Isolation of Toxoplasma gondii in cell culture: an alternative to bioassay

Toxoplasma gondii is an apicomplexan protozoan parasite that can infect mammals and birds. The infection can cause acute toxoplasmosis and death in susceptible hosts. Bioassay using cats and mice has been the standard for the isolation of T. gondii from infected hosts for the past several decades. However, bioassay is labor-intensive, expensive, and involves using laboratory animals. To search alternative approaches and o work towards replacement of animal experiments, we summarized the key literature and conducted four experiments to isolate T. gondii in vitro by cell culture. A few heart tissue samples from animals with the highest antibody titers in a given collection were used for T. gondii isolation. These experiments included samples from five out of 51 wild ducks, four of 46 wild turkeys, six of 24 white-tailed deer, as well as from six kangaroos that had died with acute toxoplasmosis in a zoo. These experiments resulted in three isolates from five chronically infected wild ducks (60%), four isolates from four chronically infected wild turkeys (100%), one isolate from six chronically infected white-tailed deer (17%), and four isolates from six kangaroos with acute toxoplasmosis (67%). In addition, five isolates from the five chronically infected wild ducks were obtained by bioassay in mice, showing a 100% success rate, which is higher than the 60% rate by direct cell culture. These T. gondii isolates were successfully propagated in human foreskin fibroblast (HFF) or Vero cells, and genotyped by multilocus PCR-RFLP markers. The results showed that it is practical to isolate T. gondii directly in cell culture. Although the cell culture approach may not be as sensitive as the bioassay, it does provide an alternative that is simple, cost-effective, ethically more acceptable, and less time-sensitive to isolate T. gondii. In this paper we propose a procedure that may be applied and further optimized for isolation of T. gondii.

Obesity Is Associated with Altered Rectal Sensitivity in Chronic Constipation

BACKGROUND

Defecation dysfunction may contribute to chronic constipation (CC), but the impact of obesity on anorectal physiology in CC remains unclear. We aimed to evaluate the relationship between obesity and anorectal function on physiologic testing in patients presenting with CC.

METHODS

This was a retrospective cohort study of consecutive adults who underwent high resolution anorectal manometry (HRAM) at a tertiary center for CC. Patient demographics, clinical history, surgical/obstetric history, medications, and HRAM results were reviewed. Patients were classified into obese (BMI > 30 kg/m2) vs non-obese (BMI < 30 kg/m2) groups at the time of HRAM. Fisher-exact/student t-test for univariate analyses and general linear regression for multivariable analysis were performed.

RESULTS

383 adults (mean 50.3 years; 85.8% female) with CC were included. On HRAM, patients with obesity had lower anal sphincter resting tone (37.3 vs 48.5 mmHg, p = 0.005) and maximum squeeze pressure (104.8 mmHg vs 120.0 mmHg, p = 0.043). No significant differences in dyssynergia (61% vs 53%, p = 0.294) and failed balloon expulsion (18% vs 25%, p = 0.381) were found between obese and non-obese groups. On balloon distention testing, the maximum tolerated (163.5 vs 147.6 mL, p = 0.042) and urge sensation (113.9 vs 103.7 mL, p = 0.048) volumes were significantly increased among patients with obesity. After adjusting for potential confounders, obesity remained independently associated with increased maximum tolerated volume (β-coefficient 13.7, p = 0.049).

CONCLUSION

Obesity was independently associated with altered rectal sensitivity among patients with CC. Altered rectal sensation may play an important role in CC among patients with obesity. Anorectal physiology testing should be considered to understand the pathophysiology and guide management.

Universal Constraints on Linguistic Event Categories: A Cross-Cultural Study of Child Homesign

Languages carve up conceptual space in varying ways-for example, English uses the verb cut both for cutting with a knife and for cutting with scissors, but other languages use distinct verbs for these events. We asked whether, despite this variability, there are universal constraints on how languages categorize events involving tools (e.g., knife-cutting). We analyzed descriptions of tool events from two groups: (a) 43 hearing adult speakers of English, Spanish, and Chinese and (b) 10 deaf child homesigners ages 3 to 11 (each of whom has created a gestural language without input from a conventional language model) in five different countries (Guatemala, Nicaragua, United States, Taiwan, Turkey). We found alignment across these two groups-events that elicited tool-prominent language among the spoken-language users also elicited tool-prominent language among the homesigners. These results suggest ways of conceptualizing tool events that are so prominent as to constitute a universal constraint on how events are categorized in language.

Prospective evaluation of an emergency department protocol to prevent hospitalization in mild acute pancreatitis: Outcomes and predictors of discharge

BACKGROUND

While acute pancreatitis (AP) contributes significantly to hospitalizations and costs, most cases are mild with minimal complications. In 2016, we piloted an observation pathway in the emergency department (ED) for mild AP and showed reduced admissions and length of stay (LOS) without increased readmissions or mortality. After 5 years of implementation, we evaluated outcomes of the ED pathway and identified predictors of successful discharge.

METHODS

We reviewed a prospectively enrolled cohort of patients with mild AP presenting to a tertiary care center ED between 10/2016 and 9/2021, evaluating LOS, charges, imaging, and 30-day readmission, and assessed predictors of successful ED discharge. Patients were divided into two main groups: successfully discharged via the ED pathway ("ED cohort") and admitted to the hospital ("admission cohort"), with subgroups to compare outcomes, and multivariate analysis to determine predictors of discharge.

RESULTS

Of 619 AP patients, 419 had mild AP (109 ED cohort, 310 admission cohort). The ED cohort was younger (age 49.3 vs 56.3,p < 0.001), had lower Charlson Comorbidity Index (CCI) (1.30 vs 2.43, p < 0.001), shorter LOS (12.3 h vs 116 h, p < 0.001), lower charges (mean $6768 vs $19886, p < 0.001) and less imaging, without differences in 30-day readmissions. Increasing age (OR: 0.97; p < 0.001), increasing CCI (OR: 0.75; p < 0.001) and biliary AP (OR: 0.10; p < 0.001) were associated with decreased ED discharge, while idiopathic AP had increased ED discharge (OR: 7.8; p < 0.001).

