Considerations for Research Funders and Managers to Facilitate the Translation of Scientific Knowledge into Practice

Research funders and managers can play a critical role in supporting the translation of knowledge into action by facilitating the brokering of knowledge and partnerships. We use semi-structured interviews with a research funding agency, the Australian Centre for International Agricultural Research (ACIAR), to explore (i) ways that funders can facilitate knowledge brokering, the (ii) barriers to, and (iii) enablers for, facilitating knowledge brokering, and (iv) the individual skills and attributes for research program funders and managers to be effective brokers. Based on these findings, we generate three considerations for research funders elsewhere, in particular R4D funders, seeking to build capacity for knowledge brokering: (i) formalise the process and practice, (ii) develop shared language and understanding, and (iii) build individual competencies and capabilities. Our findings complement the existing literature with a context specific analysis of how research funders can facilitate knowledge brokering, and by identifying the barriers and enablers in doing so.

85 QUALITY IMPROVEMENT INITIATIVE TO ASSESS FRAILTY AWARENESS AND USE CLINICAL FRAILTY SCALE AMONGST STAFF IN ACUTE AND PRIMARY CARE SITES

Background

Frailty describes a condition characterized by decreased physiological reserve and a decreased resistance to stressors, leading to an increased vulnerability to adverse outcomes. Identification of frailty can generate greater complexity in treatment choices, care planning, and costs of care.

Methods

30 inpatient, Emergency Department and Ambulatory Hub charts were audited to assess the presence of the word Frailty. The use of the Clinical Frailty Scale or alternative frailty scale was also audited. A staff survey was completed across four sites, a total of 115 staff were surveyed.

Results

Awareness of frailty across all services is very good ranging from 92% to 100%. The use and awareness of the Clinical Frailty Scale varied with 41% Emergency department and 12% of acute staff respectively but only 25% Emergency Department and 12% of acute staff feeling competent to complete the scale. Conversely, there was a 73% awareness of the Clinical Frailty Scale amongst primary care staff, 33% feeling competent in it's use. The Ambulatory Hub had 100% awareness of the scale with 54% of staff feeling competent.

The chart audit showed that 20% of charts in the Emergency Department identified frailty, all by the Frailty Intervention Team. 26% of the inpatient charts identified Frailty by the Frailty Intervention Team's notes and from one visiting consultant. Frailty was identified and measured using the Clinical Frailty Scale in all cases of the Ambulatory Hub notes.

Conclusion

By identifying frailty at the first point of contact, targeted specialist interventions and services can be planned for the service user. Frailty identification on the acute site was mainly linked to the Frailty Intervention Team with the Ambulatory Hub leading out on frailty identification and measurement in the community. Future initiatives aim to increase frailty identification and awareness in acute and primary care sites.

61 AUDIT: MEDICATION REVIEW POST INPATIENT FALLS

Background

Falls are the most commonly reported incident in the Health Service Executive (HSE). Inappropriate medications and polypharmacy in the elderly can contribute to increased falls risk.

Our aim was to assess whether a medication review was being completed at the time of the post-fall clinician review.

Methods

We completed a retrospective chart review using an audit tool of consecutive inpatient falls, resulting in serious injury, from March–December 2019.

Standards measured against were: HSE Guideline—Service User Falls: A Practical Guide for Review, Medicines and Falls in Hospital: British Society Guidelines, STOPP & START criteria and NICE Guidelines: Falls in Older People 2013.

Results

We identified 33 charts for review (n = 33)—54.55% (18) female and 45.45% (15) male. Average age was 81 ± 11.2 years. The immediate post-fall review was mainly completed by interns (48.49% (16)) and SHO’s (39.39% (13)). A medication review was carried out 9.09% (3) of the time.

A total of n = 28 (84.85%) had poly pharmacy. When analysed for medications known to increase risk of falling, 51.52% (n = 17) were on anti-hypertensives, 45.45% (n = 15) on laxatives, 24.24% (n = 8) on sedative medications, 18.18% (n = 6) on hypnotics/anxiolytics, 15.15% (n = 5) on opioids and 15.15% (n = 5) on diuretics at the time of fall. The majority of these medications (77.42% (n = 24)) were commenced prior to admission. None of these medications were discontinued or the dose changed on review post fall.

