortho HCV core antigen EIA and reduced activity in the Ortho Trak-C until day 69. Immunoblot (Ortho RIBA-3) and HCV PRISM became positive on day 62, whilst Ortho HCV ELISA was not positive until day 132 or Biorad HCV ELISA until day 160. An alternative immunoblot (Innogenetics Innolia III) was positive from day 55. RNA levels fluctuated considerably during the follow-up period, being completely undetectable by routine screening methods at the time-point around seroconversion; subsequently, antibody was detected using all assays investigated.

CONCLUSIONS

This HCV-converting blood donor provided a unique panel of samples for using to assess current (and future) HCV assay systems. The overall test results led to the conclusion that individual HCV antigen testing should not be considered as equivalent to HCV NAT minipool screening. Trak-C antigen testing may be considered as a suitable confirmatory assay for isolated HCV NAT reactivity.

Preliminary evaluation of an immunochromatographic strip test for specific Treponema pallidum antibodies

We evaluated a prototype immunochromatographic strip (ICS) test for qualitative detection of Treponema pallidum antibodies in 353 sera from 157 patients. For sera from 43 syphilis patients, the ICSs were reactive, while for sera from 114 patients without syphilis, including 22 with biologically false-positive Rapid Plasma Reagin test results, the ICSs were nonreactive. The ICS test may expand the available options for serological testing for syphilis.

Vitamin A levels and immunity in humans

In animal studies, vitamin A deficiency induces a shift from type 2 (humoral) to type 1 (cellular) cytokines; there are no similar data for humans. Control of human immunodeficiency virus (HIV) and Mycobacterium tuberculosis infections requires type 1 cytokine (cellular) immunity. These infections and vitamin A deficiency are highly prevalent in Africa. We therefore examined the interactions among serum vitamin A levels, immune parameters, HIV infection status, Mycobacterium bovis BCG vaccine scarring (as an indicator of a type 1 cytokine profile), and clinical findings for 70 hospitalized children in Malawi, Africa. Directly conjugated monoclonal antibodies and flow cytometry were used to assess cell-specific cytokine production by peripheral blood monocytes and lymphocyte subpopulations. The statistical techniques employed included nonparametric statistics and logistic regression analyses. Thirty percent of the participants had severe vitamin A deficiency (<10 microg/dl), 34% had moderate deficiency (10 to <20 microg/dl), and 36% had normal levels (> or = 20 microg/dl). Vitamin A levels were lower for HIV-positive than for HIV-negative children (median, 10 and 17 microg/dl, respectively). Vitamin A-deficient children (<20 microg/dl) were more likely than non-vitamin A-deficient children to have higher proportions of natural killer (NK) cells (median, 8.3 and 5.2%, respectively) and lower ratios of interleukin-10-producing monocytes to tumor necrosis factor alpha-producing monocytes after induction (median, 1.0 and 2.3, respectively). Vitamin A-deficient children were also more likely than non-vitamin A-deficient children to exhibit respiratory symptoms (47% versus 12%) and visible BCG vaccine scars (83% versus 48%), which are indicative of a type 1 response to vaccination. Vitamin A status did not vary with gender, age, incidence of malaria parasitemia, blood culture positivity, or rates of mortality (6% of vitamin A-deficient children died versus 20% of non-vitamin A-deficient children). Lower vitamin A levels were associated with a relative type 1 cytokine dominance and proportionately more NK cells, both of which may be somewhat beneficial to persons who are exposed to HIV, M. tuberculosis, or other type 1 pathogens.

Hepatitis B vaccinees may be mistaken for confirmed hepatitis B surface antigen-positive blood donors

BACKGROUND AND OBJECTIVES

Hepatitis B surface antigen (HBsAg) test sensitivities have gradually increased, and neutralizable weak HBsAg-positive donations, with no other hepatitis B virus (HBV) markers, have occasionally been found in our donor population. On investigation, these donors have admitted to receiving hepatitis B vaccine up to 5 days previously. A study was therefore initiated to monitor HBsAg reactivity amongst volunteers after receiving their first dose of hepatitis B vaccine.

MATERIALS AND METHODS

Eight volunteers were tested using three HBsAg assays (Abbott Auszyme, Ortho HBsAg-3 and Abbott/Murex GE34/36) on days 0, 3, 5, 7 and 10 after administration of hepatitis B vaccine.

