Provision of eye care services and interventions in care homes: a narrative synthesis review

BACKGROUND

The prevalence of eye disease and visual impairment in care home residents is disproportionately higher compared to the general population. Access to eye care services and treatment can be variable for this vulnerable population.

OBJECTIVE

This paper reviews the available evidence of services and interventions for delivering eye care to care home residents. The key review questions are: (1) What is the existing evidence for eye care interventions or services (including service configuration) for care home residents? (2) Does the provision of these interventions or services improve outcomes?

METHODS

Literature search of EMBASE/MEDLINE for original papers published since 1995. Two reviewers independently reviewed abstracts/papers. Data were extracted and evaluated using narrative synthesis.

RESULTS

13 original papers met the inclusion criteria. Domiciliary optometrist services improved diagnosis and management of eye conditions, with one study showing 53% of residents benefited from direct ophthalmology intervention. Provision of interventions, such as cataract surgery, refractive error correction and low-vision rehabilitation, improved visual acuity and vision-related quality of life but did not improve cognitive or physical function, depression or health-related quality of life. There was little UK-based literature to inform eye service design or interventions to improve outcomes such as falls.

CONCLUSION

Care home-based eye assessments improve the management of eye conditions. Interventions improve visual acuity and vision-related quality of life. Further research is needed to better understand current UK services, access difficulties or examples of good practice as well as to identify and test cost-effective service models for this vulnerable group.

1210 PROVISION OF EYE CARE SERVICES AND INTERVENTIONS IN CARE HOMES - A NARRATIVE SYNTHESIS REVIEW

Introduction

The prevalence of eye disease and visual impairment in care home residents is disproportionately higher compared to the general population. Access to eye care services and treatment can be variable for this vulnerable population.

Objective

This narrative synthesis reviews the available evidence of services and interventions for delivering eye care to care home residents. The key review questions:

Methods

Literature search of EMBASE/MEDLINE for original papers published since 1995. Two reviewers independently reviewed abstracts/papers. Data was extracted and evaluated using narrative synthesis.

Results

13 original papers met the inclusion criteria. On-site optometrist-led services improved diagnosis and management of eye conditions, with one study showing 53% of residents benefited from direct ophthalmology intervention. Provision of interventions such as cataract surgery, refractive error correction and low vision rehabilitation improved visual acuity and vision-related quality of life but did not improve cognitive or physical function, depression or health-related quality of life. There was little UK-based literature to inform eye service design or interventions to improve outcomes.

Conclusion

Care home-based eye assessments improve the management of eye conditions. Interventions improve visual acuity and vision-related quality of life. Further research and/or clinical service scoping is needed to better understand current UK services, access difficulties or examples of good practice as well as to identify and test cost-effective service models for this vulnerable group.

1226 A MULTI-DISCIPLINARY APPROACH TO TRANSFORMING EYE CARE SERVICES FOR CARE HOME RESIDENTS

Introduction

Care home residents can have variable access to eye care services and treatments. We developed a collaborative approach between optometrists, care homes, and primary and secondary care to enable personalised patient-centred care.

Objective

To develop and evaluate an integrated model of eye care for care home residents.

Methods

Small scale plan-do-study-act (PDSA) service tests were completed in three care-homes in Southwark (2 residential, 1 nursing) between November 2021 to May 2022. Processes were compared to historical feedback and hospital-based ophthalmology clinic attendances (Mar 2019-2020). Hospital-like assessments were piloted at two care homes for feasibility and acceptability. Further piloting utilised usual domiciliary optometry-led assessment with multidisciplinary meeting access (including optometrist, GP, geriatrician, ophthalmologist and care home nurse) to reduce duplication of assessments and to evaluate MDM processes and referral rates.

Results

Examination was 100% successful at home (visual acuity and pressure measurement) compared to hospital outpatients (71.7% success visual acuity, 54.5% pressures). Examination was faster than in hospital settings (16 minutes vs 45 minutes-1 hour). Residents were away from usual activities for 32 minutes vs 6 hours for hospital visits including transport. Residents were less distressed with home-based assessments. Did-Not-Attend (DNA) rates reduced (26.7% to 0%), secondary care discharge rates improved (8.4% to 32%). Hospital eye service referral were indicated in 19% -23%, half of which were for consideration of cataract surgery. Alternative conservative plans were agreed at MDM for nursing home residents who were clinically too frail or would not have been able to comply with treatments avoiding 33% unnecessary referrals.

Conclusions

Home-based eye care assessments appear better tolerated and are more efficient for residents, health and care staff. Utilising an MDM for optometrists to discuss residents with ophthalmologists and wider MDT members enabled personalised patient-centred decision-making. Future work to test this borough wide is in progress.