CONCLUSIONS

After appropriate triage, patients with mild AP (age <50, CCI <2, idiopathic AP) can safely discharge from the ED with improved outcomes and cost savings.

Acquisition of turn-taking in sign language conversations: An overview of language modality and turn structure

The task of transitioning from one interlocutor to another in conversation – taking turns – is a complex social process, but typically transpires rapidly and without incident in conversations between adults. Cross-linguistic similarities in turn timing and turn structure have led researchers to suggest that it is a core antecedent to human language and a primary driver of an innate “interaction engine.” This review focuses on studies that have tested the extent of turn timing and turn structure patterns in two areas: across language modalities and in early language development. Taken together, these two lines of research offer predictions about the development of turn-taking for children who are deaf or hard of hearing (DHH) acquiring sign languages. We introduce considerations unique to signed language development – namely the heterogenous ecologies in which signed language acquisition occurs, suggesting that more work is needed to account for the diverse circumstances of language acquisition for DHH children. We discuss differences between early sign language acquisition at home compared to later sign language acquisition at school in classroom settings, particularly in countries with national sign languages. We also compare acquisition in these settings to communities without a national sign language where DHH children acquire local sign languages. In particular, we encourage more documentation of naturalistic conversations between DHH children who sign and their caregivers, teachers, and peers. Further, we suggest that future studies should consider: visual/manual cues to turn-taking and whether they are the same or different for child or adult learners; the protracted time-course of turn-taking development in childhood, in spite of the presence of turn-taking abilities early in development; and the unique demands of language development in multi-party conversations that happen in settings like classrooms for older children versus language development at home in dyadic interactions.

The communicative importance of agent-backgrounding: Evidence from homesign and Nicaraguan Sign Language

Some concepts are more essential for human communication than others. In this paper, we investigate whether the concept of agent-backgrounding is sufficiently important for communication that linguistic structures for encoding this concept are present in young sign languages. Agent-backgrounding constructions serve to reduce the prominence of the agent - the English passive sentence a book was knocked over is an example. Although these constructions are widely attested cross-linguistically, there is little prior research on the emergence of such devices in new languages. Here we studied how agent-backgrounding constructions emerge in Nicaraguan Sign Language (NSL) and adult homesign systems. We found that NSL signers have innovated both lexical and morphological devices for expressing agent-backgrounding, indicating that conveying a flexible perspective on events has deep communicative value. At the same time, agent-backgrounding devices did not emerge at the same time as agentive devices. This result suggests that agent-backgrounding does not have the same core cognitive status as agency. The emergence of agent-backgrounding morphology appears to depend on receiving a linguistic system as input in which linguistic devices for expressing agency are already well-established.

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center

BACKGROUND

Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality.

RESULTS

Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race.

CONCLUSIONS

Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.

Regression of Peripheral Subclinical Enthesopathy in Therapy-Naive Patients Treated With Ustekinumab for Moderate-to-Severe Chronic Plaque Psoriasis: A Fifty-Two-Week, Prospective, Open-Label Feasibility Study

OBJECTIVE

To investigate whether sonographically determined subclinical enthesopathy in patients with moderate-to-severe psoriasis regresses with the use of ustekinumab therapy for skin disease.

METHODS

Seventy-three patients with moderate-to-severe psoriasis, who were not treated with systemic therapy and did not have symptoms of psoriatic arthritis (PsA), and 23 healthy volunteers were screened by ultrasound for subclinical enthesitis. Subsequently, 23 patients with psoriasis whose ultrasound results showed inflammatory changes were treated with ustekinumab for 52 weeks. The evolution of sonographic abnormalities of the upper and lower limb entheses was assessed using an extensive gray-scale and power Doppler (PD) ultrasound protocol at weeks 0, 12, 24, and 52. For each parameter, a gray-scale or PD ultrasound score of >0 was determined to be abnormal, and a summative score based on the Glasgow Ultrasound Enthesitis Scoring System was calculated.

RESULTS

Of all the patients with psoriasis screened using ultrasound, 49.3% had at least 1 inflammatory entheseal abnormality. Mean ± SD inflammation scores were higher in the patients with psoriasis compared with the healthy volunteers (9.9 ± 6.6 versus 1.0 ± 1.4). With treatment, the mean inflammation scores decreased significantly by 42.2% from week 0 to week 24 (-4.2 [95% confidence interval -6.3, -2.1]; P < 0.001) and by 47.5% by week 42 (-4.7 [95% confidence interval -7.1, -2.3]; P = 0.001). Entheseal structural abnormalities did not change significantly during treatment.

CONCLUSION

Within 12 weeks of treatment, interleukin-12 (IL-12)/IL-23 inhibition for psoriasis appears to suppress subclinical enthesopathy, and the suppression is maintained through week 52. Further longitudinal studies are needed to determine whether therapy initiated for skin disease may prevent the development of PsA.

Calibration of neutron detectors on the Joint European Torus

The present paper describes the findings of the calibration of the neutron yield monitors on the Joint European Torus (JET) performed in 2013 using a ²⁵²Cf source deployed inside the torus by the remote handling system, with particular regard to the calibration of fission chambers which provide the time resolved neutron yield from JET plasmas. The experimental data obtained in toroidal, radial, and vertical scans are presented. These data are first analysed following an analytical approach adopted in the previous neutron calibrations at JET. In this way, a calibration function for the volumetric plasma source is derived which allows us to understand the importance of the different plasma regions and of different spatial profiles of neutron emissivity on fission chamber response. Neutronics analyses have also been performed to calculate the correction factors needed to derive the plasma calibration factors taking into account the different energy spectrum and angular emission distribution of the calibrating (point) ²⁵²Cf source, the discrete positions compared to the plasma volumetric source, and the calibration circumstances. All correction factors are presented and discussed. We discuss also the lessons learnt which are the basis for the on-going 14 MeV neutron calibration at JET and for ITER.

