Presence of optrA-mediated linezolid resistance in multiple lineages and plasmids of Enterococcus faecalis revealed by long read sequencing

Transferable linezolid resistance due to optrA, poxtA, cfr and cfr-like genes is increasingly detected in enterococci associated with animals and humans globally. We aimed to characterize the genetic environment of optrA in linezolid-resistant Enterococcus faecalis isolates from Scotland. Six linezolid-resistant E. faecalis isolated from urogenital samples were confirmed to carry the optrA gene by PCR. Short read (Illumina) sequencing showed the isolates were genetically distinct (>13900 core SNPs) and belonged to different MLST sequence types. Plasmid contents were examined using hybrid assembly of short and long read (Oxford Nanopore MinION) sequencing technologies. The optrA gene was located on distinct plasmids in each isolate, suggesting that transfer of a single plasmid did not contribute to optrA dissemination in this collection. pTM6294-2, BX5936-1 and pWE0438-1 were similar to optrA-positive plasmids from China and Japan, while the remaining three plasmids had limited similarity to other published examples. We identified the novel Tn6993 transposon in pWE0254-1 carrying linezolid (optrA), macrolide (ermB) and spectinomycin [ANT(9)-Ia] resistance genes. OptrA amino acid sequences differed by 0–20 residues. We report multiple variants of optrA on distinct plasmids in diverse strains of E. faecalis. It is important to identify the selection pressures driving the emergence and maintenance of resistance against linezolid to retain the clinical utility of this antibiotic.

Flying with a Safety Net: Use of REBOA to Enable Safe Transfer to a Level 1 Trauma Center

Abstract Background: Using Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) during air and ground transport requires coordination among the responding clinical team, transport team, and receiving surgical team. Here, we describe the development of a REBOA transport program in a civilian medical system that demonstrates the value of REBOA as part of the toolkit for safe casualty transport. Methods: The regional REBOA program was developed at St. Anthony Summit Medical Center in a multi-step planning and training process to ensure coordination among the facilities and transport resources during trauma patient care. Retrospective record review was performed on all patients (n=5) that received REBOA for transport from the Level 3 Trauma Center to the Level 1 Trauma Center, since inception of the program in March 2019. Data were gathered from hospital electronic medical records. Results: SASMC has transported five trauma patients under the REBOA program; all successfully arrived at the Level 1 Trauma Center to receive definitive care. The integrated arterial blood pressure monitoring capability in the REBOA catheter provided robust physiologic data to enable data-driven interventions during transport. Conclusion: The REBOA program described here is a model of how REBOA can be used to enable safe transport between levels of care, when, without REBOA, such transport might not be possible. The model is applicable during care of civilian trauma patients and combat casualties, where injured patients are initially treated in a prehospital or Role1/2 environment but require transport to a Level 1 Trauma Center or Role 3+ for definitive care.  Keywords: REBOA, non-compressible hemorrhage, patient transport

P5472Social economic deprivation and adverse clinical outcomes after acute coronary syndrome

Background

NHS was created in 1948 to redress the healthcare inequality through provision of universal healthcare service in the UK. However even of late, significant health inequality persists. Socioeconomic deprivation is known to result in increased overall morbidity and mortality.

Aim

To assess the impact of socioeconomic deprivation (as categorised by Scottish Index of Multiple Deprivation, SIMD) on the medical management and clinical outcomes of patients with ACS (NSTEMI/STEMI) who were treated with PCI

Methods

A retrospective study of NSTEMI/NSTEMI patients after inpatient treatment with coronary angiogram and PCI. The parameters include basic demographics, risk factors, LV EF on echocardiogram, lipid profile and discharge medication. Individual's socioeconomic deprivation index, as described SIMD was also recorded (1 – most deprived and 10 – least deprived), and accordingly placed into quintile (SIMD 1–2, 3–4, 5–6,7 –8, 9–10). Follow-up for 24 months. Clinical outcome assessed was composite endpoint event of MACE.

Results

357 from the lowest quintile (SIMD 1–2), 319 from SIMD 3–4, 191 from SIMD 5–6, 120 from SIMD 7–8, and 99 from the highest quintile (SIMD 9–10) were included. No statistical difference exists between age or gender. No difference in past medical history (inclusive of hypertension, diabetes, dyslipidemia, family history. No difference in incidence of nicotine use.

Prescription of aspirin, P2Y12 inhibitors (clopidogrel, ticagrelor or prasugrel) as well as secondary prevention medications (such as ace inhibitor/angiotensin II receptor blocker, beta blocker, statin and GTN) were good and not statistically different between all groups.

No statistical difference exists between all groups relating to pre-discharge LV ejection fraction on echocardiogram or random cholesterol level check on admission.

24 months follow-up demonstrated composite endpoint of MACE was statistically higher among patients of lowest socioeconomic quintile (Kaplan Meier plot, p<0.001). Step-wise multiple regression analysis also confirmed multiple socioeconomic deprivation as an independent predictor for more adverse clinical outcomes (p<0.001, R2=14.5%).

Patients from the least deprived quintile possess survival advantage almost 14-folds as compared to those of most deprived group (Odd-ratio 13.8 (95% CI: 39.4–48.5)).

Summary

After an ACS event, despite initial coronary intervention and subsequent optimal prescription of prognostically beneficial secondary prevention medications, patients from the lower socioeconomic group (as described by SIMD) are still more likely to experience readmission for cardiovascular death, non-fatal myocardial infarction and non-fatal stroke. Socioeconomic deprivation has been shown to be an independent predictor of adverse clinical outcome for those who survived initial ACS.

Acknowledgement/Funding

None

Periorbital Necrotizing Fasciitis: Outcomes Using a CT-Guided Surgical Debridement Approach

Purpose

The surgical management of necrotizing fasciitis usually involves early radical/wide and aggressive debridement of involved areas. We describe 5 cases of periorbital necrotizing fasciitis (NF), managed using a computed tomographic (CT)-guided approach to surgical debridement.

Methods

Retrospective case series review.