Chondromyxoid fibroma of the iliac bone: a brief radiological review

Chondromyxoid fibroma (CMF) is a rare, benign bone tumour most commonly located within the metaphyseal region of the long bones surrounding the knee joint. Here, we present an interesting case of a young woman in her early 20s with CMF of the left iliac bone and include a literature review of comparable studies with an emphasis on radiological findings and important differential diagnoses to be aware of in this atypical location.

Anatomical and Radiological Description of the Spring Ligament Articular Facet (SLAF)

Category:

Basic Sciences/Biologics; Midfoot/Forefoot

Introduction/Purpose:

Spring ligament is a principle static stabilizer of the medial longitudinal arch. There is a triangular facet of fibrocartilage in its superomedial bundle that articulates with the talar head which is poorly described in the literature. The aim of this study was to carry out a formal anatomical and radiological description of the spring ligament articular facet (SLAF).

Methods:

Anatomically, we dissected 10 normally aligned cadaveric lower limbs. The spring ligament was approached from the superior direction. The talus was disarticulated and high-resolution images were taken of the ligament complex. ImageJ and Tracker software was used to calculate the surface area and the maximum linear measurements of the spring ligament articular facet (SLAF). 22 normally aligned feet were analysed on reformatted PD space sequences on MRI using PACS.

Results:

The meniscus was consistently trapezoid in shape in all specimens. The mean area of the SLAF was 203.31 mm2. The average longest proximal to distal length was 11.93 mm and at the shortest plantar and lateral margin was 5.34 mm. The attachment of the SLAF with calcaneum and navicular articular surface was defined by a distinct thick fibrous ligamentous structure that measured 3.67 and 1.69 mm at its medial and lateral margin on the calcaneal side and 2.72 and 2.87 mm respectively on the navicular side. SLAF was visible on MRI but it was not possible to differentiate between SLAF and its investing ligaments. MRI measurements showed a mean surface area of 354 mm2 with mean thickness of 2.7 - 4.3 mm throughout its course.

Conclusion:

The paper describes the anatomical and radiological parameters of SLAF, a constant fibrocartilaginous structure within the superomedial portion of the spring ligament, as well as its ligamentous attachments.

Incidence of and Risk Factors for Aortic Arch Interventions After the Comprehensive Stage II Procedure for Hypoplastic Left Heart Syndrome

Minimal data exist about the incidence and risk factors for arch intervention after comprehensive stage II (CSII). Goal of this study was to document incidence of arch interventions after CSII and determine if any differences existed between those who underwent an arch intervention (aiCSII) versus those did not have an intervention. Single-center retrospective chart review of all hypoplastic left heart syndrome patients who underwent a CSII between 6/1/2005 and 2/1/2020 was performed. Univariate analysis was conducted in addition to principal components analysis (PCA). One hundred patients were evaluated. Sixteen patients underwent 24 arch interventions. Age at initial arch reintervention was 1.3 ± 1.2 years (median 1.0 years, range 0.5-2.2 years). Univariate analysis showed that the aiCSII group were more likely to be female, to have had a retrograde arch intervention post-hybrid procedure, and to be younger at time of CSII. On echocardiograms, aiCSII group had significantly higher pre-CSII patent ductus arteriosus velocities, arch velocities on their 1st post-operative and discharge study post-CSII, and arch velocities pre-Fontan. Gradients were higher in the aiCSII via pre-Fontan catheterization. With PCA, echocardiographic and catheterization data remained significantly associated with aiCSII versus those who did not undergo an arch intervention (OR = 4.5 (1.9, 19.8), p = 0.008). Incidence of arch intervention post-CSII was 16%. Echocardiographic arch velocities during the CSII hospitalization were the strongest predictors for subsequent aortic arch interventions. Further studies are needed to determine any modifiable variables that may reduce the incidence of arch interventions.

Juvenile Dermatomyositis Magnetic Resonance Imaging Score (JIS) does not correlate with criteria for clinically inactive disease: a single-centre retrospective evaluation