RESULTS

Two HBsAg tests (Abbott Auszyme and Ortho HBsAg-3) did not detect HBsAg reactivity amongst the volunteers, although the Abbott Auszyme test results reached 70-80% of the manufacturer's cut-off at day 3 in two volunteers. The most recently launched assay (Abbott/Murex GE 34/36) detected seven (87%) of the eight volunteers as HBsAg reactive on day 3, and two (25%) volunteers were still reactive on day 5.

CONCLUSION

The Abbott/Murex GE 34/36 assay demonstrated HBsAg reactivity in most volunteers on day 3 and in some on day 5 after vaccination. It is therefore recommended that individuals who have recently been vaccinated with hepatitis B be deferred from blood donation for at least 7 days.

HTLV antibody screening using mini-pools

At the present time, the UK blood transfusion services do not screen blood donations for anti-HTLV. This presentation describes a pilot study to ascertain the feasibility of HTLV antibody screening using mini-pools and also provides an estimate of HTLV prevalence within our donor population in Scotland and Northern Ireland. The Abbott/Murex HTLV I/II GE80/81 ELISA was selected for the trial. Thirty confirmed HTLV positive library samples were tested at various dilutions and five were shown to be nonreactive at a dilution of 1:100. Residues of mini-pools (of up to 95 individual donations) prepared for HCV NAT testing were tested with the Abbott/Murex GE80/81 assay. Of 6666 mini-pools (equivalent to 570 609 donations) tested, six were repeatedly reactive. All six mini-pools were confirmed HTLV antibody positive by line immunoassay. Four were confirmed to be HTLV-I positive, one HTLV-II positive and one HTLV positive (unable to type). Dilutions (1:100) of the five HTLV "nonreactive" positive samples were included in each test plate and used to determine a grey-zone cut-off. Using this grey-zone system an additional six (0.09%) mini-pool samples gave repeatedly reactive grey-zone results, none of which were confirmed. The minimum Scottish/Irish HTLV donor prevalence was shown to be 1:95 000.

The effects of iron deficiency on lymphocyte cytokine production and activation: preservation of hepatic iron but not at all cost

Worldwide, over 40% of children have iron deficiency anaemia, frequently associated with infections. Certain cytokines are involved in both immune activation/response to infection and iron transport/metabolism. We therefore assessed the relations among iron deficiency, cytokine production and lymphocyte activation markers in 142 hospitalized Malawian children. We examined peripheral blood lymphocyte antigens/cytokine production using four- colour flow cytometry and serum transferrin receptor (TfR) levels, an inverse measure of iron status unaffected by acute illness or infection, with an enzyme-linked immunosorbent assay. Wilcoxon rank sum tests and logistic regression analyses (LRA) were performed. Iron deficiency (TfR > or = 10 microg/ml) versus TfR < 10 microg/ml, was associated with higher percentages of lymphocytes producing: (a) induced or spontaneous IL-6 (medians: induced, 15.9% for iron-deficient children versus 8.8% for iron-replete children, P = 0.002; spontaneous, 24.4% versus 13.0%, P < 0.001) and (b) induced IFN-gamma (medians:18.4% versus 12.4%, P = 0.006). The percentages of CD8(+) T cells spontaneously producing IL-6 and of all lymphocytes producing induced TNF-alpha and IFN-gamma in the same cell had the strongest relationships to iron deficiency (b = + 0.0211, P = 0.005 and b = + 0.1158, P = 0.012, respectively, LRA) and were also positively related to the co-expression of the T cell activation markers HLA DR and CD38. Severe iron deficiency (TfR > or = 30 microg/ml) was associated with the percentage of lymphocytes producing induced IL-4 (medians: 0.5% versus 1.6%, P < 0.010). The cytokine patterns associated with iron deficiency in our study would preserve iron stores but also preferentially retain the activation capabilities of T cells, albeit not necessarily other immune cells, until a critical level of iron depletion is reached.

CD8(+) T cells express a T-helper 1--like phenotype after burn injury

BACKGROUND

Previous studies suggest that CD8(+) T cells are immunosuppressive after burn injury, but recent reports indicate that CD8(+) T cells have several functions similar to CD4(+) T cells, including the secretion of cytokines. This study uses HY male antigen in transgenic HY female mice to determine the antigen-specific response of activated CD8(+) T cells after burn injury.

METHODS

HY TCR transgenic female mice underwent burn or sham injury. Seventy-two hours after the burn, splenocytes were stimulated with 20 micromol/L HY peptide for 16, 48, and 64 hours; cellular proliferation, intracellular interferon-gamma and interleukin-2, and apoptosis were measured.