Results

Five patients (4 female, 1 male; age range 39–81) were treated for periorbital NF. The diagnosis was confirmed in all cases with blood cultures and wound swabs. All patients were managed medically by a surviving sepsis regimen. CT scans confirmed suprafascial infection and excluded orbital cellulitis. Four patients had minimal surgical debridement to the surface muscle. All patients survived. Four out of 5 patients underwent delayed reconstruction.

Conclusions

Periorbital NF behaves differently from NF of other areas. CT-guided surgical debridement of the superficial muscle maximizes preservation of healthy tissue and facilitates reconstruction. Delayed reconstruction allows fibrosis to settle and good cosmetic and functional results are possible. However, NF remains potentially lethal and close observation and a flexible management plan are required.

Post-viraemic detection of bovine ephemeral fever virus by use of autogenous lymphoid tissue-derived bovine primary cell cultures

BACKGROUND

The potential tissue replication sites and specific cell types that support in vivo virus survival beyond the acute phase of bovine ephemeral fever virus (BEFV) infection have not been fully defined in cattle. To clarify the knowledge gap, tissue specimens were tested after collection from an adult steer necropsied 1 week after acute BEF.

CASE REPORT

Significant necropsy findings included fibrinoproliferative synovitis in the stifle joints and fibrin clot-laden fluid in serous body cavities. Moderate numbers of infiltrating neutrophils were demonstrated in sections of the prefemoral lymph nodes and haemal node, and lymphoid hyperplasia in the spleen, haemal node and prefemoral lymph nodes. Viral RNA was detected by qRT-PCR in fresh spleen, haemal node, prefemoral lymph node, synovial fluid and in several spleen-derived cell cultures. BEFV was isolated from autogenously derived splenic primary cell cultures 6 days after cessation of viraemia, and characteristic bullet-shaped virions were confirmed by electron microscopy of an ultrathin haemal node section. In sections of the spleen, haemal node and other tissues, immunohistochemistry demonstrated BEFV antigens that were intracellularly associated with probable histiocytic cells.

CONCLUSION

BEFV has preferential tropism for bovine lymphoid tissues and the spleen and haemal node may be potential sites for post-viraemic virus replication.

Viral neurotropism, peripheral neuropathy and other morphological abnormalities in bovine ephemeral fever virus-infected downer cattle

OBJECTIVE

This study assessed the neurotropism of bovine ephemeral fever (BEF) virus (BEFV) and described histomorphological abnormalities of the brain, spinal cord and peripheral nerves that may causally contribute to paresis or paralysis in BEF.

METHODS

Four paralysed and six asymptomatic but virus-infected cattle were monitored, and blood and serum samples screened by qRT-PCR, virus isolation and neutralisation tests. Fresh brain, spinal cord, peripheral nerve and other tissues were qRT-PCR-tested for viral RNA, while formalin-fixed specimens were processed routinely and immunohistochemically evaluated for histomorphological abnormalities and viral antigen distribution, respectively.

RESULTS

The neurotropism of BEFV was immunohistochemically confirmed in the brain and peripheral nerves and peripheral neuropathy was demonstrated in three paralysed but not the six aneurological but virus-infected animals. Wallerian degeneration (WD) was present in the ventral funicular white matter of the lumbar spinal cord of a paralysed steer and in cervical and thoracic spinal cord segments of three paralysed animals. Although no spinal cord lesions were seen in the steer euthanased within 7 days of illness, peripheral neuropathy was present and more severe in nerves of the brachial plexuses than in the gluteal or fibular nerves. The only steer with WD in the lumbar spinal cord also showed intrahistiocytic cell viral antigen that was spatially distributed within areas of moderate brain stem encephalitis.

CONCLUSION

The data confirmed neurotropism of BEFV in cattle and documented histomorphological abnormalities in peripheral nerves and brain which, together with spinal cord lesions, may contribute to chronic paralysis in BEFV-infected downer cattle.

Pathologic processing of the total mesorectal excision

Total mesorectal excision (TME) is the current optimal surgical treatment for patients with rectal carcinoma. A complete TME is related to lower local recurrence rates and increased patient survival. Many confounding factors in the patient's anatomy and prior therapy can make it difficult to obtain a perfect plane, and thus a complete TME. The resection specimen can be thoroughly evaluated, grossly and microscopically, to identify substandard surgical outcomes and increased risk of local recurrence. Complete and accurate data reporting is critical for patient care and helps surgeons improve their technique.

Intra-articular injection of hyaluronic acid is not superior to saline solution injection for ankle arthritis: a randomized, double-blind, placebo-controlled study

BACKGROUND

Intra-articular injections of hyaluronic acid are potentially useful to treat ankle osteoarthritis, yet their effectiveness has not been proven. Both single and multiple-dose treatments for ankle arthritis with use of various hyaluronic acid products have been recommended, but few high-quality studies have been published. The aim of this study was to compare the effectiveness of a single intra-articular injection of hyaluronic acid with a single intra-articular injection of normal saline solution (placebo) for osteoarthritis of the ankle.

METHODS

Sixty-four patients with ankle osteoarthritis who met all study criteria were randomly assigned to a single intra-articular injection of 2.5 mL of low-molecular-weight, non-cross-linked hyaluronic acid or a single intra-articular injection of 2.5 mL of normal saline solution. The primary outcome measure was the change from baseline in the American Orthopaedic Foot & Ankle Society (AOFAS) clinical rating score at the six-week and twelve-week follow-up examination. Secondary outcome measures included the Ankle Osteoarthritis Scale score and patient-reported pain with use of a visual analog pain scale.

RESULTS

Of the sixty-four patients randomized and treated, eight patients withdrew, leaving fifty-six patients who completed the entire study. There was one mild adverse event (1.6%) among the sixty-four patients. At six weeks and twelve weeks, the mean AOFAS scores in the hyaluronic acid group had improved from baseline by 4.9 and 4.9 points, respectively, whereas the mean AOFAS scores in the placebo group initially worsened by 0.4 point at six weeks and then improved by 5.4 points at twelve weeks. While the change at twelve weeks from baseline was substantial for both groups, the between-group differences were not significant.