The Paediatric Rheumatology International Trials Organisation (PRINTO) criteria for clinically inactive disease (CID) and their proposal for glucocorticoid tapering do not consider MRI findings, despite the growing use of MRI and development of reliable MRI scoring tools. We aim to evaluate how CID correlates with MRI scores and physician decision making. We retrospectively used the Juvenile Dermatomyositis Imaging Score (JIS) to score MRIs of all children with JDM over a 10-year period. Demographic, diagnosis, treatment and core set measures data were collected. Correlation between CID and JIS was assessed as well as correlation with the physician treatment decision. There were 25 patients with 59 follow-up episodes to analyse correlation between physician treatment decision and JIS; and 50 episodes for the CID category and JIS correlation. JIS was not significantly associated with the CID category but did correlate with the physician decision. No significant association was found between clinical decision and CID category. The JIS area under the ROC curve (AUC) was 0.80 (95% CI 0.62-0.99) with a score ≥ 8 to predict an escalation. JIS sensitivity and specificity were both 78% with accuracy of 78%, compared to only 67%, 46% and 49%, respectively, for the CID criteria. Clinical criteria alone are not sufficient to assess disease activity status. Clinical decision trends correlated to MRI findings but not PRINTO CID criteria. Multi centre prospective studies are needed to replicate our findings and establish how to best use MRI as a biomarker of disease activity.

Echocardiographic changes in patients with a cylinder mitral valve replacement: Preliminary analysis

AIMS

Cylinder mitral valve construct (cMVC) is new technique for replacing the mitral valve compared to more traditional mitral valve replacement (MVR) procedures. Goal of this study was to describe echocardiographic changes over time in patients undergoing a cMVC. Secondary goal was to compare echocardiographic changes in patients that underwent a cMVC to a group of patients that underwent a MVR.

METHODS

Retrospective analysis of patients undergoing a cMVC was performed. Demographics, discharge echocardiogram, and recent echocardiogram vales were evaluated. Age matched patients undergoing a MVR were assessed. Discharge and recent echocardiographic parameters were compared within the cMVC group. cMVC and MVR values were compared between groups.

RESULTS

Five cMVC patients were studied. Age at surgery for the cMVC was 4.3 ± 4.2 years (median 2.2, .8-10.3 years). Time interval from hospital discharge echocardiogram to the most recent echocardiogram was 1.2 ± .7 years (median 1.0, .6-2.0 years). Mean mitral valve gradient significantly increased over time (3.6 ± 3.0 mm Hg vs 7.6 ± 2.9 mm Hg). There were significant improvements in left ventricular diameters, systolic sphericity index, shortening fraction, and ejection fraction over time. There were no significant differences in demographics, discharge echocardiogram values, and follow up echocardiogram values between the cMVC and MVR groups.

CONCLUSION

In conclusion, echocardiographic indices of left ventricular function improved over time in patients undergoing cMVC. In addition, there were no significant differences between cMVC and MVR patients in echocardiographic values. Studies with a larger patient sample with longer follow up are needed to determine if cMVC continues to have comparable echocardiographic results to MVR.

POS0035 ONE IN TWENTY INFLAMMATORY BOWEL DISEASE PATIENTS WHO UNDERWENT ABDOMINOPELVIC COMPUTED TOMOGRAPHY HAVE UNDIAGNOSED AXIAL SPONDYLOARTHRITIS

Background:

The diagnosis of axial spondyloarthritis (axSpA) is challenging and hindered by delay. There may be an opportunity to identify sacroiliitis for further rheumatology review in inflammatory bowel disease (IBD) patients who undergo Computed Tomography (CT) for non-musculoskeletal (MSK) indications.

Objectives:

To identify what proportion of IBD patients who underwent abdominopelvic CT for non-MSK indications have axSpA and to explore the role of an imaging strategy for identifying axSpA.

Methods:

Abdominopelvic CT scans of verified IBD patients were identified retrospectively from eight years of imaging archive. Patients between 18-55 yrs. were selected as having the highest diagnostic yield for axSpA. CT review (using criteria from a validated CT screening tool developed by Chan1) was undertaken by a trained radiology team for presence of CT-defined sacroiliitis (CTSI). All CTSI patients were sent a screening questionnaire. Those with self-reported chronic back pain (CBP), duration > 3 months, onset < 45 years were invited for rheumatology review. This included a medical interview, physical examination (joint count, MASES, dactylitis count, BASMI), patient reported outcomes (BASDAI, BASFI, BASGI, Harvey-Bradshaw-Index, Partial-Mayo-Index), relevant laboratory tests (CRP, ESR, HLA-B27), axSpA protocol MRI, and remote review by a panel of experienced rheumatologists with a special interest in axSpA.

Results:

CTSI was identified in 60 of 301 patients. Thirty-two (53%) responded to the invitation to participate and 27 (84%) were enrolled. Of these, eight had a pre-existing axSpA diagnosis and five did not report chronic back pain. Fourteen patients underwent rheumatological assessment; three of 14 (21.4% [95% CI: 4.7%, 50.8%]) had undiagnosed axSpA. In total, 11 of 27 (40.7% [95% CI: 22.4%, 61.2%]) patients had a rheumatologist verified diagnosis of axSpA.