RESULTS

Burn injury significantly impaired proliferation to HY antigen (P < or =.05). Activated CD8(+) T cells from burned mice showed increased intracellular interferon-gamma and interleukin-2 16 hours after stimulation compared with sham (P < or =.05) and at no time was less than control mice. The percent of CD8(+) T cells decreased with the time of stimulation but was not due to apoptosis by Annexin V staining.

CONCLUSIONS

Activated CD8(+) T cells express a T(h1)-like phenotype after burn injury. This provides evidence that CD8(+) T cells are not simply suppressive and that is consistent with data that CD4(+) T cells are primed for a T(h1) response after burn injury.

Cytokines and malaria parasitemia

The balance between pro- and antiinflammatory cytokines may be important in malaria presentation and outcome. Malaria tends to be more severe in children than in adults, presumably because partial immunity develops with age. However, the full nature of, and age-related differences in, anti-malarial immunity are unknown. We compared: (1) serum and cell-specific cytokines of patients with acute malaria to those of patients with other acute illnesses and to those of healthy adults and (2) the cytokine responses of parasitemic children and parasitemic adults. Flow cytometry was done on the peripheral blood mononuclear cells of 148 hospitalized children, 161 febrile hospitalized adults, and 20 healthy adults in Malawi, Africa, a malaria-endemic country. Serum cytokines were also assessed for 80 of these patients. Thirty-eight participants were parasitemic with Plasmodium falciparum. Serum interleukin (IL)-10 (an antiinflammatory, immunoregulatory, and type 2 cytokine) levels were higher in malaria patients than in other patients (medians 502 pg/mL vs 16 pg/mL, P = 0.002), and the percentages of various lymphocyte populations making IL-6 (a proinflammatory, type 2 cytokine regulating iron distribution) were lower in malaria patients than in other patients (e.g., for spontaneous production by children's CD8(+) T cells: medians 1.4% vs 33.1%, P = 0.004). For adult patients, the percentages of lymphocytes spontaneously making IL-4 (a type 2 cytokine) were significantly lower in those with malaria than in those without malaria (medians 0.9% vs 2.1%, P = 0.005). The percentages of monocytes spontaneously making IL-8 (a chemotactic, proinflammatory chemokine) were higher in parasitemic children than in parasitemic adults (medians 5.8% vs 1.7%, P = 0.003). A number of cellular proinflammatory, type 1 parameters were significantly higher in all children (with or without malaria) than in all adults; these included the percentages of various lymphocyte populations making IL-6, both IL-6 and interferon-gamma, or IL-8. These data support the importance of IL-10 in malaria parasitemia. Given the lack of an IL-4 (type 2) response, IL-10's primary role may be immunoregulatory rather than type 2 in nature. In this study, the immune response to malaria was more proinflammatory in children than in adults. This difference, if corroborated by other studies, could be related to malaria's greater severity in children.

Risk-resistance adaptation model for caregivers and their children with sickle cell syndromes

This investigation examined the risk-resistance adaptation model for children with sickle cell disease and their primary caregivers. Participants were 55 children, ranging in age from 5 to 16 years with a mean age of 9 years 2 months, diagnosed with sickle cell disease and their primary caregivers, recruited from a university medical center. Measures included adjustment (i.e. primary caregiver and child adjustment), risk factors (i.e. disease and disability, functional independence, and psychosocial stressors), resistance factors (i.e. intrapersonal health locus of control, social-ecological), and stress processing (coping). Primary caregivers' adjustment was associated with developmental coping, changeR2 = .08, and child adaptation was associated with an internal health locus of control, changeR2 = .22. An indirect effect of primary caregivers' coping on child adjustment was found through influence on primary caregivers' adjustment, changeR2 = .11. The findings support research among other chronically ill populations that suggests an association between coping and disease adjustment. The results were interpreted to support the use of theoretically driven models in predicting the adaptation of children with chronic illness and adjustment in their caregivers.