Development and assessment of inter- and intra-rater reliability of a novel ultrasound tool for scoring tendon and sheath disease - A pilot study

BACKGROUND

Tendon and synovial sheath disease is common. A method of monitoring the status of tendons and sheaths is important for both diagnosis of pathology and evaluation of the efficacy of treatments. For this study, an ultrasound scoring tool was developed and its reliability tested between raters. The tool is novel in that it scores tendons and sheaths separately, an important consideration since disorders of these structures are not necessarily concurrent.

METHODS

Thirty diseased tendons and sheaths were included in this pilot cross-sectional study. Tendon and sheath measurements were taken and the semi-quantitative five-grade score was applied to assess tendon greyscale, tendon Doppler activity and sheath Doppler activity. Inter-rater and intra-rater agreement exercises were undertaken to test the reliability of the scoring tool.

RESULTS

The Intra-class Correlation Coefficient values for both the inter-rater and intra-rater reliability tests showed excellent agreement for the tendon and sheath measurements. Unweighted kappa estimations for inter-rater scores showed excellent agreement for tendon Doppler; good agreement was shown for scoring sheath Doppler, while poor agreement was shown for tendon grey-scale scoring. The intra-rater reliability scores demonstrated similar results.

CONCLUSION

Overall, the study strongly supports the use of this scoring tool for the diagnosis and follow-up of tendon and sheath disorders. The results may be used as a starting point from which to base further work in this important area. Future studies should address the limitations found in this research with a strong focus on improving tendon grey-scale measurement accuracy and agreement.

Ultrasound and magnetic resonance imaging assessment of joint disease in symptomatic patients with cystic fibrosis arthropathy

OBJECTIVES

Cystic fibrosis arthropathy (CFA) is a term commonly used for joint pain with and without swelling seen in some patients with CF. Early studies into CFA focused on the presence of rheumatoid factor and immunological changes on synovial biopsy, with parallels drawn between respiratory and joint activity. Identification of anti-cyclic citrullinated peptide antibodies (anti-CCP) as a marker of rheumatoid arthritis (RA), along with increased access to sensitive imaging techniques including ultrasound (US) and magnetic resonance imaging (MRI), offer great potential to investigate and more accurately understand the type(s) of inflammatory arthritis that may underlie CFA. The aim of this study was to phenotype an active CFA cohort using serology and imaging, as a basis for further work in this understudied area.

METHODS

This was a prospective observational cohort study of symptomatic CFA patients presenting with joint pain. Participants underwent serological testing, clinical and US joint and entheseal assessment, as well as MRI of the most symptomatic joint/joint area.

RESULTS

Ten symptomatic patients were studied with 9/10 having positive clinical findings. Inflammatory changes on US were seen in 8/10 cases. Five patients had positive findings on MRI (3 of whom had received IV gadolinium contrast). This included patients with significant erosive changes. One patient was anti-CCP positive suggestive of RA, and two were anti-nuclear antibody positive.

CONCLUSION

Imaging, and to a lesser extent serology, identified inflammatory joint pathology in a proportion of cases, providing important data to explore in a large CFA cohort examining the clinical and imaging phenotype of this group.

Forging a morphological system out of two dimensions: Agentivity and number

Languages have diverse strategies for marking agentivity and number. These strategies are negotiated to create combinatorial systems. We consider the emergence of these strategies by studying features of movement in a young sign language in Nicaragua (NSL). We compare two age cohorts of Nicaraguan signers (NSL1 and NSL2), adult homesigners in Nicaragua (deaf individuals creating a gestural system without linguistic input), signers of American and Italian Sign Languages (ASL and LIS), and hearing individuals asked to gesture silently. We find that all groups use movement axis and repetition to encode agentivity and number, suggesting that these properties are grounded in action experiences common to all participants. We find another feature - unpunctuated repetition - in the sign systems (ASL, LIS, NSL, Homesign) but not in silent gesture. Homesigners and NSL1 signers use the unpunctuated form, but limit its use to No-Agent contexts; NSL2 signers use the form across No-Agent and Agent contexts. A single individual can thus construct a marker for number without benefit of a linguistic community (homesign), but generalizing this form across agentive conditions requires an additional step. This step does not appear to be achieved when a linguistic community is first formed (NSL1), but requires transmission across generations of learners (NSL2).

Ibrutinib inhibits collagen-mediated but not ADP-mediated platelet aggregation

The BTK (Bruton's tyrosine kinase) inhibitor ibrutinib is associated with an increased risk of bleeding. A previous study reported defects in collagen- and adenosine diphosphate (ADP)-dependent platelet responses when ibrutinib was added ex vivo to patient samples. Whereas the collagen defect is expected given the central role of BTK in glycoprotein VI signaling, the ADP defect lacks a mechanistic explanation. In order to determine the real-life consequences of BTK platelet blockade, we performed light transmission aggregometry in 23 patients receiving ibrutinib treatment. All patients had reductions in collagen-mediated platelet aggregation, with a significant association between the degree of inhibition and the occurrence of clinical bleeding or bruising (P=0.044). This collagen defect was reversible on drug cessation. In contrast to the previous ex vivo report, we found no in vivo ADP defects in subjects receiving standard doses of ibrutinib. These results establish platelet light transmission aggregometry as a method for gauging, at least qualitatively, the severity of platelet impairment in patients receiving ibrutinib treatment.