CONCLUSIONS

We found that a single intra-articular injection of low-molecular-weight, non-cross-linked hyaluronic acid is not demonstrably superior to a single intra-articular injection of saline solution for the treatment of osteoarthritis of the ankle.

The sensitivity and specificity of sentinel lymph node biopsy for breast cancer at Baylor University Medical Center at Dallas: a retrospective review of 488 cases

Sentinel lymph node (SLN) biopsy has become the standard of care for breast carcinoma management, as it precludes the negative morbid effects-including decreased shoulder range of motion, lymphedema, and paresthesias-of unnecessary axillary lymph node dissection. However, the method of pathologic evaluation of the lymph node has been scrutinized to obtain the greatest sensitivity, specificity, and negative predictive value, ultimately for the benefit of the patient. This retrospective study analyzed 488 biopsies completed by two surgeons and read by multiple pathologists affiliated with Pathologists Biomedical Laboratories. When metastatic disease was not grossly obvious, analysis of the SLN began with touch imprint cytology and, if necessary, a frozen section analysis. On the subsequent day, three levels of the SLN were analyzed with hematoxylin and eosin stain and immunohistochemistry with cytokeratin AE1-3 and the appropriate control. Touch imprint cytology and/or frozen section analysis (where applicable) correctly identified 78 of 89 macrometastases, with a sensitivity of 88%, specificity of 100%, and negative predictive value of 97%. Sensitivity was 72% for micrometastases and 60% for isolated tumor cells, each with 100% specificity. In conclusion, the sensitivity and specificity of SLN biopsy at our institution compares with the higher end of percentages reported in the literature.

Seniors at risk: the association between the six-month use of publicly funded home support services and quality of life and use of health services for older people

This study examines the baseline characteristics and changes in health status and cost of use of health services associated with use of publicly funded home support services. The analysis includes 122 people 75 years of age or more who were eligible for home support services. Over a 6-month period, one third of the sample used home support services for more than 1 hr/week; these seniors had higher rates of depression and cognitive impairment, lower levels of physical and emotional functioning, and less effective coping styles than those who used fewer services. Cognitive impairment explained 17 per cent of the variation in use of home support services. At 6 months, use of home support services for more than 1 hr/week by seniors with higher levels of need was associated with lower cost of use of health services and lower levels of improvement in health status. These findings suggest the need for further research to identify efficacious ways of providing home support services to this population to enhance their health status using available resources.

Interbody fusion with allograft and rhBMP-2 leads to consistent fusion but early subsidence

We carried out a prospective study to determine whether the addition of a recombinant human bone morphogenetic protein (rhBMP-2) to a machined allograft spacer would improve the rate of intervertebral body fusion in the spine. We studied 77 patients who were to undergo an interbody fusion with allograft and instrumentation. The first 36 patients received allograft with adjuvant rhBMP-2 (allograft/rhBMP-2 group), and the next 41, allograft and demineralised bone matrix (allograft/demineralised bone matrix group). Each patient was assessed clinically and radiologically both pre-operatively and at each follow-up visit using standard methods. Follow-up continued for two years. Every patient in the allograft/rhBMP-2 group had fused by six months. However, early graft lucency and significant (> 10%) subsidence were seen radiologically in 27 of 55 levels in this group. The mean graft height subsidence was 27% (13% to 42%) for anterior lumbar interbody fusion, 24% (13% to 40%) for transforaminal lumbar interbody fusion, and 53% (40% to 58%) for anterior cervical discectomy and fusion. Those who had undergone fusion using allograft and demineralised bone matrix lost only a mean of 4.6% (0% to 15%) of their graft height. Although a high rate of fusion (100%) was achieved with rhBMP-2, significant subsidence occurred in more than half of the levels (23 of 37) in the lumbar spine and 33% (6 of 18) in the cervical spine. A 98% fusion rate (62 of 63 levels) was achieved without rhBMP-2 and without the associated graft subsidence. Consequently, we no longer use rhBMP-2 with allograft in our practice if the allograft has to provide significant structural support.

Systematic review of the effectiveness of population screening for colorectal cancer

AIM

To estimate the effectiveness of colorectal cancer screening with faecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), and combinations of FOBT and FS in preventing colorectal cancer (CRC) deaths.

METHOD

A systematic review was conducted examining randomised controlled trials (RCTs) published between 1997 and 2004 inclusive. A systematic search of Medline, Embase, Current Contents, and the Cochrane Library was undertaken. Studies that evaluated screening with FOBT, FS or combinations of FOBT and FS, were appraised. A meta-analysis of population-based trials of FOBT was conducted.

RESULTS

Four RCTs were identified that examined FOBT screening. The three trials that investigated guaiac-based FOBT found CRC mortality was reduced in the screening group. In the two population-based trials, the pooled relative risk was 0.86 (95%CI 0.79-0.93). A fourth RCT was identified, with shorter term follow-up, which considered FOBT screening combined with FS compared with FOBT alone. No significant reduction in CRC mortality was reported in this trial.

CONCLUSION

There is high-quality evidence showing that guaiac-based FOBT screening reduces mortality from CRC. No such evidence exists for screening with FS either alone, or in combination with FOBT, but this should be re-evaluated once data become available from four large ongoing trials.

New multifunctional prosthetic arm and hand systems

We are building a new hand with 18 DOF which has all its actuators inside the body of the hand. This hand is in a form suitable for the 50% women but has the strength capabilities of a 50% male.

Intra-arterial reteplase compared to urokinase for thrombolytic recanalization in acute ischemic stroke

BACKGROUND AND PURPOSE

Reteplase (RP) and urokinase (UK) are being used "off-label" to treat acute ischemic stroke. The safety and efficacy of intra-arterial RP or UK in the treatment of acute ischemic stroke, however, has yet to be proved. We aim to evaluate the safety and efficacy of RP compared with UK in acute ischemic stroke patients with large vessel occlusion.