Natural T, gammadelta, and NK cells in mycobacterial, Salmonella, and human immunodeficiency virus infections

NK cells, gammadelta T cell antigen receptor chain-positive cells, and CD3(+)CD16/56(+) (natural T [NT]) cells are involved in innate immunity and immunoregulation; however, their role in clinical infection is not well defined. Cytofluorometric analysis was used to examine peripheral blood from bacteremic, nonbacteremic, and healthy human immunodeficiency virus (HIV)-positive and -negative persons in Malawi, Africa. Mycobacteremia was associated with a higher proportion of CD3(+)CD8(-) gammadelta cells (median, 16.6% vs. 0.7% for all other cells; P<.001), and Salmonella bacteremia was associated with a higher proportion of NT cells (4.3% vs. 2.2%; P=. 002). HIV plasma RNA levels were weakly positively correlated with NT cells (rs=.39; P=.002), NK cells (rs=.38; P=.003), and gammadelta cells (rs=.43; P<.001). Compared with patients who survived, patients who died had a higher percentage of NT cells (3.7% vs. 1. 9%; P=.017) and a higher percentage of NT cells that spontaneously produced interferon-gamma (2.4% vs. 1.2%; P=.035). The data support the clinical relevance of gammadelta and NT cells in mycobacterial, Salmonella, and HIV infections and of NT cells in mortality.

(2) User Participation Now: Evidence‐Based Practice in Best Value

The user voice has been diminished by New Labour's increased reliance on regulation and inspection, notably in Best Value. Reflecting on community care implementation, the paper contends that within Best Value users may maximise their influence in an evidence‐based practice frame.

Relevance of RIBA-3 supplementary test to HCV PCR positivity and genotypes for HCV confirmation of blood donors

HCV antibody screening of 624,910 blood donations resulted in 3,832 samples being referred for confirmation. All were tested by RIBA-3 with 2,710 negative, 945 indeterminate and 177 positive results. HCV RNA was detected by PCR in an average of 69.5% of RIBA-3 positives (4 bands 84.1%; 3 bands 74.1%; 2 bands 34.1%) and only 0.53% of RIBA-3 indeterminates. Eighty-four percent of samples with a total RIBA-3 band intensity score (maximum 16) of > or = 8 were PCR positive compared with only 22% of those with a score of < 8. Total mean band intensities for HCV genotype 1 samples (n = 65) were 13.2, genotype 2 (n = 17) 11.4 and genotype 3 (n = 65) 11.2 with type 1 samples showing greater reactivity with c100 and c33 antibodies. No PCR positive type 1 samples were found with RIBA-3 total band scores less than 8, no PCR positive type 2 samples less than 6, whilst PCR positive type 3 samples were found with scores as low as 2. NS5 indeterminates were the most common (40.2%) single band pattern but yielded no PCR positive samples, followed by c33 (23.3%) with one PCR positive and c100 (20.2%) with one PCR positive whilst c22 indeterminates were least common (16.3%) but included three PCR positive donors. All five RIBA-3 indeterminate PCR positive donors were type 3.

Third-generation recombinant immunoblot assay: comparison of reactivities according to hepatitis C virus genotype

BACKGROUND

Recombinant immunoblot assay (RIBA) is widely used as a supplemental test in hepatitis C virus (HCV) confirmatory algorithms. As this assay is based on HCV type 1, its performance was examined with the common European HCV genotypes (1, 2, and 3).

STUDY DESIGN AND METHODS

A study was performed to retest in third-generation RIBA (RIBA-3) all 146 second-generation RIBA (RIBA-2)-positive polymerase chain reaction-positive samples detected by second-generation enzyme-linked immunosorbent assays and having known HCV genotypes (74 HCV type 1, 21 type 2, 51 type 3). RIBA band intensities were examined according to HCV genotype. An additional 90 RIBA-3-confirmed PCR-positive samples (47 HCV type 1, 5 type 2, 38 type 3) detected by third-generation enzyme-linked immunosorbent assays were also examined.

RESULTS

In the first group of 146 samples, the RIBA-3 NS4 (c100p) band showed a marked improvement in sensitivity for the detection of HCV types 2 and 3 over that of the c100 antigen of RIBA-2, but the mean band intensities of HCV types 2 and 3 remained significantly lower than those of type 1. Improved sensitivity of the NS3 band of RIBA-3 to HCV type 3 was also apparent, but, again, the mean band intensity measured was lower for type 3 than for either type 1 or type 2. The c22 band of RIBA-2 and RIBA-3 exhibited equal sensitivity for all HCV genotypes. These differences were also apparent when RIBA-3 was used in conjunction with third-generation enzyme-linked immunosorbent assays.

CONCLUSION

The current RIBA-3 lacks sensitivity to the NS4 antibody for HCV types 2 and 3. The incorporation of type-specific components to other genotypes for NS4 (and NS3) antigens should be considered by the manufacturers.