The Incidence of Infection Complicating Snakebites in Tropical Australia: Implications for Clinical Management and Antimicrobial Prophylaxis

Objective

To define the incidence of infection following snakebite in tropical Australia and the resulting implications for the routine prescription of prophylactic antibiotics.

Methods

A retrospective study of all individuals presenting to Cairns Hospital, a tertiary referral hospital in tropical Australia, after a snakebite between December 2013 and October 2020.

Results

There were 732 hospitalisations, 720 (98.4%) patients presented within 8 hours of the snakebite, and 29/732 (4.0%) were envenomated. Envenomated patients were more likely to receive empirical antibiotics than nonenvenomated patients (8/29 (27.6%) versus 14/703 (2.0%), p < 0.001), although this was frequently as a bundle of care for critically ill individuals. Superficial skin infection was diagnosed by clinicians in 6/732 (0.8%) patients during their hospitalisation; infection was diagnosed more commonly in envenomated than in nonenvenomated patients (3/29 (10.3%) versus 3/703 (0.4%), p = 0.001). All 3 envenomated individuals diagnosed with infection were believed to have taipan (genus Oxyuranus) bites. Five (83%) of the six patients diagnosed with infection had received empirical antibiotics at presentation; only 1/710 (0.1%) patients who received no antibiotics developed a (superficial) infection.

Conclusion

Infection is a very uncommon complication of snakebite in tropical Australia. Individuals bitten by snakes in tropical Australia should not routinely receive antibiotic prophylaxis.

The aetiology and clinical characteristics of cryptococcal infections in Far North Queensland, tropical Australia

Cryptococcal infections are an important cause of morbidity and mortality in tropical Australia. This retrospective audit was conducted to characterise the aetiology, temporospatial epidemiology, and clinical course of 49 cryptococcal infections in Far North Queensland between 1 January 1999 and 31 December 2019. Cryptococcus gattii was identified in 15/32 (47%) in whom it was possible to speciate the organism. Among these 15 patients, 13 (87%) had a rural residential address, 10 (67%) were Indigenous Australians and 11 (73%) presented during the May-November dry season. When compared to the 17 patients with Cryptococcus neoformans infection, patients with C. gattii were less likely to be immunocompromised (0/15 versus 8/17 (47%), p = 0.003). Neurosurgery was necessary in 5/15 C. gattii cases and 3/17 (18%) C. neoformans cases (p = 0.42). Outcomes were generally good with 42/49 (86%) cases—and 14/15 (93%) with C. gattii infection—surviving to hospital discharge. These positive outcomes are likely to be explained by the development of standardised treatment guidelines during the study period, low rates of comorbidity in the patients with C. gattii infection and access to liposomal amphotericin and neurosurgical support in the well-resourced Australian healthcare system.

Closed- and open-vocabulary approaches to text analysis: A review, quantitative comparison, and recommendations

Technology now makes it possible to understand efficiently and at large scale how people use language to reveal their everyday thoughts, behaviors, and emotions. Written text has been analyzed through both theory-based, closed-vocabulary methods from the social sciences as well as data-driven, open-vocabulary methods from computer science, but these approaches have not been comprehensively compared. To provide guidance on best practices for automatically analyzing written text, this narrative review and quantitative synthesis compares five predominant closed- and open-vocabulary methods: Linguistic Inquiry and Word Count (LIWC), the General Inquirer, DICTION, Latent Dirichlet Allocation, and Differential Language Analysis. We compare the linguistic features associated with gender, age, and personality across the five methods using an existing dataset of Facebook status updates and self-reported survey data from 65,896 users. Results are fairly consistent across methods. The closed-vocabulary approaches efficiently summarize concepts and are helpful for understanding how people think, with LIWC2015 yielding the strongest, most parsimonious results. Open-vocabulary approaches reveal more specific and concrete patterns across a broad range of content domains, better address ambiguous word senses, and are less prone to misinterpretation, suggesting that they are well-suited for capturing the nuances of everyday psychological processes. We detail several errors that can occur in closed-vocabulary analyses, the impact of sample size, number of words per user and number of topics included in open-vocabulary analyses, and implications of different analytical decisions. We conclude with recommendations for researchers, advocating for a complementary approach that combines closed- and open-vocabulary methods. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Associations between social and behavioural factors and the risk of late stillbirth - findings from the Midland and North of England Stillbirth case-control study

OBJECTIVE

To investigate behavioural and social characteristics of women who experienced a late stillbirth compared with women with ongoing live pregnancies at similar gestation.

DESIGN

Case-control study.

SETTING

41 maternity units in the UK.

POPULATION

Women who had a stillbirth ≥28 weeks' gestation (n = 287) and women with an ongoing pregnancy at the time of interview (n = 714).

METHODS

Data were collected using an interviewer-administered questionnaire which included questions regarding women's behaviours (e.g. alcohol intake and household smoke exposure) and social characteristics (e.g. ethnicity, employment, housing). Stress was measured by the 10-item Perceived Stress Scale.

MAIN OUTCOME MEASURE

Late stillbirth.

RESULTS

Multivariable analysis adjusting for co-existing social and behavioural factors showed women living in the most deprived quintile had an increased risk of stillbirth compared with the least deprived quintile (adjusted odds ratio [aOR] 3.16; 95% CI 1.47-6.77). There was an increased risk of late stillbirth associated with unemployment (aOR 2.32; 95% CI 1.00-5.38) and women who declined to answer the question about domestic abuse (aOR 4.12; 95% CI 2.49-6.81). A greater number of antenatal visits than recommended was associated with a reduction in stillbirth (aOR 0.26; 95% CI 0.16-0.42).

CONCLUSIONS

This study demonstrates associations between late stillbirth and socio-economic deprivation, perceived stress and domestic abuse, highlighting the need for strategies to prevent stillbirth to extend beyond maternity care. Enhanced antenatal care may be able to mitigate some of the increased risk of stillbirth.

TWEETABLE ABSTRACT

Deprivation, unemployment, social stress & declining to answer about domestic abuse increase risk of #stillbirth after 28 weeks' gestation.