Conclusion:

One in five patients (60/301) with IBD who underwent abdominopelvic CT for non-MSK indications have CTSI and at least one in five (11/60) have axSpA. Five percent (3/60) were previously undiagnosed. This highlights a hidden disease burden and a potential strategy for identifying new cases.

References:

[1]Chan J, Sari I, Salonen D, Inman RD, Haroon N. Development of a Screening Tool for the Identification of Sacroiliitis in Computed Tomography Scans of the Abdomen. J Rheumatol 2016; 43(9); 1687-94.

Acknowledgements:

We are indebted to Baljeet Dhillon and Shin Azegami for their assistance in the scoring of the CTSI.

Disclosure of Interests:

Chong Seng Edwin Lim Grant/research support from: AbbVie, Louise Hamilton: None declared, Samantha Low: None declared, Andoni Toms: None declared, Alex MacGregor: None declared, Karl Gaffney Speakers bureau: AbbVie, Eli Lilly, Novartis, UCB Pharma, Consultant of: AbbVie, Eli Lilly, Novartis, UCB Pharma, Grant/research support from: AbbVie, Gilead, Eli Lilly, Novartis, UCB Pharma.

Zinc-α2-glycoprotein is associated with non-albuminuric chronic kidney disease progression in type 2 diabetes: a retrospective study with 4-year follow-up

AIM

To investigate the association between baseline plasma zinc-α2-glycoprotein and non-albuminuric chronic kidney disease progression in type 2 diabetes.

METHODS

Adults with normoalbuminuria at entry (n=341; age 57±10 years, 52% men) were analysed. Chronic kidney disease progression was defined as a decrease in chronic kidney disease stage and a decline of ≥25% in estimated GFR from baseline. Baseline plasma zinc-α2-glycoprotein levels were quantified by immunoassay, and analysed either as a continuous variable or by tertiles in Cox proportional hazards models. Model discrimination was assessed using Harrell's C-index. A sensitivity analysis was performed on a subset of individuals who maintained normoalbuminuria during follow-up.

RESULTS

Chronic kidney disease progression occurred in 54 participants (16%). Zinc-α2-glycoprotein levels were elevated in chronic kidney disease progressors (P = 0.011), and more progressors were assigned to the higher zinc-α2-glycoprotein tertile than non-progressors. In the unadjusted Cox model, zinc-α2-glycoprotein, both as a continuous variable (hazard ratio 1.72, 95% CI 1.08-2.75) and tertile 3 (vs tertile 1; hazard ratio 2.14, 95% CI 1.10-4.17), predicted chronic kidney disease progression. The association persisted after multivariable adjustment. The C-index of the Cox model increased significantly after incorporation of zinc-α2-glycoprotein into a base model comprising renin-angiotensin system antagonist usage. Sensitivity analysis showed that zinc-α2-glycoprotein independently predicted chronic kidney disease progression among individuals who maintained normoalbuminuria during follow-up.

CONCLUSIONS

Plasma zinc-α2-glycoprotein is associated with chronic kidney disease progression, and may serve as a useful early biomarker for predicting non-albuminuric chronic kidney disease progression in type 2 diabetes.

CCM PILOT STUDY OVERVIEW: GEOMETRICAL MEASUREMENT OF THE ROCKWELL DIAMOND INDENTER

This paper describes an overview of the capability of the NMIs that participated on the CCM Pilot Study measurement systems, conducted by the CIPM/CCM/Working Group on Hardness, to characterize the Rockwell hardness diamond indenter geometry, by measuring the included cone angle, the straightness of the generatrix, the spherical tip radius, the deviation of the local radius and the tilt angle. Nine NMIs took part in this study: INMETRO (Brazil); INRiM (Italy); KRISS (South Korea); NIM/PR (China); NIMT (Thailand); NIST (USA); PTB (Germany); TUBITAK UME (Turkey); VNIIFTRI (Russia), where INMETRO (Brazil) served as pilot laboratory.

Tie a yellow ribbon around a papillary muscle

An 8-year-old boy with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals status post complete repair including a fenestrated ventricular septal defect patch presented to the catheterization laboratory for fenestration closure. During the procedure, the catheterization wire was found to have an unusual intracardiac loop and was unable to be straightened within the heart. Three-dimensional transesophageal echocardiography revealed the wire was looped around a right ventricular papillary muscle. The wire was readjusted, and the fenestration was successfully closed. Three-dimensional imaging was essential in unambiguously defining the catheter course and assisting in fenestration closure.