Conclusion

Our audit demonstrates that in a cohort of patients who had an inpatient fall medication discontinuation and dose reductions were not performed. Yet, a high burden of polypharmacy and high-risk falls medication were found. This may result in missing a pertinent opportunity to prevent future falls. We advise a structured medication review is carried out for each patient who suffers an in-patient fall to efficiently modify such an easily identifiable risk factor.

57 POTENTIALLY INAPPROPRIATE MEDICATION USE AND MORTALITY IN PATIENTS WITH COGNITIVE IMPAIRMENT

Background

Potentially inappropriate medications (PIMs are associated with falls, hospitalisation, and cognitive decline. Few studies have investigated the association between PIMs related to cognitive impairment (PIMCog) and mortality in dementia or mild cognitive impairment (MCI).

Methods

This was a retrospective observational study. Patients diagnosed with MCI or dementia (DSM-IV criteria) presenting to a tertiary-referral memory clinic from 2013–2019 were eligible. The primary outcome was all-cause death. Secondary outcomes were vascular death and non-vascular death defined according to formal certification. The primary exposure variable of interest was PIMCog, defined as any medication in the Beers 2015 or STOPP criteria, classified as potentially inappropriate for patients with cognitive impairment. Anticholinergic burden was measured using the anticholinergic cognitive burden (ACB) scale. Polypharmacy was defined as ≥5 medications. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs).

Results

There were 418 patients included (n = 261 dementia, n = 157 MCI). The median age was 79 (interquartile range {IQR} 74–82) and median follow-up was 809 days (IQR 552–1,571). One or more PIMCog was prescribed in 141 patients (33.4%). PIMCog use was associated with all-cause mortality after adjustment for age, sex, dementia severity, Charlson Co-morbidity Index, chronic obstructive pulmonary disease, congestive cardiac failure, and peripheral vascular disease (HR 1.96, 95% CI 1.24–3.09). PIMCog use was associated with vascular death (HR 3.28, 95% CI 1.51–7.11) but not with non-vascular death (HR 1.40 95% CI: 0.78–2.52). Neither an ACB ≥3 (HR 0.87, 95% CI: 0.46–1.64) or polypharmacy (HR 1.87, 95% CI: 0.67–5.24) were associated with death.

Conclusion

The burden of PIMCog use in patients with cognitive impairment is high. PIMCog use is independently associated with all-cause mortality and vascular death. This is a potential modifiable risk factor for death in patients with neurocognitive disorders. Further research is required to independently validate this finding.

509 POTENTIALLY INAPPROPRIATE MEDICATION USE AND MORTALITY IN PATIENTS WITH COGNITIVE IMPAIRMENT

Introduction

Potentially inappropriate medications (PIMsare associated with falls, hospitalisation, and cognitive decline. Few studies have investigated the association between PIMsrelated to cognitive impairment (PIMCog) and mortality in dementia or mild cognitive impairment (MCI).

Methods

This was a retrospective observational study. Patients diagnosed with MCI or dementia (DSM-IV criteria) presenting to a tertiary-referral memory clinic from 2013–2019 were eligible. The primary outcome was all-cause death. Secondary outcomes were vascular death and non-vascular death defined according to formal certification. The primary exposure variable of interest was PIMCog, defined as any medication in the Beers 2015 or STOPP criteria, classified as potentially inappropriate for patients with cognitive impairment. Anticholinergic burden was measured using the anticholinergic cognitive burden (ACB) scale. Polypharmacy was defined as ≥5 medications. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs).

Results

There were 418 patients included (n = 261 dementia, n = 157 MCI). The median age was 79 (interquartile range {IQR} 74–82) and median follow-up was 809 days (IQR 552–1,571). One or more PIMCog was prescribed in 141 patients (33.4%). PIMCog use was associated with all-cause mortality after adjustment for age, sex, dementia severity, Charlson Co-morbidity Index, chronic obstructive pulmonary disease, congestive cardiac failure, and peripheral vascular disease. (HR 1.96, 95% CI 1.24–3.09). PIMCog use was associated with vascular death (HR 3.28, 95% CI 1.51–7.11) but not with non-vascular death (HR 1.40 95% CI: 0.78–2.52). Neither an ACB ≥3 (HR 0.87, 95% CI: 0.46–1.64) or polypharmacy (HR 1.87, 95% CI: 0.67–5.24) were associated with death.