Parents' experiences of care following the loss of a baby at the margins between miscarriage, stillbirth and neonatal death: a UK qualitative study

OBJECTIVE

To explore the healthcare experiences of parents whose baby died either before, during or shortly after birth between 20⁺⁰ and 23⁺⁶  weeks of gestation in order to identify practical ways to improve healthcare provision.

DESIGN

Qualitative interview study.

SETTING

England through two parent support organisations and four NHS Trusts.

SAMPLE

A purposive sample of parents.

METHODS

Thematic analysis of semi-structured in-depth narrative interviews.

MAIN OUTCOME MEASURES

Parents' healthcare experiences.

RESULTS

The key overarching theme to emerge from interviews with 38 parents was the importance of the terminology used to refer to the death of their baby. Parents who were told they were 'losing a baby' rather than 'having a miscarriage' were more prepared for the realities of labour, the birth experience and for making decisions around seeing and holding their baby. Appropriate terminology validated their loss, and impacted on parents' health and wellbeing immediately following bereavement and in the longer term.

CONCLUSION

For parents experiencing the death of their baby at the margins between miscarriage, stillbirth and neonatal death, ensuring the use of appropriate terminology that reflects parents' preferences is vital. This helps to validate their loss and prepare them for the experiences of labour and birth. Reflecting parents' language preferences combined with compassionate bereavement care is likely to have a positive impact on parents' experiences and improve longer-term outcomes.

TWEETABLE ABSTRACT

Describing baby loss shortly before 24 weeks of gestation as a 'miscarriage' does not prepare parents for labour and birth, seeing their baby and making memories.

Flow synthesis of coumalic acid and its derivatization

Coumalic acid is a valuable platform compound which can be prepared from malic acid, a biorenewable feedstock derived from glucose. Two flow syntheses of coumalic acid and a new heated rotating reactor are presented.

The Language of Religious Affiliation

Religious affiliation is an important identifying characteristic for many individuals and relates to numerous life outcomes including health, well-being, policy positions, and cognitive style. Using methods from computational linguistics, we examined language from 12,815 Facebook users in the United States and United Kingdom who indicated their religious affiliation. Religious individuals used more positive emotion words ( β = .278, p < .0001) and social themes such as family ( β = .242, p < .0001), while nonreligious people expressed more negative emotions like anger ( β = −.427, p < .0001) and categories related to cognitive processes, like tentativeness ( β = −.153, p < .0001). Nonreligious individuals also used more themes related to the body ( β = −.265, p < .0001) and death ( β = −.247, p < .0001). The findings offer directions for future research on religious affiliation, specifically in terms of social, emotional, and cognitive differences.

Variations in very preterm birth rates in 30 high-income countries: are valid international comparisons possible using routine data?

OBJECTIVE

Concerns about differences in registration practices across countries have limited the use of routine data for international very preterm birth (VPT) rate comparisons.

DESIGN

Population-based study.

SETTING

Twenty-seven European countries, the United States, Canada and Japan in 2010.

POPULATION

A total of 9 376 252 singleton births.

METHOD

We requested aggregated gestational age data on live births, stillbirths and terminations of pregnancy (TOP) before 32 weeks of gestation, and information on registration practices for these births. We compared VPT rates and assessed the impact of births at 22-23 weeks of gestation, and different criteria for inclusion of stillbirths and TOP on country rates and rankings.

MAIN OUTCOME MEASURES

Singleton very preterm birth rate, defined as singleton stillbirths and live births before 32 completed weeks of gestation per 1000 total births, excluding TOP if identifiable in the data source.

RESULTS

Rates varied from 5.7 to 15.7 per 1000 total births and 4.0 to 11.9 per 1000 live births. Country registration practices were related to percentage of births at 22-23 weeks of gestation (between 1% and 23% of very preterm births) and stillbirths (between 6% and 40% of very preterm births). After excluding births at 22-23 weeks, rate variations remained high and with a few exceptions, country rankings were unchanged.

CONCLUSIONS

International comparisons of very preterm birth rates using routine data should exclude births at 22-23 weeks of gestation and terminations of pregnancy. The persistent large rate variations after these exclusions warrant continued surveillance of VPT rates at 24 weeks and over in high-income countries.

TWEETABLE ABSTRACT

International comparisons of VPT rates should exclude births at 22-23 weeks of gestation and terminations of pregnancy.

Seeing the "Big" Picture: Big Data Methods for Exploring Relationships Between Usage, Language, and Outcome in Internet Intervention Data

Background

Assessing the efficacy of Internet interventions that are already in the market introduces both challenges and opportunities. While vast, often unprecedented amounts of data may be available (hundreds of thousands, and sometimes millions of participants with high dimensions of assessed variables), the data are observational in nature, are partly unstructured (eg, free text, images, sensor data), do not include a natural control group to be used for comparison, and typically exhibit high attrition rates. New approaches are therefore needed to use these existing data and derive new insights that can augment traditional smaller-group randomized controlled trials.

Objective

Our objective was to demonstrate how emerging big data approaches can help explore questions about the effectiveness and process of an Internet well-being intervention.

Methods

We drew data from the user base of a well-being website and app called Happify. To explore effectiveness, multilevel models focusing on within-person variation explored whether greater usage predicted higher well-being in a sample of 152,747 users. In addition, to explore the underlying processes that accompany improvement, we analyzed language for 10,818 users who had a sufficient volume of free-text response and timespan of platform usage. A topic model constructed from this free text provided language-based correlates of individual user improvement in outcome measures, providing insights into the beneficial underlying processes experienced by users.

Results

On a measure of positive emotion, the average user improved 1.38 points per week (SE 0.01, t122,455=113.60, P<.001, 95% CI 1.36–1.41), about a 27% increase over 8 weeks. Within a given individual user, more usage predicted more positive emotion and less usage predicted less positive emotion (estimate 0.09, SE 0.01, t6047=9.15, P=.001, 95% CI .07–.12). This estimate predicted that a given user would report positive emotion 1.26 points higher after a 2-week period when they used Happify daily than during a week when they didn’t use it at all. Among highly engaged users, 200 automatically clustered topics showed a significant (corrected P<.001) effect on change in well-being over time, illustrating which topics may be more beneficial than others when engaging with the interventions. In particular, topics that are related to addressing negative thoughts and feelings were correlated with improvement over time.