METHODS

Retrospective analysis was conducted of cases from a prospectively collected stroke data base on consecutive acute ischemic stroke patients with large vessel occlusion by digital subtraction angiography treated with intra-arterial RP or UK. Thrombolytic dosage, recanalization rate, intracerebral hemorrhage (ICH), mortality, and outcome were determined.

RESULTS

Thirty-three patients received RP and 22 received UK (mean doses, 2.5 +/- 1.4 mg and 690,000 +/- 562,000 U, respectively). Vascular occlusions included 9 basilar arteries (BAs), 7 internal carotid arteries (ICAs), and 17 middle cerebral arteries (MCAs) with RP and 9 BAs, 4 ICAs, and 9 MCAs with UK. Median baseline National Institutes of Health Stroke Scales were as follows: 16 (range, 5-25; 81% > or = 10) with RP and 17 (range, 6-38; 85% > or =10) with UK. Mean time from symptom onset to thrombolytic initiation: 333 +/- 230 minutes with RP and 343 +/- 169 minutes with UK. Recanalization rates were as follows: 82% with RP and 64% with UK (P = .13). Symptomatic ICH rates were as follows: 12% with RP and 4.5% with UK (P = .50). The mortality rate was 24% with RP and 27% with UK (P = .8).

CONCLUSION

Although limited in statistical power, our study suggests that, although IA thrombolysis with RP shows a trend for higher recanalization rates and hemorrhage rates, IA thrombolysis with RP is not significantly different in recanalization, outcome, mortality, and ICH compared with that of UK or rates reported with IA pro-UK.

Treatments that improve outcome in the patient with heart failure, left ventricular systolic dysfunction, or both after acute myocardial infarction

Patients with heart failure, left ventricular systolic dysfunction, or both, after acute myocardial infarction have a poor prognosis. It is important to focus treatment on this high risk group to reduce the persistently high morbidity and mortality after acute myocardial infarction. As in chronic heart failure, there is now good evidence that inhibition of the renin-angiotensin-aldosterone system and sympathetic nervous system, with the appropriate drugs, can reduce morbidity and mortality. In addition to angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and beta blockers, the aldosterone blocker eplerenone has now been shown to be effective in reducing adverse outcomes.

The Amsler chart is of doubtful value in retinal screening for early laser therapy of subretinal membranes. The West London Survey

PURPOSE

Validating the current protocol of Amsler chart grid surveillance for the early detection of subretinal neovascular membrane(SRN) in age-related macular degeneration(AMD), and investigating its value in facilitating early laser therapy.

METHODS

A retrospective pilot study.

SETTING

Central London eye hospital with dedicated 24-h ophthalmic casualty serving West and West-central London.

PARTICIPANTS

100 consecutive AMD patients who attended casualty with vision loss fulfilling the following criteria: patients had received and been instructed in the use of Amsler charts according to the unit's dispensation protocol,fluorescein angiography which confirmed new SRN. Patients presented over 20 months. Outcome measures were detection of SRN by the Amsler chart, and laser treatment of SRN.

RESULTS

The Amsler chart surveillance protocol had detected SRN in 29 of the 100 patients. The surveillance protocol detected less than 30% of the specific patients who subsequently underwent laser treatment. A statistically significant difference was seen on comparing the ages of patients in whom the screening protocol was successful versus those in whom it was unsuccessful (student's t-test,P<3.2 x 103). Younger patients were more likely to be detected using the Amsler chart. A one-tailed Z2 test approached, but did not achieve, statistical significance (Z2 = 1.057,P <0.3) suggesting that patients who have already lost vision to SRN in one eye might not be more likely to be detected using the surveillance protocol than patients in whom SRN was affecting their first eye. In all, 38% of surveillance responders went on to receive laser therapy, compared with 37% of surveillance nonresponders.

CONCLUSIONS

The current Amsler chart surveillance protocol is suboptimal for detecting SRN in AMD, and a proportion of cases suitable for early laser therapy may be missing rapid detection. The results are especially important since recent advances in laser therapy for SRN require early detection for optimal effectiveness.

[Studies on human cytokine responses before and after praziquantel chemotherapy in an endemic area of schistosomiasis japonica]

OBJECTIVE

To observe the cellular immune responses in a population of an endemic area of schistosomiasis japonica and the influence of praziquantel treatment.

METHODS

Blood was taken from 129 residents (64 cases were egg-positive, 65 cases were egg-negitive) of an endemic area of Poyang Lake before and 45 days after praziquantel treatment. Cytokines induced by the schistosome soluble egg antigen (SEA) and soluble worm antigen preparations (SWAP) in the peripheral blood cells including IL-5, IL-10 and IFN-gamma were measured.

RESULTS

Among 129 cases, the cytokine levels were found much higher in egg negative individuals than in egg-positive individuals. The cytokine levels induced by both antigens were increased significantly after praziqantel treatment especially IL-5 and IFN-gamma.

CONCLUSION

The cellular immune responses in the population in schistosomiasis japonica endemic area exhibited a general trend of down-regulation and were elevated significantly after praziquantel treatment.

Interventions for disability management

BACKGROUND

With an increasing prevalence of low back pain, management can include modified work, work-conditioning, or work-hardening programs. Modified work programs, or employer's worksite interventions or clinic-based programs under medical supervision, provide a gradual increase of workload. Work-conditioning programs, or unimodal physical conditioning and function activities, promote return to work. Work-hardening programs, or graded work simulations and psychological interventions, are used as part of an interdisciplinary program addressing physical and functional needs.

OBJECTIVE

The objective of the review was to determine how effective modified work programs, work hardening, and work conditioning are in the management of chronic pain disability.

METHODOLOGY

The literature search identified two systematic literature reviews to provide the evidence about these interventions for disability management.

RESULTS

Studies of work conditioning showed methodological variability, heterogeneous subjects, variable definitions of modified work, and limited outcome measures. Using return-to-work outcomes, 8 of the 11 studies of adequate methodological quality reported positive effects of modified work programs, mostly light duty. For work conditioning and work hardening, studies showed methodological variability combined with heterogeneous subjects, including varying times out of work and varying work ethics from different countries. Most study results were uncertain, though results of three of the four medium-quality studies were positive.