Conclusion

The burden of PIMCog use in patients with cognitive impairment is high. PIMCog use is independently associated with all-cause mortality and vascular death. This is a potential modifiable risk factor for death in patients with neurocognitive disorders. Further research is required to independently validate this finding.

Estimating bias in derived body mass index in the Maternity Experiences Survey

INTRODUCTION

The objective of this study was to assess bias in the body mass index (BMI) measure in the Canadian Maternity Experiences Survey (MES) and possible implications of bias on the relationship between BMI and selected pregnancy outcomes.

METHODS

We assessed BMI classification based on self-reported versus measured values. We used a random sample of 6175 women from the MES, which derived BMI from self-reported height and weight, and a random sample of 259 women who had previously given birth from the Canadian Health Measures Survey (CHMS), which derived BMI from self-reported and measured height and weight. Two correction equations were applied to self-reported based BMI, and the impact of these corrections on associations between BMI and caesarean section, small-for-gestational age (SGA) and large-for-gestational age (LGA) births was studied.

RESULTS

Overall, 86.9% of the CHMS subsample was classified into the same BMI category based on self-reported versus measured data. However, misclassification had a substantial effect on the proportion of women in underweight and obese BMI categories. For example, 14.5% versus 20.8% of women were classified as obese based on self-reported data versus measured data. Corrections improved estimates of obesity prevalence, but over- and underestimated other BMI categories. Corrections had nonsignificant effects on the associations between BMI and SGA, LGA, and caesarean section.

CONCLUSION

While there was high concordance in BMI classification based on selfreported versus measured height and weight, bias in self-reported based measures may slightly over- or underestimate the risks associated with a particular BMI class. However, the general trend in associations is unaffected.

Seroprevalence of Q Fever in Patients Undergoing Heart Valve Replacement Surgery

BACKGROUND AND AIM OF THE STUDY

Q fever, caused by the rickettsia Coxiella burnetii, is a worldwide zoonotic disease with both acute and chronic manifestations. Endocarditis is the principal chronic manifestation. Q fever can easily be mistaken for degenerative valve disease due to its indolent presentation, the fastidious nature of the organism (routine cultures are negative), and the absence of a typical echocardiographic and macroscopic appearance for endocarditis. Prosthetic valve failure, with associated morbidity and mortality, have been described following unrecognized infections.

METHODS

Previous studies have documented the value of screening strategies in areas of high prevalence. Hence, a pilot study was conducted in a low-prevalence setting, in which 139 patients at two tertiary cardiac centers attending for elective valve replacement for degenerative valvular disease underwent testing for chronic Q fever infection by serological and molecular methods on blood and valve tissue.

RESULTS

Five patients (3.7%) had serological evidence of past exposure to Q fever (consistent with rates in the literature). None had evidence of chronic Q fever endocarditis. The cost of adopting a universal screening strategy is around £40,000 per case (if serology is used to screen patients prior to surgery).

CONCLUSIONS

Alternative and more cost-effective methods for identifying clinically quiet cases of chronic Q fever endocarditis are required.

Falls and fractures 2 years after acute stroke: the North Dublin Population Stroke Study

BACKGROUND

Stroke patients are at increased risk of falls and fractures. The aim of this study was to determine the rate, predictors and consequences of falls within 2 years after stroke in a prospective population-based study in North Dublin, Ireland.

DESIGN

Prospective population-based cohort study.

SUBJECTS

567 adults aged >18 years from the North Dublin Population Stroke Study.

METHODS

Participants were enrolled from an Irish urban population of 294,592 individuals, according to recommended criteria. Patients were followed for 2 years. Outcome measures included death, modified Rankin Scale (mRS), fall and fracture rate.

RESULTS

At 2 years, 23.5% (124/522) had fallen at least once since their stroke, 14.2% (74/522) had 2 or more falls and 5.4% (28/522) had a fracture. Of 332 survivors at 2 years, 107 (32.2%) had fallen, of whom 60.7% (65/107) had 2 or more falls and 23.4% (25/107) had fractured. In a multivariable model controlling for age and gender, independent risk factors for falling within the first 2 years of stroke included use of alpha-blocker medications for treatment of hypertension (P = 0.02). When mobility measured at Day 90 was included in the model, patients who were mobility impaired (mRS 2-3) were at the highest risk of falling within 2 years of stroke [odds ratio (OR) 2.30, P = 0.003] and those functionally dependent (mRS 4-5) displayed intermediate risk (OR 2.02, P = 0.03) when compared with independently mobile patients.