Watching language grow in the manual modality: nominals, predicates, and handshapes

All languages, both spoken and signed, make a formal distinction between two types of terms in a proposition--terms that identify what is to be talked about (nominals) and terms that say something about this topic (predicates). Here we explore conditions that could lead to this property by charting its development in a newly emerging language--Nicaraguan Sign Language (NSL). We examine how handshape is used in nominals vs. predicates in three Nicaraguan groups: (1) homesigners who are not part of the Deaf community and use their own gestures, called homesigns, to communicate; (2) NSL cohort 1 signers who fashioned the first stage of NSL; (3) NSL cohort 2 signers who learned NSL from cohort 1. We compare these three groups to a fourth: (4) native signers of American Sign Language (ASL), an established sign language. We focus on handshape in predicates that are part of a productive classifier system in ASL; handshape in these predicates varies systematically across agent vs. no-agent contexts, unlike handshape in the nominals we study, which does not vary across these contexts. We found that all four groups, including homesigners, used handshape differently in nominals vs. predicates--they displayed variability in handshape form across agent vs. no-agent contexts in predicates, but not in nominals. Variability thus differed in predicates and nominals: (1) In predicates, the variability across grammatical contexts (agent vs. no-agent) was systematic in all four groups, suggesting that handshape functioned as a productive morphological marker on predicate signs, even in homesign. This grammatical use of handshape can thus appear in the earliest stages of an emerging language. (2) In nominals, there was no variability across grammatical contexts (agent vs. no-agent), but there was variability within- and across-individuals in the handshape used in the nominal for a particular object. This variability was striking in homesigners (an individual homesigner did not necessarily use the same handshape in every nominal he produced for a particular object), but decreased in the first cohort of NSL and remained relatively constant in the second cohort. Stability in the lexical use of handshape in nominals thus does not seem to emerge unless there is pressure from a peer linguistic community. Taken together, our findings argue that a community of users is essential to arrive at a stable nominal lexicon, but not to establish a productive morphological marker in predicates. Examining the steps a manual communication system takes as it moves toward becoming a fully-fledged language offers a unique window onto factors that have made human language what it is.

Comprehensive assessment of alcohol-related brain damage (ARBD): gap or chasm in the evidence?

Alcohol-related brain damage (ARBD) causes a broad range of both neurological and neurocognitive impairment. Mental health nurses are required to provide programmes designed to facilitate individuals with chronic alcohol dependency to radically change their drinking behaviour, invariably with an abstinence focus. No evidence that related to the nutritional and physical intervention needs of this group was found. Most instruments used to access domains relevant to ARBD in terms of providing a comprehensive assessment have not been validated in this group. Alcohol-related brain damage (ARBD) is primarily caused by chronic alcohol misuse and thiamine deficiency, and results in a broad range of impairments. Despite the increasing incidence of ARBD in the UK in recent decades, it is currently underdiagnosed, managed inappropriately and treated inadequately. Moreover, information about assessments for individuals with ARBD is currently absent from clinical guidelines and policy documents. The aim of this paper was to review the evidence relating to the neurological, neuropsychological, psychosocial, physical and nutritional assessment of individuals with ARBD to identify appropriate assessment tools that could be used to measure and monitor the impact of ARBD over time. A systematic online database search revealed a total of 160 separate references, 133 of which were rejected and two of which could not be accessed. Twenty-five papers were included in the review, including six neuroimaging studies, 17 neuropsychological studies and two studies using psychosocial methods of assessment. A lack of evidence for nutritional and physical assessment of individuals with ARBD was found. The review findings are inconclusive; most instruments currently used in ARBD research have not specifically been validated for use within an ARBD context. Further research is required to identify comprehensive methods of ARBD assessment.

Tomographic analysis of neutron and gamma pulse shape distributions from liquid scintillation detectors at Joint European Torus

The Joint European Torus (JET, Culham, UK) is the largest tokamak in the world devoted to nuclear fusion experiments of magnetic confined Deuterium (D)/Deuterium-Tritium (DT) plasmas. Neutrons produced in these plasmas are measured using various types of neutron detectors and spectrometers. Two of these instruments on JET make use of organic liquid scintillator detectors. The neutron emission profile monitor implements 19 liquid scintillation counters to detect the 2.45 MeV neutron emission from D plasmas. A new compact neutron spectrometer is operational at JET since 2010 to measure the neutron energy spectra from both D and DT plasmas. Liquid scintillation detectors are sensitive to both neutron and gamma radiation but give light responses of different decay time such that pulse shape discrimination techniques can be applied to identify the neutron contribution of interest from the data. The most common technique consists of integrating the radiation pulse shapes within different ranges of their rising and/or trailing edges. In this article, a step forward in this type of analysis is presented. The method applies a tomographic analysis of the 3-dimensional neutron and gamma pulse shape and pulse height distribution data obtained from liquid scintillation detectors such that n/γ discrimination can be improved to lower energies and additional information can be gained on neutron contributions to the gamma events and vice versa.

Value of ultrasound in rheumatologic diseases

The use of musculoskeletal ultrasound in rheumatology clinical practice has rapidly increased over the past decade. Ultrasound has enabled rheumatologists to diagnose, prognosticate and monitor disease outcome. Although international standardization remains a concern still, the use of ultrasound in rheumatology is expected to grow further as costs fall and the opportunity to train in the technique improves. We present a review of value of ultrasound, focusing on major applications of ultrasound in rheumatologic diseases.

Using a Ludic Simulation to Make Learning of Middle School Space Science Fun

In this paper, the authors describe a ludic simulation designed for middle school space science and examine its use to support students’ learning and motivation. The participants were 383 sixth graders and 447 seventh graders. The findings of this study showed that sixth- and seventh-graders perceived the simulation as having substantial ludic characteristics and educational value. The results indicated that having a playful experience is important for this age group and that participating in a ludic simulation can help motivate students to learn school subjects. Results also indicated that incorporating ludus into the learning experience can improve students’ attitudes toward the subject matter. Implications of policy, research, and practice with regard to using ludic simulations to support classroom-based learning were discussed.