CONCLUSIONS

Modified work programs may improve return-to-work rates of workers with work-related injuries for 6 months or longer (level 2). There is inadequate evidence (level 4a) to determine what particular aspects of modified work programs are helpful. Work conditioning and work hardening may or may not improve the return to work of more chronically disabled workers (level 4b).

Biopsychosocial approaches to the treatment of chronic pain

BACKGROUND

Biopsychosocial treatments address the range of physical, psychological, and social components of chronic pain.

OBJECTIVE

This review sought to determine how effective unimodal and multimodal biopsychosocial approaches are in the treatment of chronic pain.

METHODOLOGY

The literature search identified three systematic reviews of the literature and 21 randomized controlled trials to provide the evidence for this review.

RESULTS

The systematic reviews and 12 randomized controlled trials reported on chronic low back pain. Other randomized controlled trials studied fibromyalgia (three trials) and back or other musculoskeletal disorders (five trials). Biopsychosocial components reviewed were electromyogram feedback and hypnosis as unimodal approaches, and behavioral and cognitive-behavioral treatments and back school, or group education, as multimodal approaches for chronic low back pain. For other chronic pain disorders, cognitive-behavioral treatments were reviewed. Comparisons were hindered by studies with heterogeneous subjects, varied comparison groups, different cointerventions and follow-up times, variable outcomes, and a range of analytic methods.

CONCLUSIONS

Multimodal biopsychosocial treatments that include cognitive-behavioral and/or behavioral components are effective for chronic low back pain and other musculoskeletal pain for up to 12 months (level 2). There is limited evidence (level 3) that electromyogram feedback is effective for chronic low back pain for up to 3 months. The remaining evidence of longer-term effectiveness and of effectiveness of other interventions was inadequate (level 4a) or contradictory (level 4b). Future studies of cognitive-behavioral treatments should be condition specific, rather than include patients with different pain conditions.

Notification of gastrointestinal illness by Canterbury and West Coast general practitioners

AIM

To identify factors influencing notification of enteric diseases by general practitioners (GPs).

METHODS

The 'laboratory-based notification rate' was calculated for each GP by dividing the number of cases they notified by their number of laboratory detected cases of selected enteric diseases during 1997 and 1998. The 'annual full time equivalent (FTE) notification rate' was defined as the number of notifications received during the study period adjusted for the proportion of that time spent in clinical practice. These measures were compared with responses to a questionnaire posted to 395 Canterbury and West Coast GPs.

RESULTS

82% responded to the questionnaire. Higher 'laboratory-based notification rates' and 'annual FTE notification rates' were associated with the practice nurse being responsible for notifying and with GPs who were more recent graduates or who practised in rural areas. Few respondents identified high risk groups in their criteria for requesting a specimen.

CONCLUSIONS

Communicable disease control could be enhanced by emphasising the importance of specimen collection in high risk groups, encouraging delegation of notification to practice nurses and encouraging the development of public health based guidelines to determine the need for specimen request

Influenza vaccination coverage in Canterbury rest homes

AIMS

First, to investigate the effect on Canterbury rest home residents of national policy making influenza vaccination free for those aged 65 years and over. Second, to assess rest home staff influenza vaccination coverage.

METHODS

A comparison of influenza vaccination coverage in Canterbury rest home residents during 1996 and 1997 was conducted. Subgroups of rest homes were formed in 1997 to minimise the bias introduced through conducting a coverage survey in 1996. Staff vaccination coverage was also assessed in 1997.

RESULTS

Influenza vaccination coverage of Canterbury rest home residents was 74% in 1996 and 76% in 1997. Staff vaccination coverage was 21% in 1997. Significantly more staff were vaccinated in rest homes that offered free influenza vaccination to their staff.

CONCLUSIONS

The free influenza vaccination policy had no measurable impact on Canterbury rest home residents' vaccination coverage. This may be due to a ceiling effect of previously high coverage. Coverage was low amongst rest home staff. Providing the vaccination free of charge might improve staff coverage.

Developing a model of collaborative research: the complexities and challenges of implementation

While the benefits of collaborative research have been well documented, fewer publications exist regarding the complex, problematic issues involved in these undertakings. This paper offers an integrated collaborative research model to depict the complexities and challenges of initiation and implementation of a 2 1/2 year joint research project between a community hospital and a university school of nursing in Southern Ontario, Canada. A sampling of the experiences of the researchers are analyzed to clarify the dynamic and often competing issues and interactions involved in encouraging hospital-wide research involvement during periods of organizational growth and change. The model reflects the simultaneous interaction of organizational, change and collaborative processes while maintaining the rigor of the research (RCT), and ensuring minimal disruption to the service agency. Quantitative outcomes of this collaboration are presented through an analysis of participant involvement on multiple organizational levels. Recommendations for future collaborative research, including design and methodological issues and collaborative and change strategies are offered. The complexity of balancing the necessary trade-offs required of successful collaborative research are highlighted and will be useful to those considering and planning future collaborations.

Economic evaluations of community-based care: lessons from twelve studies in Ontario

A series of 12 studies (five historic cohort and seven randomized trials) examined clients in community settings in Southern Ontario suffering from a variety of chronic physical and mental health conditions. These studies are appraised using a framework for evaluating possible outcomes of economic evaluation. In the 12 studies, sample composition and size varied. Each study was designed to quantify the well-being outcomes and expenditures associated with different community-based approaches to care provided in the context of a system of national health insurance. As a collective, these studies represent increasing methodological rigour. Multiple-perspective client well-being outcome measures were used. In two studies, caregiver burden also was analysed. A common approach to quantification and evaluation of expenditures for service consumption was used in all 12 studies. The nature of community-based health services (health vs. disease care orientation) was found to have direct and measurable impact on total expenditures for health service utilization and client well-being outcomes. In most cases, a recurring pattern of equal or better client outcomes, yet lower expenditures for use of community based health services, was associated with well-integrated health oriented services. Integrated services aimed at factors which determine health are superior when compared to individual, fragmented, disease oriented, and focused approaches to care. The main lessons from the 12 studies are that it is as or more effective and as or less expensive to offer complete, proactive, community health services to persons living with chronic circumstance than to provide focused, on-demand, piecemeal services. Complete services would have a psychosocial and mental health focus included with the physical care approach. Furthermore, people with coexisting risk factors (age, living arrangements, mental distress and problem-solving ability) are the ones who most benefit at lower expense from health oriented, proactive interventions.