CONCLUSION

Greater attention to falls risk, fall prevention strategies and bone health in the stroke population are required.

Stroke recurrence within the time window recommended for carotid endarterectomy

OBJECTIVE

In the North Dublin Population Stroke Study, we investigated the risk of recurrent stroke within the 14-day time window recommended for endarterectomy.

METHODS

In a population-based prospective cohort study, all ischemic stroke patients were identified over 1 year and categorized into those with (CS-positive) and without (CS-negative) ipsilateral carotid stenosis (CS) (≥50% lumen narrowing). Nonprocedural stroke recurrence was determined at 72 hours and 7 and 14 days.

RESULTS

Of 365 ischemic stroke patients with carotid imaging, 51 were excluded due to posterior circulation or nonlateralizing stroke, ipsilateral carotid occlusion, or intracranial stenosis, leaving 314 included for analysis (36 CS-positive and 278 CS-negative). Recurrent stroke occurred in 5.6% (2/36) CS-positive and 0.4% (1/278) CS-negative patients by 72 hours of symptom onset (p =0.003), 5.6% (2/36) CS-positive and 0.7% (2/278) CS-negative patients (p =0.01) by 7 days, and in 8.3% (3/36) CS-positive and 1.8% (5/278) CS-negative patients by 14 days (p =0.02). On multivariable Cox regression analysis, CS was the only independent predictor of recurrence at 72 hours (adjusted hazard ratio [HR] 36.1, 95% confidence interval [CI] 1.6-837.5, p =0.03), and 7 days (HR 9.1, 1.1-79.2, p =0.05), with a trend at 14 days (HR 4.6, 0.9-22.8, p =0.06).

CONCLUSIONS

Although only a minority of patients with symptomatic CS had a recurrent stroke within 14 days, early recurrent stroke risk was high, particularly within the first 72 hours. Earlier carotid revascularization or improved acute medical treatment may reduce recurrence in this high-risk group.

Imaging multiple phases of neurodegeneration: a novel approach to assessing cell death in vivo

Nerve cell death is the key event in all neurodegenerative disorders, with apoptosis and necrosis being central to both acute and chronic degenerative processes. However, until now, it has not been possible to study these dynamically and in real time. In this study, we use spectrally distinct, well-recognised fluorescent cell death markers to enable the temporal resolution and quantification of the early and late phases of apoptosis and necrosis of single nerve cells in different disease models. The tracking of single-cell death profiles in the same living eye over hours, days, weeks and months is a significant advancement on currently available techniques. We identified a numerical preponderance of late-phase versus early-phase apoptotic cells in chronic models, reinforcing the commonalities between cellular mechanisms in different disease models. We showed that MK801 effectively inhibited both apoptosis and necrosis, but our findings support the use of our technique to investigate more specific anti-apoptotic and anti-necrotic strategies with well-defined targets, with potentially greater clinical application. The optical properties of the eye provide compelling opportunities for the quantitative monitoring of disease mechanisms and dynamics in experimental neurodegeneration. Our findings also help to directly observe retinal nerve cell death in patients as an adjunct to refining diagnosis, tracking disease status and assessing therapeutic intervention.

Antiretroviral therapy in the lives of women of colour with HIV

Non-adherence to antiretroviral medication is associated with adverse patient outcomes. Considerable research and clinical work has focused on issues surrounding patient compliance to prescribed regimens. Few studies have explored the essence of antiretroviral medications in the lives of women of colour with HIV. A qualitative study of HIV-infected women of colour was undertaken in response to the question: What is the role of antiretroviral medication in your life? Taped interviews were conducted with graduate psychology students and commercially transcribed. Transcriptions were analyzed by Spiegelberg's category-cluster-theme process by four different reviewers. Three themes were distilled: trust/mistrust, approach/avoidance motivation and 'constantly tethered'. Strategies designed to increase medication adherence may need to consider these basic themes in order to be successful.