Conclusions

Using observational analyses on naturalistic big data, we can explore the relationship between usage and well-being among people using an Internet well-being intervention and provide new insights into the underlying mechanisms that accompany it. By leveraging big data to power these new types of analyses, we can explore the workings of an intervention from new angles, and harness the insights that surface to feed back into the intervention and improve it further in the future.

Gaining insights from social media language: Methodologies and challenges

Language data available through social media provide opportunities to study people at an unprecedented scale. However, little guidance is available to psychologists who want to enter this area of research. Drawing on tools and techniques developed in natural language processing, we first introduce psychologists to social media language research, identifying descriptive and predictive analyses that language data allow. Second, we describe how raw language data can be accessed and quantified for inclusion in subsequent analyses, exploring personality as expressed on Facebook to illustrate. Third, we highlight challenges and issues to be considered, including accessing and processing the data, interpreting effects, and ethical issues. Social media has become a valuable part of social life, and there is much we can learn by bringing together the tools of computer science with the theories and insights of psychology. (PsycINFO Database Record

Economic costs associated with moderate and late preterm birth: a prospective population-based study

OBJECTIVE

We sought to determine the economic costs associated with moderate and late preterm birth.

DESIGN

An economic study was nested within a prospective cohort study.

SAMPLE

Infants born between 32(+0) and 36(+6)  weeks of gestation in the East Midlands of England. A sample of infants born at ≥37 weeks of gestation acted as controls.

METHODS

Data on resource use, estimated from a National Health Service (NHS) and personal social services perspective, and separately from a societal perspective, were collected between birth and 24 months corrected age (or death), and valued in pounds sterling, at 2010-11 prices. Descriptive statistics and multivariable analyses were used to estimate the relationship between gestational age at birth and economic costs.

MAIN OUTCOME MEASURES

Cumulative resource use and economic costs over the first two years of life.

RESULTS

Of all eligible births, 1146 (83%) preterm and 1258 (79%) term infants were recruited. Mean (standard error) total societal costs from birth to 24 months were £12 037 (£1114) and £5823 (£1232) for children born moderately preterm (32(+0) -33(+6)  weeks of gestation) and late preterm (34(+0) -36(+6)  weeks of gestation), respectively, compared with £2056 (£132) for children born at term. The mean societal cost difference between moderate and late preterm and term infants was £4657 (bootstrap 95% confidence interval, 95% CI £2513-6803; P < 0.001). Multivariable regressions revealed that, after controlling for clinical and sociodemographic characteristics, moderate and late preterm birth increased societal costs by £7583 (£874) and £1963 (£337), respectively, compared with birth at full term.

CONCLUSIONS

Moderate and late preterm birth is associated with significantly increased economic costs over the first 2 years of life. Our economic estimates can be used to inform budgetary and service planning by clinical decision-makers, and economic evaluations of interventions aimed at preventing moderate and late preterm birth or alleviating its adverse consequences.

TWEETABLE ABSTRACT

Moderate and late preterm birth is associated with increased economic costs over the first 2 years of life.

Total syntheses of natural products containing spirocarbocycles

The spiro motif is becoming an increasingly prevalent structure in medicinal and organic chemistry. The total syntheses of natural products containing all-carbon spirocycles is reviewed.

Experiences with maternal and perinatal death reviews in the UK--the MBRRACE-UK programme

Established in 1952, the programme of surveillance and Confidential Enquiries into Maternal Deaths in the UK is the longest running such programme worldwide. Although more recently instituted, surveillance and confidential enquiries into perinatal deaths are also now well established nationally. Recent changes to funding and commissioning of the Enquiries have enabled both a reinvigoration of the processes and improvements to the methodology with an increased frequency of future reporting. Close engagement with stakeholders and a regulator requirement for doctors to participate have both supported the impetus for involvement of all professionals leading to greater potential for improved quality of care for women and babies.

Demonstration of ignition radiation temperatures in indirect-drive inertial confinement fusion hohlraums

We demonstrate the hohlraum radiation temperature and symmetry required for ignition-scale inertial confinement fusion capsule implosions. Cryogenic gas-filled hohlraums with 2.2 mm-diameter capsules are heated with unprecedented laser energies of 1.2 MJ delivered by 192 ultraviolet laser beams on the National Ignition Facility. Laser backscatter measurements show that these hohlraums absorb 87% to 91% of the incident laser power resulting in peak radiation temperatures of T(RAD)=300 eV and a symmetric implosion to a 100 μm diameter hot core.

Post-operative blood salvage with autologous retransfusion in primary total hip replacement

Clinical, haematological or economic benefits of post-operative blood salvage with autologous blood re-transfusion have yet to be clearly demonstrated for primary total hip replacement. We performed a prospective randomised study to analyse differences in postoperative haemoglobin levels and homologous blood requirements in two groups of patients undergoing primary total hip replacement. A series of 158 patients was studied. In one group two vacuum drains were used and in the other the ABTrans autologous retransfusion system. A total of 58 patients (76%) in the re-transfusion group received autologous blood. There was no significant difference in the mean post-operative haemoglobin levels in the two groups. There were, however, significantly fewer patients with post-operative haemoglobin values less than 9.0 g/dl and significantly fewer patients who required transfusion of homologous blood in the re-transfusion group. There was also a small overall cost saving in this group.

Mortality in adults with moderate to profound intellectual disability: a population-based study

BACKGROUND

People with intellectual disability (ID) experience a variety of health inequalities compared with the general population including higher mortality rates. This is the first UK population-based study to measure the extent of excess mortality in people with ID compared with the general population.

METHOD

Indirectly standardized all-cause and disease mortality ratios (SMRs) and exact Poisson confidence intervals were calculated by age and sex for all adults, aged 20 years or over, with moderate to profound ID living in Leicestershire and Rutland, UK, between 1993 and 2005. The general population of Leicestershire and Rutland, which has a population of approximately 700,000 individuals in this age range, was used for comparison. To explore differences within the study population, overall SMRs were also calculated by presence of Down syndrome and last place of residence (city or county).