The quick response initiative in the emergency department: who benefits?

OBJECTIVES

This collaborative project between two community hospitals, a Metropolitan Home Care Program and the University, was designed to quantify the applicability (who is eligible for) and acceptability (who will likely comply with) Home Care services, provided through a Quick Response Program (QRP) initiative as compared to usual hospital care services, to patients, families and physicians.

METHODS

During a 6 week period of sampling (5 days per week, 8 hours per day) in two Emergency Departments (ED) in moderately sized community hospitals in a major metropolitan city, all patients triaged to the urgent category were assessed for eligibility for QRP services by on-site Home Care Coordinators using specific criteria. Patients meeting the criteria initially were reviewed by the ED physician for approval for QRP services and then randomized to experimental and control conditions. Patients not meeting the eligibility criteria were managed by the usual ED services procedures. Demographic and clinical data were obtained on all urgent category patients at presentation to the ED. Additionally, the nature and cost of all health care services used by the ED patients during the ED event and 10 days follow up, were obtained through hospital and Home Care record abstraction and compared among the different sample groups.

RESULTS

The QRP Initiative was applicable to 2% of the total ED patient population and 5% of the urgent category of patients triaged in the ED. It was acceptable to 97% of this eligible group. One hundred and fifty-five patients who initially qualified for QRP were excluded from eligibility at a subsequent assessment. Ninety of these patients were admitted to hospital and 65 were discharged home. In the total "exclusion" group, 37 refused Home Care services including the QRP. HEALTH CARE PRACTICE IMPLICATIONS: The sampling results raise important questions about broader system issues concerning the role of the hospital and community in providing health care services and the social value or utility that guides the allocation of health care funds. What level of applicability and acceptability would justify priority services for certain target groups. In the future, policy makers will need to be able to show that it is in the best interest of patients and society to prioritize mixtures of services to certain target groups.

Informed consent and general surgeons' attitudes toward the use of pain medication in the acute abdomen

To determine general surgeons' attitudes about the use of pain medications in the acute abdomen, a questionnaire was mailed to all practicing general surgeons in Iowa. The questionnaire sought to determine the frequency with which pain medications were administered either before informed consent was obtained or before the patient with an acute abdomen was examined, and, in cases when pain medications were withheld, the reasons for withholding. The response rate was 72% (131 of 182). Seven percent of patients with an acute abdomen received pain medications by a general surgeon before being seen and 22% received pain medication by another physician in the emergency department (ED). Fifty-three percent of general surgeons responded that they believe pain medications preclude a patient from signing a valid informed consent; 78% reported that concerns about informed consent enter into their decision to withhold pain medications. Sixty-seven percent agreed that pain medications interfere with diagnostic accuracy, and 82% consider diagnostic accuracy when deciding to withhold pain medication.

CD4-immunoglobulin G2 protects Hu-PBL-SCID mice against challenge by primary human immunodeficiency virus type 1 isolates

CD4-immunoglobulin G2 (IgG2) is a fusion protein comprising human IgG2 in which the Fv portions of both heavy and light chains have been replaced by the V1 and V2 domains of human CD4. Previous studies found that CD4-IgG2 potently neutralizes a broad range of primary human immunodeficiency virus type 1 (HIV-1) isolates in vitro and ex vivo. The current report demonstrates that CD4-IgG2 protects against infection by primary isolates of HIV-1 in vivo, using the hu-PBL-SCID mouse model. Passive administration of 10 mg of CD4-IgG2 per kg of body weight protected all animals against subsequent challenge with 10 mouse infectious doses of the laboratory-adapted T-cell-tropic isolate HIV-1(LAI), while 50 mg of CD4-IgG2 per kg protected four of five mice against the primary isolates HIV-1(JR-CSF) and HIV-1(AD6). In contrast, a polyclonal HIV-1 Ig fraction exhibited partial protection against HIV-1(LAI) at 150 mg/kg but no significant protection against the primary HIV-1 isolates. The results demonstrate that CD4-IgG2 effectively neutralizes primary HIV-1 isolates in vivo and can prevent the initiation of infection by these viruses.

Involvement of the complement system in antibody-mediated post-exposure protection against human immunodeficiency virus type 1

We previously reported that passive transfer of a murine V3-specific monoclonal antibody (BAT123) to hu-PBL-SCID mice challenged with HIV-1LAI confers postexposure protection from infection. The role of the Fc fragment of this antibody as well as the involvement of the complement system in protection were evaluated in vivo. When we compared the postexposure protection offered by BAT123 and CGP 47439, a chimeric form of BAT123 in which the murine Fc domain has been replaced by a human IgG1 Fc domain, CGP 47439 failed to provide postexposure protection against HIV-1LAI despite having similar pharmacokinetics and in vitro neutralizing activity. Furthermore, when hu-PBL-SCID mice were treated with cobra venom factor, which inactivates serum complement activity, the postexposure protective ability of BAT123 was abrogated. These findings suggest that the complement system is involved in the passive protection against HIV-1 infection conferred by the murine monoclonal antibody BAT123 in hu-PBL-SCID mice.