The effect of cricoid pressure on intubation facilitated by the gum elastic bougie

Tracheal tube impingement is common during gum elastic bougie facilitated intubation and a 90 degrees anti-clockwise rotation of the tube usually relieves it. We detail a case where this manoeuvre failed in the presence of cricoid pressure. We investigated the effect of cricoid pressure on gum elastic bougie facilitated intubation in 120 patients randomly allocated to receive sham cricoid pressure (n = 60) or 30 N cricoid pressure (n = 60). Impingement occurred in 23/60 (38%) with sham cricoid pressure and 36/60 (60%) with 30 N cricoid pressure (p < 0.025). Only females showed an increase in impingement with cricoid pressure: 29% sham cricoid pressure vs 63% 30 N cricoid pressure, p < 0.01, whereas the impingement in males was approximately 60% in both groups. Ninety degree anti-clockwise rotation of the tube was successful in all 23 patients (100%) with sham cricoid pressure and in 32/36 patients (89%) with 30 N cricoid pressure. Releasing cricoid pressure relieved the obstruction in the four cases where 90 degrees anti-clockwise rotation of the tube failed. Impingement is common and 90 degrees anti-clockwise rotation is highly effective in both the presence and absence of cricoid pressure. In a small number of cases, cricoid pressure may cause the manoeuvre to fail.

Anticonvulsant use in elderly patients in long-term care units

BACKGROUND

Elderly patients in long-term care units are frailer than their community-dwelling peers and may be more at risk from toxic side-effects of anticonvulsant medication at standard doses.

AIM

To examine the prescribing of anticonvulsants to patients in elderly care units.

METHODS

Drug prescription sheets and case notes were reviewed. Serum anticonvulsant concentration, renal and liver profiles and albumin level were measured.

RESULTS

Anticonvulsants were prescribed to twice as many male as female patients (32 vs 14%; p<0.03) and to 33% of those younger than 80 years of age versus 10% of those aged 80 years or older (p<0.0002). No patient had significant hypoalbuminaemia and routine measurement of serum anticonvulsant concentration did not indicate an alteration of dosage.

CONCLUSIONS

Anticonvulsants appear to be well tolerated in these patients. The younger age of those receiving anticonvulsants is inadequately explained by the characteristics of the patient cohort and may reflect a shift towards a younger age in patients requiring anticonvulsants due to increased mortality in this group.

Benefits of treating hypertension in the elderly: should age affect treatment decisions?

Do the benefits of treating hypertension extend equally to all age groups, particularly the very elderly? Several large controlled trials have been published in recent years that confirm the benefits of the treatment of hypertension in terms of morbidity and mortality. However, these trials included only relatively small numbers of patients aged > or = 80 years. Data regarding such patients have been extracted and subjected to meta-analysis, but with inconclusive results. Further difficulties arise as a result of the range of therapeutic agents employed. Therefore, uncertainty still surrounds the value of treating very elderly patients with hypertension. The J-curve hypothesis, i.e. that a blood pressure threshold exists below which there is an increase in the rate of cardiac events, has been a concern in treating elderly patients. Upon close examination, this appears to be spurious. The Hypertension in the Very Elderly Trial study sets out to provide conclusive evidence for the benefits or otherwise of treating hypertension in the very elderly and has just commenced. The results of this trial will not be available for some time. In the meantime, should physicians initiate or continue treatment for very elderly individuals with hypertension? If so, what regimens should be employed and should target blood pressure levels be set? At the present time, it would appear sensible to provide treatment for very elderly patients with hypertension, particularly those with evidence of complications or target organ damage. In relatively healthy individuals with mild-to-moderate hypertension, the guiding principle should be 'the lower the blood pressure the better'. Regarding the choice of therapeutic agent, a low-dose diuretic remains the first choice therapy.

Motor block in regional anaesthesia. Quantification by muscle strength at the ankle joint

A device based on a load cell was constructed to measure the strength of foot dorsiflexion and plantarflexion. Performance of the device was evaluated for both movements. The influence of foot position within the device, its use over a 30-min period at 30-s intervals and the effect of the removal and reapplication of the device on measured force of dorsiflexion and plantarflexion was studied in six volunteers. Both dorsiflexion and plantarflexion are suitable movements on which to base a device to quantify the density of motor block during the onset and offset of neuraxial block. Dorsiflexion has a number of advantages: muscle strength is independent of knee position, and therefore a below-knee device can be constructed; strength of dorsiflexion is less affected by the foot position; we found the device easier to apply using dorsiflexion as the heel tended to self-locate; innervation of the muscles responsible for dorsiflexion involves fewer spinal segments.