RESULTS

Of 2436 adults identified, 409 (17%) died during 23,000 person-years of follow-up. Both all-cause and disease-specific mortality were around three times higher than the general population but varied considerably with age. The largest differences were observed in people in their twenties, where all-cause mortality was almost nine times higher in men (SMR=883; 95% CI=560-1325) and more than 17 times higher in women (SMR=1722; 95% CI=964-2840). At a particular disadvantage were people with Down syndrome and women with ID living in the city.

CONCLUSIONS

The relatively high SMRs observed in young people and in women, particularly those living in inner city areas and with Down syndrome, deserve further investigation for possible explanations, including socio-economic factors.

The identification and characterisation of a novel null HLA-DRB1 allele

Since the introduction of DNA-based human leukocyte antigen (HLA) typing a number of discrepancies with serological typing have been documented. At the time of submission of this abstract (July 2005 ImMunoGeneTics project (IMGT) project database release) 42 HLA class I and II null alleles had been described characterised by a lack of expression of cell surface antigen. These null alleles can be accounted for by a number of demonstrated molecular mechanisms including insertion, deletion and point mutation and may lead to a nonsense codon, splicing defect or premature stop codon.

Sequencing-based typing identifies novel alleles due to single nucleotide polymorphisms in ‘conserved’ regions

The Royal Perth Hospital laboratory has been using sequencing-based typing for all HLA loci since 2002. In the period to October 2005, approximately 12,000 HLA A and HLA B, 5000 HLA C and DQB1, and 17,000 DRB1 requests have been processed. Twenty nine novel alleles have been identified in that time. These comprise 10 HLA-A (including one null allele), five HLA-B, six HLA-C, six DRB1 (including a null allele), and one DQB1 novel allele. (At the time of identifying the DRB1 null allele, there were no other reported examples.) In addition, we have seen one example of a blast-specific HLA-A null allele. One HLA-A allele (HLA-A*0264) and one HLA-B allele (HLA-B*400104) were subsequently identified in other laboratories and submitted to the international ImMunoGeneTics project (IMGT) database.

Socioeconomic inequalities in very preterm birth rates

AIMS

To investigate the extent of socioeconomic inequalities in the incidence of very preterm birth over the past decade.

METHODS

Ecological study of all 549 618 births in the former Trent health region, UK, from 1 January 1994 to 31 December 2003. All singleton births of 22(+0) to 32(+6) weeks gestation (7 185 births) were identified from population surveys of neonatal services and stillbirths. Poisson regression was used to calculate incidence of very preterm birth (22-32 weeks) and extremely preterm birth (22-28 weeks) by year of birth and decile of deprivation (child poverty section of the Index of Multiple Deprivation).

RESULTS

Incidence of very preterm singleton birth rose from 11.9 per 1000 births in 1994 to 13.7 per 1000 births in 2003. Those from the most deprived decile were at nearly twice the risk of very preterm birth compared with those from the least deprived decile, with 16.4 per 1000 births in the most deprived decile compared with 8.5 per 1000 births in the least deprived decile (incidence rate ratio 1.94; 95% CI (1.73 to 2.17)). This deprivation gap remained unchanged throughout the 10-year period. The magnitude of socio-economic inequalities was the same for extremely preterm births (22-28 weeks incidence rate ratio 1.94; 95% CI (1.62 to 2.32)).

CONCLUSIONS

This large, unique dataset of very preterm births shows wide socio-economic inequalities that persist over time. These findings are likely to have consequences on the burden of long-term morbidity. Our research can assist future healthcare planning, the monitoring of socio-economic inequalities and the targeting of interventions in order to reduce this persistent deprivation gap.

Up-to-date estimates of long-term cancer survival in England and Wales

Cancer survival in England and Wales has improved over the last 30 years. However, cohort survival estimates delay recognition of these improvements. Here we show that period survival estimates, based on survival in a recent time period, suggest a more optimistic pattern for England and Wales than cohort-based measures for most cancers.British Journal of Cancer (2003) 89, 74-76. doi:10.1038/sj.bjc.6600976 www.bjcancer.com

Latest trends in cancer incidence among UK South Asians in Leicester

Using cancer registry data, we show that although South Asians have lower rates of cancer than the rest of the population, this is changing with age and time. Younger South Asians, particularly children, are at increased risk. While generally cancer rates have fallen over the last decade, they are increasing among South Asians.

A study of heredity as a risk factor in strabismus

AIMS

Inheritance is recognised to have a part in the aetiology of strabismus but previous studies have not adequately distinguished between different types of strabismus leading to wide variations in reported findings. The aim of this study was to investigate the importance of heredity in different types of strabismus.

METHODS

The parents of children attending for treatment of strabismus over a one-month period were interviewed to identify relatives with a history of strabismus. A complete three-generation pedigree was established for 96 index cases who were classified into four groups: infantile esotropia (26 cases), accommodative esotropia (49 cases), anisometropic esotropia (15 cases), and exotropia (six cases).

RESULTS

Forty-three of a total of 165 (26.1%) first degree relatives of patients with hypermetropic accommodative esotropia were affected. In contrast, 15 of a total of 101 (14.9%) first degree relatives of patients with infantile esotropia, eight of a total of 66 (12.1%) first degree relatives of patients with anisometropic esotropia, and one of a total of 25 (4%) first degree relatives of patients with exotropia were affected. Analysing the data using logistic regression with a random term for family showed a significantly higher proportion of affected first degree relatives in the accommodative group than in any of the other three diagnostic groups.

CONCLUSION

A history of strabismus appears to be more common in hypermetropic accommodative esotropia than in infantile esotropia, anisometropic esotropia or exotropia. More detailed investigation of the role of heredity in the aetiology of accommodative esotropia is needed.