Development of a mirror-based endoscope for divertor spectroscopy on JET with the new ITER-like wall (invited)

A new endoscope with optimised divertor view has been developed in order to survey and monitor the emission of specific impurities such as tungsten and the remaining carbon as well as beryllium in the tungsten divertor of JET after the implementation of the ITER-like wall in 2011. The endoscope is a prototype for testing an ITER relevant design concept based on reflective optics only. It may be subject to high neutron fluxes as expected in ITER. The operating wavelength range, from 390 nm to 2500 nm, allows the measurements of the emission of all expected impurities (W I, Be II, C I, C II, C III) with high optical transmittance (≥ 30% in the designed wavelength range) as well as high spatial resolution that is ≤ 2 mm at the object plane and ≤ 3 mm for the full depth of field (± 0.7 m). The new optical design includes options for in situ calibration of the endoscope transmittance during the experimental campaign, which allows the continuous tracing of possible transmittance degradation with time due to impurity deposition and erosion by fast neutral particles. In parallel to the new optical design, a new type of possibly ITER relevant shutter system based on pneumatic techniques has been developed and integrated into the endoscope head. The endoscope is equipped with four digital CCD cameras, each combined with two filter wheels for narrow band interference and neutral density filters. Additionally, two protection cameras in the λ > 0.95 μm range have been integrated in the optical design for the real time wall protection during the plasma operation of JET.

High dose caffeine citrate for extubation of preterm infants: a randomised controlled trial

OBJECTIVE

To compare two dosing regimens for caffeine citrate in the periextubation period for neonates born at less than 30 weeks gestation in terms of successful extubation and adverse effects.

DESIGN

A multicentre, randomised, double blind, clinical trial.

SETTING

Four tertiary neonatal units within Australia.

PATIENTS

Infants born less than 30 weeks gestation ventilated for more than 48 hours.

INTERVENTIONS

Two dosing regimens of caffeine citrate (20 v 5 mg/kg/day) for periextubation management. Treatment started 24 hours before a planned extubation or within six hours of an unplanned extubation.

MAIN OUTCOME MEASURE

Failure to extubate within 48 hours of caffeine loading or reintubation and ventilation or doxapram within seven days of caffeine loading.

RESULTS

A total of 234 neonates were enrolled. A significant reduction in failure to extubate was shown for the 20 mg/kg/day dosing group (15.0% v 29.8%; relative risk 0.51; 95% confidence interval (CI) 0.31 to 0.85; number needed to treat 7 (95% CI 4 to 24)). A significant difference in duration of mechanical ventilation was shown for infants of less than 28 weeks gestation receiving the high dose of caffeine (mean (SD) days 14.4 (11.1) v 22.1 (17.1); p = 0.01). No difference in adverse effects was detected in terms of mortality, major neonatal morbidity, death, or severe disability or general quotient at 12 months.

CONCLUSIONS

This trial shows short term benefits for a 20 mg/kg/day dosing regimen of caffeine citrate for neonates born at less than 30 weeks gestation in the periextubation period, without evidence of harm in the first year of life.

Bms1p, a novel GTP-binding protein, and the related Tsr1p are required for distinct steps of 40S ribosome biogenesis in yeast

Bms1p and Tsr1p define a novel family of proteins required for synthesis of 40S ribosomal subunits in Saccharomyces cerevisiae. Both are essential and localize to the nucleolus. Tsr1p shares two extended regions of similarity with Bms1p, but the two proteins function at different steps in 40S ribosome maturation. Inactivation of Bms1p blocks at an early step, leading to disappearance of 20S and 18S rRNA precursors. Also, slight accumulation of an aberrant 23S product and significant 35S accumulation are observed, indicating that pre-rRNA processing at sites A0, A1, and A2 is inhibited. In contrast, depletion of Tsr1p results in accumulation of 20S rRNA. Because processing of 20S to 18S rRNA occurs in the cytoplasm, this suggests that Tsr1p is required for assembly of a transport- or maturation-competent particle or is specifically required for transport of 43S pre-ribosomal particles, but not 60S ribosome precursors, from the nucleus to the cytosol. Finally, Bms1p is a GTP-binding protein, the first found to function in ribosome assembly or rRNA processing.

Adapting the HCUP QIs for hospital use: the experience in New York State

BACKGROUND

The Agency for Healthcare Research and Quality developed the Healthcare Cost and Utilization Project (HCUP) quality indicators (QIs) in 1994. The Healthcare Association of New York State (HANYS; Albany), which represents more than 500 nonprofit and public hospitals, long-term care facilities, and home health care agencies, has adapted the HCUP QIs since 1997 to produce annual comparative reports for its member hospitals. Specifically designed for internal use, the reports have been well received and have drawn interest from other hospital associations and state health departments.

METHODS

The HCUP QIs were applied to the New York State hospital discharge abstract. A risk adjustment model was constructed for each complication measure. Measures of utilization and access to care were adjusted for differences in patient demographics and payer status by indirect standardization. Data are presented in graphic format. Each hospital receives its own report (in both paper copy and CD-ROM) with comparisons to statewide norms, regional averages, and peer group averages. Report prepared for hospital systems include data for each affiliated hospital.

CONCLUSIONS

When used appropriately, the HCUP QIs provide valuable information for individual hospitals to assess quality of care and target potential areas for improvement. The HCUP QIs also give hospitals a broad perspective to look beyond their own institutions and develop community-based quality improvement initiatives. Nevertheless, given the limitations that commonly exist with administrative databases and the lack of standard risk adjustment systems, the HCUP QIs are best used for internal purposes and not for public reporting.