Tsl and LP-BM5: a comparison of two murine retrovirus models for HIV

The ts1 murine leukemia virus produces an immunodeficiency state in mice that parallels human immunodeficiency virus (HIV) infection in humans. Other murine leukemia viruses, such as LP-BM5 used in the murine acquired immune deficiency virus (MAIDS) model, have been studied extensively as a small animal model for HIV research, but lack many key similarities to HIV. Mice infected with ts1, however, utilize CD4 target cells for infection, undergo neuronal loss and demyelination, and develop clinical immunodeficiency. These features make this retrovirus in many ways an ideal candidate for a small animal model for HIV research. In this review article, the early development, the molecular and clinical pathogenesis of both the ts1 mutant of the Moloney murine leukemia virus and LP-BM5 are examined. Based on an extensive evaluation of the literature on LP-BM5 and ts1, it is concluded that the ts1 virus may serve as a better animal model to human retrovirus infection.

The efficacy of subsurface flow reed bed treatment in the removal of Campylobacter spp., faecal coliforms and Escherichia coli from poultry litter

The use of poultry waste as a fertiliser on arable land is an accepted method of waste treatment. However, run-off from such practices may result in contamination of the watercourse by human pathogens. In this study the effectiveness of using constructed wetlands as an alternative treatment for poultry manure waste was evaluated. Enumeration of Campylobacter spp., Escherichia coli, total coliforms and total aerobes were carried out on influent and effluent samples from reed beds loaded with poultry waste. For both sequential loading and continuous loading there was a statistically significant mean log reduction of 3.56 and 4.25 for E. coli, 3.2 and 3.88 for coliforms, 3.85 and 4.2 for total aerobic counts and 3.13 and 2.96 for Campylobacter spp., respectively. This method, which has been previously recognised as cost-effective and environmentally acceptable, provides an efficient method for reducing numbers of these bacteria in poultry waste and therefore an effective alternative treatment for such waste or waters containing run off from land previously spread with poultry manure.

Use of complementary and alternative therapies in HIV-infected patients

The use of complementary and alternative medicine (CAM) therapies is widespread in many chronic illnesses, including human immunodeficiency virus (HIV) infection. The objective of this study was to determine the impact of increasingly effective antiretroviral therapy on the use of CAM in an HIV-positive patient population. A written survey was given to 191 HIV-positive outpatients. Participation was voluntary and anonymous. One hundred twenty-eight patients (67%) used CAM at some time to control HIV and 76 (40%) of the patients were currently using CAM. The major forms of CAM used were exercise (43%), lifestyle changes (38%), dietary supplements (37%), counseling (27%), herbal medications (26%), megavitamins (24%), and prayer therapy (24%). One hundred forty-one patients (74%) used a protease inhibitor medication, 28 (15%) used a protease inhibitor sparing regime, and 22 (11%) had no current or prior antiretroviral use. Eighty-two (43%) patients indicated that their doctor knew they used CAM and 56 patients (29%) received their information about CAM from a doctor or other health care professional. Of 128 patients who used CAM, 90 (70%) felt CAM improved their quality of life. Income of $15,000 or more per year and discontinuation of medications by patients for any reason in the past were the best predicators of CAM use for patients in general and also those on protease inhibitor therapy. CD(4) count, educational status, year of HIV diagnosis, and martial status were not effective predictors of CAM use. Use of CAM remains widespread among patients with HIV infection even with the availability of effective, yet noncurative antiretroviral therapy and does not correlate with type of antiretroviral therapy used or clinical status.

Colorectal cancer screening:potential pitfalls

The National Health and Medical Research Council has recently issued guidelines on colo-rectal cancer, and givensignificant support to Colorectal Cancer Screening. However, the evidence of cost-effectiveness is inconclusiveaccording to the Cochrane Centre.I argue that it would be wise to undertake trials that are appropriately funded. Otherwise, there is a risk that muchmoney will be spent that cannot subsequently be justified.

Vaccine era measles in an adult

Measles should be included in the differential diagnosis of patients with fever and the characteristic viral exanthem, even if a history of adequate immunization is obtained. We present the case of a 23-year-old white female who developed high fever (103 degrees F), brightly erythematous eruptions on the face, sore throat, dry cough, and myalgia 5 days after her return to the United States following a trip to Calcutta, India. The patient had extensive facial erythema from the hairline to the neck, but some areas beneath the chin were spared. Fine erythematous papules extended down the anterior neck, and white papules were seen on the buccal mucosa. The erythematous macules spread to the trunk and extremities, eventually becoming confluent and desquamating over a period of 1 week. Defervescence occurred with desquamation. Measles serology revealed the IgM antibody as positive and the IgG antibody as negative despite 2 measles, mumps, and rubella (MMR) vaccinations at ages 15 months and 7 years. Skin biopsy was consistent with viral infection.