Changes in the diet of free-ranging black bears in years of contrasting food availability revealed through milk fatty acids

We studied patterns of fatty acid signatures in milks and major foods of free-ranging lactating black bears (Ursus americanus) in western Massachusetts to examine the degree to which changes in milk fatty acids could be related to measured changes in food availability and scat analysis, and to assess whether fatty acids could be used to infer aspects of the diets of individuals. Milk samples (n = 45) were obtained from 17 individual bears during years of contrasting hard-mast abundance. Paired winter-den and spring-foraging samples were obtained from females in 1994 (n = 10), 1995 (n = 2), and 1996 (n = 8). In seven of these females, paired den and foraging samples were collected in both 1994 and 1996, representing two consecutive lactation periods. Milk fatty acid patterns indicated that the diet of individuals responded strongly to food availability both prior to denning and during spring foraging. During spring foraging, although females likely continued to mobilize stored fat, the greatest contribution to milk fatty acids appeared to be from dietary fat intake. Hence, qualitative changes in spring diets of individual bears could be reasonably inferred from milk fatty acid signatures. During the year of lowest hard-mast abundance, milk fatty acid patterns suggested that females relied predominantly on a diet of skunk cabbage, although this varied among individuals. This study demonstrates that milk fatty acid signatures can be used to provide insight into the nutritional ecology of bears at the level of the individual.

Relation of coronary artery calcium identified by electron beam tomography to serum lipoprotein levels and implications for treatment

This study was designed to determine whether the National Cholesterol Education Program (NCEP) lipid guidelines accurately identify subclinical atherosclerosis and whether low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) levels are related to the extent and prematurity of coronary artery disease (CAD) as determined by electron beam tomography (EBT). Out of personal concern for CAD risk, 930 consecutive asymptomatic subjects, without clinical CAD and on no lipid-lowering agents, underwent EBT. Calcium score and percentile were correlated with total cholesterol (TC), LDL-C, HDL-C, triglycerides, and demographic parameters. A calcium score of > 0 (EBT+) was found in 55% of patients; 45% of patients had a 0 score (EBT-). Mean age (58.0 +/- 10.5 vs 49.3 +/- 9.7 years, p = 0.0001), TC (218 +/- 39 vs 211 +/- 41 mg/dl, p = 0.006), LDL-C (136 +/- 36 vs 127 +/- 27 mg/dl, p = 0.005), and TC/HDL-C (4.6 +/- 1.4 vs 4.2 +/- 1.5, p = 0.0001) were significantly higher and HDL-C (52.2 +/- 17.6 vs 55.4 +/- 19.3 mg/dl, p = 0.008) lower in the EBT+ compared with EBT- group. In the EBT+ group, 75.1% of subjects had LDL-C < 160 mg/dl and would not be advised to use lipid-lowering medications according to NCEP guidelines. In subjects with LDL-C < 160 mg/dl, 51.8% of subjects were EBT+, as were 46.1% of those with LDL-C < 100 mg/dl. There were no significant differences in the calcium scores throughout the entire range of all lipid parameters; calcium percentiles were virtually identical within lipid value subgroups. We conclude that asymptomatic patients with EBT-defined subclinical atherosclerosis are not reliably identified by NCEP guidelines, and TC, LDL-C, HDL-C, TC/HDL-C, and triglyceride levels do not correlate with either the extent or prematurity of calcified plaque burden.

A quality control program for crossmatching procedures for solid organ transplantation. The participating laboratories of the Australasian and South Asian Tissue Typing Association

The National Kidney Matching Scheme (NKMS) allows matching and allocation of donor organs throughout Australia. Sera from potential recipients are distributed to each interstate tissue typing laboratory on a monthly basis for crossmatching in the event of a cadaver donor. Therefore, it is essential there is consensus for results between these laboratories in order for donated organs to be allocated appropriately. A quality control program conducted under the auspices of ASEATTA was undertaken for (1) panel reactive antibody characterization; (2) routine T lymphocyte crossmatching; and (3) characterization of antibody isotype by DTT treatment. These aims were achieved by distribution of (1) six sera for the determination of PRA activity; (2) 20 scrambled trays including replicate dilutions of a strongly positive lymphocytotoxic serum, high titer monoclonal antibody and negative sera and; (3) 20 trays containing sera with IgG and/or IgM antibodies. These were then evaluated by each laboratory on a panel of T cells. There was concordance between laboratories for PRA levels and antibody characterization. However, there was considerable variation in crossmatch sensitivity and reproducibility, several laboratories had carryover and others could not detect weak IgM antibodies. These results demonstrate the utility and need for ongoing crossmatch exchange programs, particularly for laboratories participating in organ exchange programs.

The therapy of amblyopia: an analysis comparing the results of amblyopia therapy utilizing two pooled data sets

CONTEXT

We previously presented the results of an original pooled data set of 961 amblyopic patients who underwent patching therapy for amblyopia from 1965 to 1994 (study group 1). Three types of amblyopia were considered: anisometropic, anisometropic-strabismic, and strabismic. Analysis of this group's success was related to the age at which therapy was initiated, the type of amblyopia, and the depth of visual loss before treatment was begun. The purpose of the current study is to test the validity of these findings on a second group of 961 amblyopes employing the data set used by Woodruff and associates in their publications (study group 2). These 2 data sets, after adjustment to conform to the definitions of age, amblyopia, anisometropia, and similar items utilized in common between the 2 study groups, will be compared for the risk factors predictive of successful occlusion therapy.

OUTCOME

As in the previous study, the success of occlusion therapy is defined as a visual acuity of 20/40 or better at the end of treatment.

RESULTS

Success by the 20/40 criteria was achieved in 73.7% in study group 1 and in 59.9% in study group 2. By category, the rate of success in study group 1 was 77.2% in strabismic amblyopia, 67.2% in anisometropic-strabismic amblyopia, and 66.0% in anisometropic amblyopia. In study group 2, success was 61.2% in strabismic amblyopia, 51.2% in anisometropic-strabismic amblyopia, and 63.0% in anisometropic amblyopia. Study group 1 univariate analysis related success in each group to the age at which therapy was initiated, the type of amblyopia, and the depth of visual loss before treatment in each group. In study group 2, univariate analysis related success of occlusion therapy to age and the depth of visual loss before treatment. Type of amblyopia was not related to outcome success in this group. When the 2 data sets were pooled, the risk factors for success were age and depth of visual loss at onset of treatment.