Multiple pathways of prostate carcinogenesis analyzed by using cultured cells isolated from rats treated with N-methyl-N-nitrosourea and testosterone

Treatment of rats with N-methyl-N-nitrosourea (MNU) and testosterone results in a high incidence of metastasizing dorsolateral prostate tumors. In previous studies, a high frequency (> or = 70%) of a G35 --> A transition mutation at the second position of codon 12 of the Ki-ras oncogene was found in these tumors. This was confirmed in the study reported here, and the frequency of this mutation appeared similar in tumors induced in four different rat strains, regardless of differences in sensitivity among these strains to the induction of prostate cancers by MNU and testosterone: Wistar Furth (62% incidence of grossly visible prostate tumors) > Lobund Wistar (55%) > Fisher 344 (40%) > Copenhagen (37%). A method was developed to isolate and separately culture epithelial and stromal cells from these rat prostate carcinomas. Of 20 primary cell cultures established from histologically confirmed rat prostate carcinomas, 19 (95%) displayed one or more of the following characteristics: the Ki-ras mutation (17 of 20; 85%), anchorage-independent growth in soft agar at early passage (12 of 20; 60%), or tumorigenicity at later passage (eight of eight; 100%). One epithelial cell culture and all five stromal cell cultures established from prostate tumors had none of these characteristics. Epithelial cultures that had the Ki-ras mutation and grew in soft agar constitute the predominant genotype/phenotype (55%), cultures with the mutation that did not grow in soft agar were less frequent (30%), 10% of the cultures had neither characteristic, and only one grew in soft agar but did not have the mutation. These findings suggest that there are at least two and perhaps more different molecular pathways of prostate carcinogenesis in rats treated with MNU plus testosterone. Furthermore, these data suggest that these pathways and the mechanisms determining strain differences in sensitivity to prostate cancer induction are unrelated.

Effect of repeated doses of sucrose during heel stick procedure in preterm neonates

The purpose of this randomized clinical trial was to test the efficacy of repeated versus single dose sucrose to decrease pain from routine heel stick procedures in preterm neonates. Infants (n = 48) in the first week of life with a mean gestational age of 31 weeks received 0.05 ml of 24% sucrose solution or sterile water by mouth (1) 2 min prior to actual lancing of the heel; (2) just prior to lancing, and (3) 2 min after lancing. The single-dose group received sucrose for the first dose and water for the second and third dose; the repeated-dose group received sucrose three times, and the placebo group received only water. The Premature Infant Pain Profile (PIPP) scores were obtained for five 30-second blocks from lancing. Both sucrose groups had lower PIPP scores (single sucrose pain scores, 6.8-8.2, p = 0.07; repeated sucrose pain scores, 5.3-6. 2, p < 0.01) than water (pain scores 7.9-9.1), and in the last block, the repeated dose had lower scores than the single dose (6.2 vs. 8. 2, p < 0.05).

Developmental changes in response to heelstick in preterm infants: a prospective cohort study

Twenty-eight preterm infants of 28 weeks gestational age were observed four times over eight weeks in order to determine changes in their pain response. Both routine and sham heelstick procedures were used. Physiological (heart rate and oxygen saturations) and behavioural parameters (three upper facial actions) were used as outcomes. The responses to real heelstick were significantly greater than to sham heelstick for heart rate and all facial actions except one at 28 weeks gestational age, but not for oxygen saturation. The magnitude of response to both real and sham heelstick increased over time. Thus, the older the infant, the more robust and recognisable the response. Since even the youngest infants showed a differential response to pain, professionals caring for such infants need to be able to recognize their more subtle pain responses.

Chemiluminescent detection of DNA probes in forensic analysis

The conditions for hybridization and detection of enzyme-labeled probes have been optimized in our laboratory for use with oligonucleotides coupled to alkaline phosphatase. We have examined several enzyme-linked probe which are complimentary to commonly used variable number of tandem repeats (VNTR) loci to determine the feasibility of using chemiluminescence for routine application in forensic DNA analysis. It was found that a chemiluminescent detection system employing an alkaline phosphatase activated dioxetane in the presence of chemiluminescent enhancers provides a high degree of sensitivity in hybridization protocols with a significant savings in overall filter processing time. The chemiluminescent system achieved equal or greater sensitivity that observed for 32P-labeled probes in much shorter development times. Furthermore, a new chemiluminescent substrate, Lumi-Phos Plus, has recently been investigated and found to further decrease the filter development time for forensic assays.

Induction at high incidence of ductal prostate adenocarcinomas in NBL/Cr and Sprague-Dawley Hsd:SD rats treated with a combination of testosterone and estradiol-17 beta or diethylstilbestrol

This study determined the incidence of prostate adenocarcinoma following long-term treatment of NBL and Sprague-Dawley rats with estradiol-17 beta or diethylstilbestrol (DES) plus testosterone and it defined the origin of these tumors. NBL and Sprague-Dawley rats were treated with two Silastic tubing implants (i.d. 1.6 mm, o.d. 3.2 mm) containing a 2 cm long filling of testosterone and one implant containing a 1 cm long filling of estradiol-17 beta or DES. Control animals received empty implants. Treated animals were killed when moribund and controls were killed at 91 (NBL) or 75 (Sprague-Dawley) weeks after initiation of treatment and accessory sex glands were sampled for histopathological examination of multiple step sections. Prostatic adenocarcinoma occurred in 100% of NBL rats after treatment with estradiol-17 beta or DES plus testosterone for 44 and 59 weeks (group means) respectively. Adenocarcinoma incidences were lower in Sprague-Dawley rats. The adenocarcinomas were small, microscopic, invasive tumors and they were spatially closely associated with the periurethral ducts of the dorsal, lateral and/or anterior (= coagulating gland) prostate, but never with the ducts of the ventral lobe and seminal vesicles. One adenocarcinoma was of uncertain origin. Duct-acinar dysplastic lesions occurred in the periphery of the dorsal and lateral prostate of all hormone-treated NBL and many Sprague-Dawley rats, but did not appear to give rise to carcinoma. Although some adenocarcinomas were contiguous with dysplastic ducts of the peripheral dorsolateral prostate, the main mass of these neoplasms was located in the periurethral area. Also, most adenocarcinomas were only connected with the periurethral ducts, in which atypical hyperplasia occurred following hormone treatment for 36 weeks or longer. Thus atypical hyperplasia of the periurethral prostate ducts, but not peripheral duct-acinar dysplasia, appeared to be the likely precursor of the induced carcinomas. Testosterone plus DES, but not estradiol-17 beta, induced marked dysplasia-like lesions in the acini of the ventral prostate of all NBL and many Sprague-Dawley rats. These lesions had progressed to carcinoma in situ (or adenoma) in 46% of NBL rats.