Connective tissue growth factor: potential role in glomerulosclerosis and tubulointerstitial fibrosis

Transforming growth factor beta (TGF-beta) is a pivotal driver of glomerulosclerosis and tubulointerstitial fibrosis in renal diseases. Because TGF-beta also plays important anti-inflammatory and antiproliferative roles in mammalian systems, there has been a recent drive to elucidate downstream mediators of TGF-beta's pro-fibrotic effects with the ultimate goal of developing new anti-fibrotic strategies for treatment of chronic diseases. Connective tissue growth factor (CTGF) belongs to the CCN family of immediate early response genes. Several lines of evidence suggest that CTGF is an important pro-fibrotic molecule in renal disease and that CTGF contributes to TGF-beta bioactivity in this setting. CTGF expression is increased in the glomeruli and tubulointerstium in a variety of renal disease in association with scarring and sclerosis of renal parenchyma. In model systems in vitro, mesangial cell CTGF expression is induced by high extracellular glucose, cyclic mechanical strain and TGF-beta. Recombinant human CTGF augments the production of fibronectin and type IV collagen by mesangial cells and the effects of high glucose on mesangial cell CTGF expression and matrix production are attenuated, in part, by anti-TGF-beta antibody. In aggregate, these observations identify CTGF as an attractive therapeutic target in fibrotic renal diseases.

Reproductive issues in HIV-seropositive women: a survey regarding counseling, contraception, safer sex, and pregnancy choices

Sixty-nine HIV-seropositive women were surveyed with regard to the reproductive counseling they had received, contraception, safer sex practices, pregnancy histories, and pregnancy plans. Of the women surveyed, 84% and 90%, respectively, felt that they had access to the birth control and safer sex methods of their choice. Less than half felt that their physician had adequately counseled them about birth control. Women primarily cited social workers (46.4%) or nurses (34.8%) as the counseling source for birth control and safer sex. When informed about the reduced risk of vertical transmission with zidovudine (AZT), 33 women indicated that information regarding AZT would affect their future pregnancy decisions. Health care professionals need to be aware of this and counsel patients accordingly.

Renal-dose (low-dose) dopamine for the treatment of sepsis-related and other forms of acute renal failure: ineffective and probably dangerous

1. Low-dose ('renal-dose') dopamine (i.e. 1-3 micrograms/kg per min) is used widely for the treatment of acute renal failure induced by ischaemia, toxins and/or sepsis. Here we review the scientific rationale, experimental studies and clinical trials evaluating its use in these settings. 2. Renal-dose dopamine augments renal blood flow, sodium excretion and probably glomerular filtration rate in healthy humans and experimental animals and limits ATP utilization and oxygen requirements in nephron segments at risk of ischaemic injury. Renal-dose dopamine is renoprotective in several ischaemic and nephrotoxic models of acute renal failure. 3. However, most studies in humans have not demonstrated prevention of acute renal failure in high-risk patients or improved outcome in those with established acute renal failure. While the safety profile of dopamine in these settings has not been extensively defined, it is known the drug may precipitate serious cardiovascular and metabolic complications in the critically ill. Therefore, we suggest that renal-dose dopamine should not be used for selective renal vasodilatory and natriuretic actions in those patients with acute renal failure until its efficacy is established in randomized control trials. 4. Renal-dose dopamine may be most valuable when combined with agents targeting other events in acute renal failure, such as cast formation, epithelial cell injury and tubule regeneration. These recommendations should not preclude the use of dopamine for its systemic effects in heart failure and septic shock.