Passive immunization with a human monoclonal antibody protects hu-PBL-SCID mice against challenge by primary isolates of HIV-1

How well antibodies can protect against disease due to HIV-1 infection remains a pivotal but unresolved issue with important implications for vaccine design and the use of prophylactic antibody to prevent infection after accidental exposure to the virus and to interrupt transmission of virus from mother to child. Strong doubts about the possible utility of antibodies in vivo have been raised because of the relative resistance of primary viruses to antibody neutralization in vitro. Primary viruses are likely to be close to the viruses transmitted during natural infection in humans. Vaccine studies have been of little value in assessing antibody efficacy in vivo because none of the strategies described to date have elicited significant neutralizing antibody responses to primary viruses. Passive immunization studies are similarly hindered by the paucity of reagents able to neutralize primary viruses effectively and a single study has suggested some benefit. Here we describe experiments to explore the ability of passive antibody to protect against primary virus challenge in hu-PBL-SCID mice. In this model, severe combined immunodeficient (SCID) mice are populated with human peripheral blood mononuclear cells (PBMCs) and infected with HIV-1. We find that the potent neutralizing human monoclonal antibody IgG1b12 at high dose is able to completely protect even when given several hours after viral challenge. The results are encouraging for antibody-based postexposure prophylaxis and support the notion that antibody induction could contribute to an effective vaccine.

Visual organization test performance in an African American population with acute unilateral cerebral lesions

Controversy abounds as to whether the Hooper Visual Organization Test (VOT) is a measure of hemisphere-specific, region-specific, or non-specific brain damage. The present study examines this issue in a group of African Americans with acute unilateral brain damage and non-brain-injured controls. Consistent with the idea that the VOT is a measure of "organic" cerebral pathology, non-brain damaged controls earned significantly higher VOT scores than brain-damaged patients. While other studies have noted that the VOT is primarily sensitive to damage in the right parietal region of the brain, the present study shows that VOT performance is especially vulnerable to acute lesions in the right anterior quadrant of the brain. This latter finding supports the idea that VOT performance is differentially sensitive to regional cerebral pathology, but challenges the region specific claim of poorer VOT performance among patients with right posterior cerebral damage.

Unilateral brain lesions and performance on Russell's version of the Wechsler Memory Scale in an African American population

Studies of patients with unilateral lesions report hemisphere-specific and locus-specific impairments on Russell's (1975) Revision of the Wechsler Memory Scale (RWMS). In the current investigation "race-homogeneous" and "race-comparative" paradigms provide the context in which the generalizability of RWMS findings are examined in a population of African Americans with unilateral lesions. The performances of brain-damaged patients were impaired relative to normal controls on five of the six RWMS measures. However, patients with left and right hemisphere damage in our sample did not differ systematically on RWMS subtests. Likewise, among patients with lesions confined to one of the quadrants in the brain, there were no quadrant group differences in performance on RWMS subtests. But, right posteriors were impaired relative to controls on immediate and delayed VR subtests. The relative merits of the race-comparative and race-homogeneous paradigms are considered in the context of these findings.

The efficacy and effectiveness of process consultation in improving staff morale and absenteeism

OBJECTIVES

The purpose of this randomized controlled trial was to test the efficacy and effectiveness of process consultation consisting of a series of nurse manager-consultant problem-solving meetings for leadership development that would lead to their staff's improved morale, quality of care, and reduced absenteeism.

METHODS

Thirteen consenting clinical inpatient units were stratified for four variables known to affect outcome and were then randomly assigned to treatment and control conditions. The nurse managers from the seven experimental units were paired with outside nurse consultants from the McMaster University School of Nursing (Hamilton, Ontario, Canada) in a cooperative form of retraining in problem-solving through process consultation. Morale was determined through measures of perceptions of the work environment, an attitude scale concerning work (alienation), a personality measure (hardiness), and one of each scale for work satisfaction and for sources of satisfaction and dissatisfaction. Demographic data and information regarding family life responsibilities were collected as well. Assessment of quality of care was determined by the frequency and type of incident reports and by patients' perception of their satisfaction. A ratio of absence hours to total paid hours of work was used to compare experimental and control units' absenteeism rates.

RESULTS

Experimental subjects reported a statistically significant improvement in the characteristics of their work setting and in the quality of working relationships. The consultation process facilitated a perceived change in the organizational context of the experimental hospital units with less centralization of authority and more clarity about expectation. These organizational changes were accompanied by improved working relationships and less alienation from work. There was no statistically significant difference in absenteeism. However, a subanalysis of the units by "dose" of the intervention identified those who benefited from the effects of the consultation. Subjects whose nurse managers participated more actively in the consultation process accounted for the changes in working relationships and perceived organizational changes. The "low-dose" experimental subjects were more like the control subjects, with the exception of absenteeism, for which they had higher rates.

CONCLUSIONS

The findings of this study suggest that process consultation can alter the staff's perceptions of the characteristics of the work setting, can reverse negative attitudes (alienation), and can create a more positive and supportive working environment (improved working relationship). However, the results suggest the need to target this type of intervention to managers who have the personal resources to engage in self-evaluation and personal development and thus to participate in the consultative process.

Nucleotide sequence of the Barmah Forest virus genome

Barmah Forest virus (BFV) is an atypical alphavirus [Dalgarno, L., Short, N. J., Hardy, C. M., Bell, J. R., Strauss, J. H., and Marshall, I. D. (1984). Virology 133, 416-426] and has been classified as the sole known member of a seventh alphavirus serocomplex. The complete nucleotide sequence of BFV genomic RNA is 11,488 nucleotides in length excluding the poly(A) tail. Two long open reading frames in the RNA encode a nonstructural polyprotein of 2411 amino acids and a structural polyprotein of 1239 amino acids, respectively. The BFV envelope protein E2 is unique among sequenced alphaviruses in having no N-linked glycosylation sites; E1 carries two glycosylation sites. From amino acid sequence comparisons with sequenced alphaviruses BFV is most closely related to Ross River and Semliki Forest viruses. Sequence homology between BFV and other alphaviruses is relatively uniform along the length of the nonstructural and structural polyproteins, providing no evidence that BFV has arisen from recombination between ancestral alphaviruses in the coding region of the genome. The BFV 3' noncoding region of 445 nucleotides has unusual features. There are two unrelated sequence blocks of 48 nucleotides (sequence I) and 47 nucleotides (sequence II) both of which are repeated once. Sequence I is closely related to a repeat in the 3' noncoding region of Ross River and Getah viruses; sequence II is unrelated to repeat blocks in other sequenced alphaviruses. Thus, recombination between ancestral viruses may have played a role in the evolution of the BFV 3' noncoding region.