Diverting managed care Medicaid patients from pediatric emergency department use

OBJECTIVE

To evaluate the health outcomes of managed care Medicaid children with non-emergent conditions who were not authorized to be seen in the Pediatric Emergency Department (PED) by their primary care provider.

DESIGN

Consecutive case surveillance from 6/29/92 to 2/2/93.

SETTING

University based PED (17,500 visits/year) in inner city Baltimore.

PARTICIPANTS

Cases were MAC children denied authorization to be seen for non-emergent conditions in the PED. Age and complaint matched MAC children were selected from the university based Pediatric Ambulatory Center (PAC) and from non-emergent PED visits (PED-seen) in order to compare utilization rates after denial.

INTERVENTION

The Maryland Access to Care (MAC) Medicaid program (started in 12/91) emphasizes primary care and appropriate health care utilization by incorporating the following elements of managed care: assignment to primary care provider, gatekeeping, mandatory enrollment and fee for service.

METHODS

Consecutive case surveillance from 6/29/92 to 2/2/93 was used to evaluate the health outcomes of MAC children denied authorization for non-emergent care in a university based PED. One week following denial, a pediatric nurse practitioner contacted the patient's caretaker and the MAC provider to ascertain health outcome. Medicaid claims data was used to compare the six month health care utilization of the denied group to age and complaint matched children seen in the PED (PED-seen) or in a primary care clinic (PAC).

RESULTS

216 MAC patients were not authorized for a PED visit by their MAC providers. 123 (57%) saw their MAC provider within one week of the denied PED visit. 40 (18%) were not seen because their presenting complaint had resolved completely. No adverse health outcomes occurred because of delay in health care delivery. The subsequent ER utilization rate of the denied group was the same as the PED-seen comparison group, and significantly higher than that of the PAC group (P = .002). The denied group was hospitalized at a significantly higher rate relative to these comparison groups (P = .003).

CONCLUSIONS

Diverting Medicaid children classified as non-emergent in an ER to their MAC providers can be a safe practice short-term. However, denial of a PED visit has no impact on subsequent ER utilization by Medicaid participants and may be associated with higher hospitalization rate. Gatekeeping in this setting does not necessarily change the health care seeking behavior of these patients.

Do provider practices conform to the new pediatric immunization standards?

OBJECTIVE

Standards for pediatric immunization practices were issued by the Centers for Disease Control and Prevention, Atlanta, Ga, in May 1992. This article provides baseline data on immunization practices related to eight of the standards.

DESIGN

Survey of pediatric providers before publication of the standards.

SETTING

Baltimore, Md.

PARTICIPANTS

Forty of the 41 health centers, clinics, and private practices serving children in designated high-risk census tracts participated in the survey. One hundred seventy-three of the 251 eligible physicians and nurse practitioners at the sites responded.

MAIN OUTCOME MEASURES

Conformity with the eight standards was measured as a percentage of either sites or physicians and nurse practitioners across the sites.

RESULTS

Conformity with the standards varied, ranging from nearly universal conformity with the need to educate parents and guardians about immunizations (standard 5) to less than 3% for simultaneous administration of all vaccine doses when a child is first eligible (standard 8). For most of the standards, considerable variability was found between and within public and private sites.

CONCLUSIONS

Providers often followed practices that did not conform to the new standards (prior to issuance). Some of the standards are ambiguous and require clarification before they can be fully applied. The impact of the standards on immunization rates and pediatric primary health care has yet to be tested empirically.

Efficacy of albuterol in the management of bronchiolitis

OBJECTIVE

To examine the efficacy of albuterol (0.15 mg/kg per dose) in the management of bronchiolitis.

DESIGN

Randomized, double-blind, placebo-controlled outpatient clinical trial utilizing four study groups: neubulized albuterol, nebulized saline, oral albuterol, and oral placebo.

SETTING

Pediatric emergency department and outpatient clinic at University of Maryland in Baltimore.

PATIENTS

Eighty-eight infants (median age 5.5 months) being treated for their first episode of wheezing were randomly assigned to nebulized albuterol (n = 22), nebulized saline (n = 23), oral albuterol (n = 19), oral placebo (n = 24).

INTERVENTIONS

The nebulized groups received two nebulizations 30 minutes apart, whereas the oral groups received one oral dose.

MAIN OUTCOME MEASURES

Respiratory and heart rates, clinical score, oxygen saturation (Spo2), and the infant's state, ie, asleep, awake, or feeding, were recorded at baseline and at 30 and 60 minutes after treatment.

RESULTS

Randomization produced equivalent groups in terms of demographics and baseline measures. There were no statistically significant differences in any outcomes among the four treatments, except for oral albuterol, which produced an increase in heart rate (15 beats per minute, P = .005). No differences in the need for additional treatment or hospitalization were observed. Change in the state of the infant during the trial had significant effects on respiratory rate and clinical score.