CONCLUSIONS

Factors that appeared closely related to a successful outcome of patching therapy were patient age and depth of visual loss before treatment. These conclusions further support the value of early detection and screening for amblyopia, its prevention, where possible, and its adequate and vigorous treatment when it is detected and diagnosed.

Effectiveness of three different doses of carvedilol for exertional angina. Carvedilol-Angina Study Group

Carvedilol is a nonselective beta-receptor antagonist with vasodilating properties primarily due to selective alpha-1 antagonism. This 4-treatment, 5-period, double-blind, crossover study evaluated the efficacy and safety of 3 doses of carvedilol (12.5, 25, and 50 mg given twice daily) versus placebo in 122 patients with chronic stable angina. Carvedilol in doses of 25 mg twice daily and 50 mg twice daily was statistically superior to placebo with respect to time to angina (placebo: 316 seconds; 25 mg carvedilol: 337 seconds, p = 0.0039; 50 mg: 345 seconds, p <0.0001) and time to 1-mm ST-segment depression (placebo: 301 seconds; 25 mg: 313 seconds; 50 mg: 323 seconds; p <0.0001). The percentage of patients reporting any adverse experience was slightly less in those receiving placebo (placebo: 28.4%; 12.5 mg: 33.1%; 25 mg: 34.5%; 50 mg: 31.9%). Carvedilol is effective and safe in treating patients with chronic stable angina.

Mechanisms underlying the absence of the pubertal shift in the playful defense of female rats

Due to the action of testicular hormones in the perinatal period, juvenile male rats engage in more play fighting than juvenile females. Also, following puberty, males, but not females, switch to using adultlike defensive tactics more frequently during play. This change in play is also due to the action of testicular hormones perinatally. In this study, two experiments were conducted to determine if the pubertal transition in defense could be induced in females. For Experiment 1, male and female cagemates were tested before and after puberty with familiar and unfamiliar partners. Even when playfully interacting with subadult males, females did not increase the use of the adultlike defensive tactics. For Experiment 2, neonatal females were either injected with testosterone propionate (TP) or ovariectomized (OVX), and again tested before and after puberty. While the TP-treated females had higher frequencies of play fighting, they did not change their pattern of defense following puberty. The OVX females exhibited the lower frequency of play fighting typical of females, but changed their pattern of defense with increased age. Thus, it appears that the pattern of pubertal change in playful defense typical of males is inhibited by ovarian hormones. The mechanisms by which ovarian hormones could exert this effect on developing females are discussed.

Torsade de pointes resulting from the addition of droperidol to an existing cytochrome P450 drug interaction

OBJECTIVE

To report a case of QT prolongation associated with concomitant cyclobenzaprine and fluoxetine administration followed by torsade de pointes potentiated by droperidol.

CASE SUMMARY

A 59-year-old white woman who had been receiving long-term fluoxetine and cyclobenzaprine therapy was admitted for Achilles tendon repair. Baseline QTc was prolonged at 497 msec. Prior to surgery, the patient received droperidol, an agent known to prolong the QT interval. During surgery the patient developed torsade de pointes, which progressed into ventricular fibrillation. On postoperative day 1, after cyclobenzaprine discontinuation, the QTc decreased toward normal (440 msec).

DISCUSSION

Cyclobenzaprine shares anticholinergic effects, tachycardia, and dysrhythmic potential with the tricyclic antidepressants (TCAs). Fluoxetine is a known inhibitor of the CYP2D6 isoenzyme (along with CYP3A4 and CYP2C) and has been shown to increase TCA serum concentrations. The combination of cyclobenzaprine and fluoxetine resulted in significant QT prolongation in our patient that progressed to torsade de pointes after preoperative droperidol administration. Resolution of QT abnormalities after cyclobenzaprine discontinuation provided further evidence of a drug-induced etiology. Other possible medical and drug-related causes of torsade de pointes are reviewed and ruled out.

CONCLUSIONS

Clinicians should be aware of the dysrhythmic potential of cyclobenzaprine and fluoxetine, monitor for other cytochrome P450 inhibitors, and avoid concomitant drugs known to prolong the QT interval.

Emergency admissions of older people to hospital: a link with material deprivation

BACKGROUND

The aim was to investigate whether variations in emergency admission to hospital amongst older people in Leicestershire vary with the level of material deprivation of the area in which they live.

METHODS

Data were extracted from the Trent Patient Information System for patients aged 65 and over, admitted as an emergency medical admission to Leicestershire's acute and community hospitals on at least one occasion during the period October 1993-September 1994. The 1991 Census was used to examine the nature of the areas from which these emergency admissions were drawn and variations in emergency admission rates across Leicestershire. The relationship between emergency medical admissions and age, sex and material deprivation as measured by the Townsend deprivation score was examined.

RESULTS

There were 13,305 people aged 65 or over with at least one emergency medical admission out of an estimated population (65 and over) in 1994 of 134,608 (9.9 per cent). Unconditional logistic regression showed that the risk of emergency admission increased with age and was also higher for men than for women. Emergency admissions increased significantly with increasing deprivation for each age group. This was most notable in the 65-74 years age group, yielding an odds ratio of 2.06 [95 per cent confidence interval (1.86, 2.29)], when comparing those from the most deprived areas with those from the least deprived areas.

CONCLUSIONS

The increased risk of emergency medical admission to hospital, which is associated with residence in areas characterized as deprived by Census-based indicators, suggests there are enduring inequalities in health or health care amongst older people. Inequalities noted for all ages persist into old age, although in the 'oldest' age groups, the effect is weaker. Material deprivation may also be a proxy for other factors, such as differences in social support and the type of care received.