Systolic Hypertension in Europe (Syst-Eur) trial phase 2: objectives, protocol, and initial progress. Systolic Hypertension in Europe Investigators

The Systolic Hypertension in Europe (Syst-Eur) trial proved that blood pressure (BP) lowering therapy starting with nitrendipine reduces the risk of cardiovascular complications in older (> or = 60 years) patients with isolated systolic hypertension (systolic BP > or = 160 mm Hg and diastolic BP < 95 mm Hg). After the completion of the Syst-Eur trial on 14 February 1997, 3506 consenting patients (93.0% of those eligible) were enrolled in phase 2 of the Syst-Eur trial. This open follow-up study aims to confirm the safety of long-term antihypertensive therapy based on a dihydropyridine. To lower the sitting systolic BP below 150 mm Hg (target BP), the first-line agent nitrendipine (10-40 mg/day) may be associated with enalapril (5-20 mg/day), hydrochlorothiazide (12.5-25 mg/day), both add-on study drugs, or if required any other antihypertensive agent. On 1 November 1998, 3248 patients were still being followed, 86 patients had proceeded to non-supervised follow-up, and 43 had died. The median follow-up in Syst-Eur 2 was 14.3 months. At the last available visit, systolic/diastolic BP in the patients formerly randomised to placebo (n = 1682) or active treatment (n = 1824), had decreased by 13.2/5.2 mm Hg and by 4.6/1.6 mm Hg, respectively, so that the between-group BP difference was 1.7 mm Hg systolic (95% Ci: 0.8 to 2.6 mm Hg; P < 0.001) and 0.9 mm Hg diastolic (95% Cl: 0.4 to 1.5 mm mm Hg; P < 0.001). At the beginning of Syst-Eur 2, the goal BP was reached by 25.4% and 50.6% of the former placebo and active-treatment groups; at the last visit these proportions were 55.9% and 63.1%, respectively. At that moment, 45.9% of the patients were on monotherapy with nitrendipine, 29.3% took nitrendipine in combination with other study drugs. Until the end of 2001, BP control of the Syst-Eur 2 patients will be further improved. Cardiovascular complications and adverse events, such as cancer or gastro-intestinal bleeding, will be monitored and validated by blinded experts.

Molecular and pathologic characterization of an AIDS-related body cavity-based lymphoma, including ultrastructural demonstration of human herpesvirus-8: a case report

Body cavity-based lymphoma, also known as primary effusion lymphoma, is a newly recognized acquired immunodeficiency syndrome (AIDS)-related lymphoma that has been linked to the Kaposi's sarcoma-associated herpesvirus (KSHV/HHV-8). To date, direct visualization of the virus in a clinical sample has not been demonstrated. We have performed an extensive clinical, histologic, immunophenotypic, ultrastructural, and molecular genetic correlative study on multiple tissue samples obtained premortem and at autopsy from an patient with AIDS with Kaposi's sarcoma and body cavity-based lymphomas. We demonstrate the presence of human herpesvirus-8 in a primary clinical sample at the ultrastructural and molecular level, as well as document multiple lymphomatous tumor masses at autopsy.

Response to dehydration in elderly patients in long-term care

Elderly patients in long-term care have a high plasma osmolality (pOSM) and associated increased mortality. In these patients, we examined pOSM, thirst (visual analogue scale, VAS) and arginine vasopressin (AVP) response to 16-hour dehydration and 2-hour rehydration. Twelve patients were randomly divided into two groups (A & B). Group A had their fluid balance monitored for two weeks, group B did not. Single measurements of VAS, pOSM and AVP were conducted on days 0, 7 and 13. Dehydration tests were conducted in both groups at the start of the study (DAY 1), and at the end of the two-week period (DAY 14). There were no significant differences between group A and B, so the results are presented for the two groups combined. There was a significant increase in both pOSM and VAS during dehydration, and a significant fall in both variables during rehydration [F (9,99) = 18.69, p < 0.001, and F(9,99) = 11.25, p < 0.001, respectively]. Plasma AVP did not change significantly during either dehydration or rehydration [F (9,99) = 0.59, p = 0.8]. There were no significant differences in response for any of the three variables between DAY 1 and DAY 14. We conclude that elderly patients in long-term care exhibit changes in thirst and osmolality during dehydration and rehydration, and that these responses are reproducible. The lack of a significant AVP response requires further investigation.

Treatment of hypertension in the elderly

Hypertension is present in over 50% of elderly patients and constitutes a major risk factor for cardiovascular morbidity and mortality. This paper reviews the rationale for treating hypertension in the elderly, discusses the choice of antihypertensive therapy and optimal target blood pressure, and summarizes ongoing clinical trials. The major questions that remain to be answered are the optimal level of blood pressure reduction in the elderly and the long-term efficacy and safety of newer antihypertensive agents compared with diuretics and beta-blockers.