CONCLUSIONS

Albuterol is as effective as oral placebo in the management of bronchiolitis. Past studies supporting the use of albuterol did not control for effects of change in state of the infant and did not use a truly inactive placebo group. This study underscores the importance of these design components in measuring the efficacy of albuterol in infants.

Multidimensional pain assessment in premature neonates: a pilot study

OBJECTIVE

To describe the physiologic and behavioral responses of premature neonates to a painful stimulus.

DESIGN

Descriptive.

SETTING

Secondary-level neonatal unit in a large metropolitan university teaching hospital.

PARTICIPANTS

Forty neonates between 32 and 34 weeks' postconceptual age and less than 5 days' postnatal age.

MAIN OUTCOME MEASURES

Physiologic (heart rate, oxygen saturation, and intracranial pressure) and behavioral (facial expression and cry) outcomes observed during a routine heel stick.

RESULTS

Physiologic responses were significant, but were not specific to pain. Behavioral responses were more promising and indicated that premature neonates were capable of responding in a manner similar to full-term neonates.

CONCLUSIONS

Premature neonates are capable of expressing their pain in a manner similar to healthy, full-term neonates. Factors that alter this response were not clearly delineated. Further research is needed to determine more precise patterns of response in this age group.

Perceptions of vaccine efficacy, illness, and health among inner-city parents

A resurgence of measles in the past decade has focused attention on the limitations of current immunization programs, particularly for inner-city, low-income populations. As part of a larger study of immunization rates, we discussed perceptions of disease severity and vaccine efficacy, as well as the prioritization of the tasks of parenthood, with 40 parents of infants living in inner-city Baltimore to discover their beliefs about immunization. Vaccines were considered only partly successful; susceptibility to chickenpox after vaccination was repeatedly cited as evidence of vaccine failure. Fever was seen as a primary indicator of illness; thus, vaccines were believed to cause, rather than prevent, illness. Immunization was not considered a high-priority parental responsibility. These findings suggest future interventions be aimed at changing parental perceptions of vaccines as ineffective and of fever after immunization as an indicator of illness. Finally, immunizations should be made easily available, even during clinic visits for a child's illness.

Biological function of the retinoblastoma protein requires distinct domains for hyperphosphorylation and transcription factor binding

Despite the importance of the retinoblastoma susceptibility gene to tumor growth control, the structural features of its encoded protein (pRb) and their relationship to protein function have not been well explored. We constructed a panel of deletion mutants of pRb expression vectors and used a biological assay for pRb that measures growth inhibition and morphologic changes in pRb-transfected Saos-2 cells to correlate structural alterations of the pRb coding region with function. We tested the deleted proteins for the ability to bind to viral oncoprotein E1A and to the transcription factor E2F. We also measured the ability of the mutant proteins to become hyperphosphorylated in vivo and to be recognized as substrates in vitro by a cell cycle-regulatory kinase associated with cyclin A. We identified two regions of pRb that are required for E2F binding and for hyperphosphorylation. E1A binding domains partially overlap but are distinct from both of these other two regions. Biological function of pRb is dependent on retention of the integrity of both of these biochemically defined domains. These data support the model that pRb is a transducer of afferent signals (via the kinase that phosphorylates it) and efferent signals (through transcription factor binding), using distinct structural elements. Preservation of both of these features is essential for the ability of pRb to induce growth inhibition and morphologic changes upon reintroduction into transfected cells.

Human tumor and normal tissue reactivity of the anti-(breast cancer) monoclonal antibody BA-Br-3 and its similarity to the anti-(epithelial membrane antigen) monoclonal antibody E29

A mouse monoclonal antibody (BA-Br-3) raised against the breast carcinoma cell line CAMA-1 was previously shown to react with a greater than or equal to 300-kDa globule-like glycoprotein from human milk fat also expressed in the cytoplasm and on the surface of human carcinoma cells of different histological types. In this report the reactivity of this mAb with a large number of normal and malignant human tissues was analyzed using immunoperoxidase techniques. When tested on sections of both fresh-frozen tissues and formalin-fixed, paraffin-embedded tissues, BA-Br-3 reacted with a formalin-resistant antigenic determinant expressed by normal and malignant epithelial cells. Preferential reactivity was observed at the apical portion of ductal epithelial cells in normal breast and in glandular epithelia distributed in several other organs. Reactivity with mucin-like secretions in the lumina of ducts was also found. BA-Br-3 reacted mostly in heterogenous staining patterns with 88% of 49 breast carcinoma specimens tested, regardless of their histological type or whether they were primary or secondary neoplasms. Testing of epithelial malignant tumors other than breast carcinomas with this antibody showed that 127 of 151 (84%) were also reactive. mAb BA-Br-3 and E29 (a commercially available anti-(epithelial membrane antigen) shared very similar staining patterns and distributions of reactivity with breast and other epithelial tumors. However, BA-Br-3 showed a significantly higher percentage of reactivity with melanoma (33% versus 6%, P = 0.003) and a trend toward a higher percentage of reactivity with sarcoma (55% versus 27%, P greater than 0.05). This antibody, therefore, defines a molecule that is a member of the mucin-like epithelial membrane antigen family. Further studies are warranted to determine its usefulness in antibody-directed cancer diagnosis, prognosis, and immunotherapy.

Serious respiratory consequences of detergent ingestions in children

After ingesting or inhaling laundry detergent powder, eight children required hospital admission. The predominant symptoms were stridor, drooling, and respiratory distress. All but one patient underwent endoscopy of the airways and the esophagus, five children were admitted to the intensive care unit, and four children required endotracheal intubation. Laundry detergent ingestions are generally considered to have minor consequences, and there exists a paucity of literature on the subject. Evidence of significant morbidity incurred because of ingestion or inhalation of sodium carbonate-containing laundry detergent powder is presented, together with a review of the existing literature.