Comparison of the fixed combination of enalapril/diltiazem ER and their monotherapies in stage 1 to 3 essential hypertension

The safety and efficacy of two fixed dose combinations of enalapril and diltiazem extended release formation (ER) (E/D) were compared with their monotherapies and placebo in patients with stage 1 to 3 hypertension. The trial design was a multicenter, randomized, double blind, placebo controlled, parallel group, 12 week treatment phase, followed by a 36 week, open label phase. A total of 891 patients with sitting diastolic blood pressure (SiDBP) between 95 and 115 mm Hg were randomly assigned to enalapril 5 mg, diltiazem ER 120 mg, diltiazem ER 180 mg, enalapril 5 mg/diltiazem ER 120 mg (E5/D120), enalapril 5 mg/ diltiazem ER 180 mg (E5/D180), or placebo. In the open label phase, 562 patients received the fixed combination, titrated as needed to control SiDBP < 90 mm Hg. Efficacy was determined with trough (24 +/- 2 h postdose) sitting blood pressure measurements at week 12 and at the end of the open label part of the study. Safety was evaluated based on patient symptoms, clinical laboratories, and electrocardiograms (ECG). E5/D120 and E5/D180 significantly reduced trough SiDBP (-7.6 and -8.3 mm Hg, respectively; P < .05) versus their monotherapies. E5/D120 and E5/D180 significantly reduced trough sitting systolic blood pressure (-7.9 and -9.0, respectively; P < .05) versus both diltiazem ER monotherapies. All active treatments significantly decreased SiDBP and SiSBP versus placebo. E/D effectively lowered SiDBP and SiSBP during the open label extension. No significant difference was seen among treatment groups for the overall incidence of adverse events. The most common drug related adverse events were headache, edema/swelling, dizziness, asthenia/fatigue, cough, rash, and impotence. The event frequency for the combinations were similar to those seen with the monotherapies. Fixed combinations of E/D were generally well tolerated, with an increased blood pressure lowering effect as compared with the individual components in patients with stage I to III hypertension.

The postpubertal change in the playful defense of male rats depends upon neonatal exposure to gonadal hormones

The pattern of playful defense used during play fighting by male rats (Rattus norvegicus) castrated at birth was compared to that of sham-operated and untreated controls during the juvenile phase and after puberty. The neonatal castrates failed to exhibit the age-related changes in playful defense present in intact male rats of the same age. Following puberty, control rats, but not neonatal castrates, switched from juvenile to more adult-typical defensive tactics. That the neonatal castrations were effective was independently shown by the animals' failure to exhibit the asymmetries in weight and play behavior indicative of dominance-subordinance relationships present in normal adult males. A previous study found that castration following weaning did not prevent the pubertal change in playful defense, but did block the formation of dominance-subordinance relationships. Therefore, it appears that the age-related shift in playful defense is a feature of the development of play fighting in males that is likely preprogrammed by gonadal hormone exposure in the perinatal period.

Multiple differences in the play fighting of male and female rats. Implications for the causes and functions of play

Play fighting is the most commonly occurring form of social play in juvenile mammals. Typically, males engage in more play fighting than females, and this difference has been shown to depend on the action of androgens perinatally. It is generally believed that the differences in play fighting between the sexes are quantitative and do not involve qualitative differences in the behavior performed. We show that this is an incorrect characterization of sex difference in play fighting. For example, in laboratory rats, there are at least five different mechanisms that contribute to the observed sex differences in play fighting. These mechanisms involve (I) the motivation to initiate play, (II) the sensory capacity to detect and respond to a play partner, (III) the organization of the motor patterns used to interact with a partner, (IV) age-related changes at puberty in initiating play and in responding to playful contact, and (V) dominance-related changes in adulthood in the pattern of playful interaction. Sex differences in the play fighting of rats are due to an interaction of all of these mechanisms, some of which are sex-typical not play-typical, and involve both quantitative and qualitative differences. This is clearly different from the prevailing view that play fighting is a unitary behavior which is masculinized perinatally. Indeed, even though all five mechanisms are androgenized perinatally, the sensorimotor differences also involve defeminization (i.e. reduction of female-typical qualities). This expanded view of the mechanisms contributing to the sex differences in play fighting has implications for both the analysis of the neural systems involved, and for the functional significance of this activity in childhood and adulthood.

The insulin-induced down-regulation of IRS-1 in 3T3-L1 adipocytes is mediated by a calcium-dependent thiol protease

Insulin receptor substrate-1 (IRS-1) is a protein expressed in 3T3-L1 adipocytes that is involved in most, if not all of the biological responses to insulin. Chronic exposure of these cells to insulin down-regulates IRS-1 by stimulating its degradation (Rice, K.M., Turnbow, M.A. and Garner, C.W. (1993) Biochem. Biophys. Res. Commun. 190, 961-967). This insulin-induced down-regulation of IRS-1 was totally abolished by BAPTA-AM (cell-permeable calcium chelator), E-64d (cell-permeable thiol protease inhibitor), Cbz-Leu-Nleu-H and Cbz-Leu-Leu-Tyr-CHN2 (selective cell-permeable calpain inhibitor peptides). Calpastatin (specific calpain inhibitor protein) also inhibited the insulin-induced down-regulation of IRS-1 in transiently permeabilized cells. In addition, 3T3-L1 adipocytes express endogenous calpain which can degrade IRS-1 in cell-free extracts. These results suggest that the insulin-induced down-regulation of IRS-1 in 3T3-L1 adipocytes is mediated by a calcium-dependent thiol protease which is sensitive to inhibition by calpain inhibitors.

Cost and time savings following introduction of rejection criteria for clinical specimens

We have evaluated the yield of several tests and have instituted specimen rejection criteria to reduce costs and save time. For a 12-month period, we recorded the reduction of these tests and calculated the resultant cost and time savings. Seven changes were analyzed: not performing fungal or mycobacterial (acid-fast bacillus) cultures on cerebrospinal fluid (CSF) specimens from patients without known immunosuppression when chemistry and cell count are normal; not performing routine stool culture or ovum and parasite examination on specimens from patients in the hospital for > 3 days; not culturing endotracheal suction aspirates when no organisms or > 10 squamous epithelial cells are present; discontinuing broth cultures on all specimens except for tissue, continuous ambulatory peritoneal dialysis fluid, and CSF from patients with shunts; and eliminating bacterial antigen tests. For each test, the number not performed (n), reagent savings, and technologist time saved, respectively, were as follows: CSF fungal culture, 267, $999, and 67 h; CSF acid-fast bacillus culture, 275, $1,662, and 124 h; stool cultures, 320, $2,991, and 98 h; ovum and parasite examinations, 216, $525, and 108 h; endotracheal suction aspirate cultures, 1,505, $4,447, and 306 h; broth cultures, 5,218, $4,931, and 80 h; and bacterial antigen tests, 2,598, $2,293, and 299 h. Overall, 5,181 tests were rejected and 5,218 broth cultures were omitted. Achievable savings were $28,000 in reagent costs and 1,082 h of technologist time. In conclusion, rejecting specimens of proven low yield saves reagent costs and, more importantly, saves technologist time. This time can be spent on specimens having greater diagnostic utility.