Gender differences in psychosocial adjustment to chronic pain and expenditures for health care services used

Gender differences in reports of chronic pain, in coping responses to the consequences of painful conditions, and in the use of health care services have recently received considerable attention. This report examines the gender effects of referral practices to a chronic pain specialty clinic and the nature of the relationship between health care needs and use of health care services. This historical cohort analytic survey of 571 patients referred to the pain clinic assessed them by gender for selected referral variables through a chart review, and randomly sampled (n = 222) these patients' current adjustment and health service use through mailed questionnaires or telephone interview. The questionnaire consisted of psychosocial scales (PAIS-SR; Social Support); cognitions, including the Meaning of Illness Questionnaire (MIQ); and a health service utilization inventory designed to assess direct, out-of-pocket, indirect, and cash transfer expenditures. Selected referral demographic characteristics were similar between the gender groups at referral with the exception of three factors: distance from clinic, referring physician, and having a disability pension. At follow-up, the adjustment groups were similar to their gender counterparts on all sociodemographic and clinical variables including a high prevalence of poor psychosocial adjustment. Women's adjustment was accounted for by cognitive variables, whereas men's adjustment was by social variables. There were differential expenditures for health service use by gender with similar health care needs. Women used specific health care services more than men, which was explained in part by psychological need and meaning. Men's use of services, on the other hand, was explained in part by meaning alone. The importance of gender, differences in the role that social support and meaning variables play in predicting psychosocial adjustment to chronic pain is elaborated in this study. The interaction effects between health care need and gender to explain variations in use of health care services indicates that users of services varied in ways that suggest a bias or barrier of their own or of service providers to access services.

Community acquired pneumonia: aetiology and usefulness of severity criteria on admission

BACKGROUND

Community acquired pneumonia remains an important cause of hospital admission and carries an appreciable mortality. Criteria for the assessment of severity during admission have been developed by the British Thoracic Society (BTS). A study was performed to determine the sensitivity and specificity of a severity rule based on a modification of the BTS prognostic rules applied on admission, to compare severity as assessed by medical staff with the modified rule, and to determine the microbiological cause of community acquired pneumonia in Christchurch.

METHODS

A 12 month study of all adults admitted to Christchurch Hospital with community acquired pneumonia was undertaken. Three hundred and sixteen consecutive patients with suspected community acquired pneumonia were screened for inclusion. Variables obtained from the history, examination, investigations, and initial treatment were examined for association with mortality.

RESULTS

Two hundred and fifty five patients met the inclusion criteria. Their mean age was 58 years (range 18-97). A microbiological diagnosis was made in 181 cases (71%), Streptococcus pneumonia (39%), Mycoplasma pneumoniae (16%), Legionella species (11%), and Haemophilus influenzae (11%) being the most commonly identified organisms. Patients had a 36-fold increased risk of death if any two of the following were present on admission: respiratory rate > or = 30/min, diastolic BP < or = 60 mm Hg, urea > 7 mmol/l, or confusion. The severity rule identified 19 of the 20 patients who died and six of eight patients admitted to the intensive care unit as having life threatening community acquired pneumonia. The sensitivity of the modified rule for predicting death was 0.95 and the specificity 0.71. In 47 cases (21%) the clinical team appeared to underestimate the severity of the illness.

CONCLUSIONS

The organisms responsible for community acquired pneumonia in Christchurch are similar to those reported from other centres except for Legionella species which were more common than in most studies. The modification of the BTS prognostic rules applied as a severity indicator at admission performed well and could be incorporated into management guidelines.

Defining antibody protection against HIV-1 transmission in Hu-PBL-SCID mice

Multiple monoclonal and polyclonal antibody preparations have been shown to neutralize HIV-1 infection in vitro. Upon direct testing in humans, however, many of these have failed to demonstrate clinical efficacy. Hu-PBL-SCID mice offer a model system in which to test the pre-clinical efficacy of antibody preparations. Testing in hu-PBL-SCID mice has shown that some antibodies are able to mediate pre- and post-exposure protection against HIV-1 infection, at concentrations that should be attainable in humans. Despite differences in the route and mode of transmission in humans and in hu-PBL-SCID mice, several aspects of the model make it a favorable model for future testing of antibody protection against HIV-1 infection. These include the architecture of the peritoneal cavity, the mixture of human cells that engraft, the density of human target cells for HIV-1 infection, and the presence of complement and NK cells that can interact with antibody preparations in blocking HIV-1 infection. The use of this model in testing newer antibody preparations for efficacy against primary isolates should enhance our knowledge of the mechanisms of antibody protection against HIV-1 infection in vivo and speed the pre-clinical evaluation of potential immunoprophylactic agents against HIV-1.

More effective and less expensive: lessons from five studies examining community approaches to care

Does the nature of community health services used by chronically ill clients and their caregivers have an impact on utilization of services, expenditure and well-being outcomes? A series of five studies, (four historic cohort and one randomized trial) examined clients suffering from a variety of chronic conditions in a number of community settings in different regions of Southern Ontario. Study sample composition and size varied. Each study was designed to quantify the well-being outcomes, and expenditure associated with different community approaches is covered under a nation-wide system of health insurance plans. As a collective, these studies represent increasing methodological rigor. Multiple-perspective client well-being outcome measures were used. Caregiver burden was also analyzed. A common approach to quantification and evaluation of expenditure for service consumption was applied across all five studies. The nature of community health services (proactive versus reactive approaches to care) was found to have direct and measurable impact on total expenditure for health service utilization and client well-being outcomes. A recurring pattern of lower expenditure for community health service utilization and equal or better client outcomes was associated with well-integrated proactive services when compared with individual fragmented, reactive approaches to care. The main lesson emerging from examining the five studies on approaches to community care is that it is as, or more, effective and less expensive to offer complete proactive health care services to chronically ill people in the early stages of their illness than to provide services on demand in a piecemeal manner.