Functional improvements following StairMaster vs. treadmill exercise training for patients with intermittent claudication

BACKGROUND

Although there have been many studies showing that exercise training is beneficial for patients with peripheral vascular occlusive disease (PVOD), there is little research comparing various modes of training. Previous studies showed that exercise tests performed on a StairMaster (StairMaster Sports/Medical Products, Kirkland, WA) produce responses similar to those elicited by treadmill tests. The purpose of this study was to compare these modes of exercise in a training program for patients with PVOD.

METHODS

Of the 23 eligible individuals who began the exercise program, 11 did not complete the regimen due to various complications. Thus, 12 patients were randomly assigned to train for 12 weeks on either a StairMaster (n = 6) or a treadmill (n = 6). Patients underwent progressive and single-stage exercise tests on both exercise modalities before and after training.

RESULTS

Mean exercise time before the onset of claudication pain for all tests rose significantly after training (P <.01), but greater improvements were seen on the specific training apparatus (i.e., treadmill training resulted in improvement in treadmill exercise performance with less improvement noted when tested on the StairMaster, and vice versa). Exercise time to maximal pain increased for the training apparatus only (P <.01). There were no changes in foot transcutaneous oxygen tension or the ankle-brachial blood pressure index.

CONCLUSIONS

Both StairMaster and treadmill training improve the exercise capacity of PVOD patients. The training effect is most apparent for the specific training apparatus, but there is some cross-over improvement to the other exercise modality. Thus, StairMaster training is appropriate and can be part of the exercise prescription for treatment of these patients.

Children's vision screening: impact on inequalities in central England

STUDY OBJECTIVE

To investigate the relationship between age at presentation of amblyopia and social deprivation before and after the introduction of changes to a vision screening service.

DESIGN

Two cohorts of children treated for amblyopia in 1983 and 1992.

SETTING

THe orthoptic department of Leicester Royal Infirmary.

PARTICIPANTS

The 209 patients treated for amblyopia who first attended the orthoptic department in 1983, and 203 who first attended in 1992.

MEASUREMENTS

Age at presentation to the orthoptic department was the main outcome measure. Social deprivation was measured by Townsend deprivation score for the electoral ward in which the child lived, using 1981 and 1991 census data.

MAIN RESULTS

After the introduction of changes in the screening programme, the mean at presentation of amblyopia associated with microtropia or no strabismus was reduced from 6.6 years to 5.0 years. In 1983 there was a significant relationship between deprivation and age at presentation (p = 0.0001), with those from more deprived areas presenting later. No similar association was found in children referred in 1992 (p = 0.17). There was no change in mean age of presentation of amblyopia associated with a large angle of strabismus (3.3 years in 1983 and 1992) and no relationship between deprivation and age at presentation 1983 or 1992 (p = 0.24 and p = 0.39 respectively).

CONCLUSION

Since the introduction of changes to vision screening, the relationship between social deprivation and the age of presentation of asymptomatic amblyopia seems to have disappeared. Children are now referred earlier and those from deprived areas are not being overlooked.

Cardiac rehabilitation as secondary prevention. Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute

This Quick Reference Guide for Clinicians highlights the conclusions and recommendations from Cardiac Rehabilitation, Clinical Practice Guideline No. 17, which was formulated by a panel representing the major health care disciplines involved in cardiac rehabilitation. The conclusions and recommendations were derived from an extensive and critical review of the scientific literature pertaining to cardiac rehabilitation, as well as from the expert opinion of the panel. This guide addresses the role of cardiac rehabilitation and the potential benefits to be derived in the comprehensive care of the 13.5 million patients with heart disease in the United States, as well as the 4.7 million patients with heart failure and the several thousand patients undergoing heart transplantation. This Quick Reference Guide for Clinicians highlights the major effects of multifactorial cardiac rehabilitation services: medical evaluation; prescribed exercise; cardiac risk factor modification; and education, counseling, and behavioral interventions. The outcomes of and recommendations for cardiac rehabilitation services are categorized as to their effects on exercise tolerance, strength training, exercise habits, symptoms, smoking, lipids, body weight, blood pressure, psychological well-being, social adjustment and functioning, return to work, morbidity and safety issues, mortality and safety issues, and pathophysiologic measures. Patients with heart failure and after cardiac transplantation, as well as elderly patients, are specifically addressed. Alternate approaches to the delivery of cardiac rehabilitation services are presented.

Wortmannin and LY294002 inhibit the insulin-induced down-regulation of IRS-1 in 3T3-L1 adipocytes

The insulin receptor substrate-1 (IRS-1) is expressed in 3T3-L1 adipocytes and is involved in at least some insulin responses, notably mitogenesis. Chronic exposure to insulin down regulates IRS-1 in these cells by stimulating its degradation (Rice, K.M., Turnbow, M.A. and Garner, C.W. (1993) Biochem. Biophys. Res. Commun. 190, 961-967). This insulin response was completely inhibited by wortmannin and LY294002 (2-(4-morpholinyl)-8-phenyl-4H-1-benzopyran-4-one), two inhibitors of phosphatidylinositol 3-kinase (PI 3-kinase). Neither wortmannin nor LY294002 had any effect on the calcium-dependent degradation of IRS-1 in vitro nor did they inhibit the phosphorylation of IRS-1 in vitro. In addition, neomycin, a cationic aminoglycoside antibiotic that binds to phosphoinositides, inhibited the insulin-induced down-regulation of IRS-1 in 3T3-L1 adipocytes and, also, the C8-PIP3-stimulated degradation of IRS-1 in vitro. These results suggest that PI 3-kinase and its 3-phosphoinositide products mediate the insulin-induced down-regulation of IRS-1 in 3T3-L1 adipocytes.