Echocardiographic diagnosis of atrial flutter in a neonate

A pregnant female presented at 37 weeks of gestation in labor. The fetus was noted to be tachycardic on fetal monitor. Postnatally, the male neonate was still noted to be tachycardic with heart rates in the low 200 bpm range. EKG was consistent with tachycardia, but rhythm diagnosis was not definitively made. Echocardiogram with M-mode analysis clearly demonstrated 2:1 atrial to ventricular contraction pattern consistent with atrial flutter. The neonate was subsequently transferred to a tertiary pediatric hospital where the diagnosis of atrial flutter was confirmed.

Technique to reduce bending issues in Rockwell B scale hardness reference blocks: preliminary results

This paper describes a new design for HRBW scale reference blocks, that has the potential to greatly reduce the bending of brass blocks and thus improve short time stability of the block's apparent reference value. The experimental results given here are preliminary and only reflect short time period stability effects. The work was carried out in 2017 at the National Institute of Standards and Technology (NIST) in Gaithersburg, USA.

Determination of test cycle sensitivity coefficients for the Rockwell HRA hardness scale

This report describes investigations carried out to determine test cycle sensitivity coefficients for the Rockwell HRA hardness scale. Sensitivity coefficients were determined for the preliminary-force, total-force and recovery-force dwell times. The work was carried out in 2017 at the National Institute of Standards and Technology (NIST) in Gaithersburg, USA.

Health Information Management: Changing with Time

Objective: With the evolution of patient medical records from paper to electronic media and the changes to the way data is sourced, used, and managed, there is an opportunity for health information management (HIM) to learn and facilitate the increasing expanse of available patient data. Methods: This paper discusses the emerging trends and lessons learnt in relation with the following four areas: 1) data and information governance, 2) terminology standards certification, 3) International Classification of Diseases, 11th edition (ICD-11), and 4) data analytics and HIM. Results: The governance of patient data and information increasingly requires the HIM profession to incorporate the roles of data scientists and data stewards into its portfolio to ensure data analytics and digital transformation is appropriately managed. Not only are terminology standards required to facilitate the structure and primary use of this data, developments in Canada in relation with the standards, role descriptions, framework and curricula in the form of certification provide one prime example of ensuring the quality of the secondary use of patient data. The impending introduction of ICD-11 brings with it the need for the HIM profession to manage the transition between ICD versions and country modifications incorporating changes to standards and tools, and the availability and type of patient data available for secondary use. Conclusions: In summary, the health information management profession now requires abilities in leadership, data, and informatics in addition to health information science and coding skills to facilitate the expanding secondary use of patient data.

Ethnic disparities in risk of cardiovascular disease, end-stage renal disease and all-cause mortality: a prospective study among Asian people with Type 2 diabetes

AIM

To study prospectively the ethnic-specific risks of cardiovascular disease, end-stage renal disease and all-cause mortality in patients with Type 2 diabetes mellitus among native Asian subpopulations.

METHODS

A total of 2337 subjects with Type 2 diabetes (70% Chinese, 17% Malay and 13% Asian Indian) were followed for a median of 4.0 years. Time-to-event analysis was used to study the association of ethnicity with adverse outcomes.

RESULTS

Age- and gender-adjusted hazard ratios for cardiovascular disease in ethnic Malay and Asian Indian subjects were 2.01 (1.40-2.88; P<0.0001) and 1.60 (1.07-2.41; P=0.022) as compared with Chinese subjects. Adjustment for conventional cardiovascular disease risk factors, including HbA1c , blood pressure and lipid profile, slightly attenuated the hazards in Malay (1.82, 1.23-2.71; P=0.003) and Asian Indian subjects (1.47, 0.95-2.30; P=0.086); However, further adjustment for baseline renal function (estimated GFR) and albuminuria weakened the cardiovascular disease risks in Malay (1.48, 0.98-2.26; P=0.065) but strengthened that in Asian Indian subjects (1.81, 1.14-2.87; P=0.012). Competing-risk regression showed that the age- and gender-adjusted sub-distribution hazard ratio for end-stage renal disease was 1.87 (1.27-2.73; P=0.001) in Malay and 0.39 (0.18-0.83; P=0.015) in Asian Indian subjects. Notably, the difference in end-stage renal disease risk among the three ethnic groups was abolished after further adjustment for baseline estimated GFR and albuminuria. There was no significant difference in risk of all-cause mortality among the three ethnic groups.

CONCLUSIONS

Risks of cardiovascular and end-stage renal diseases in native Asian subjects with Type 2 diabetes vary substantially among different ethnic groups. Differences in prevalence of diabetic kidney disease may partially explain the ethnic disparities.

Energy requirements for maintenance and growth of entire male Bali cattle in East Timor

The metabolisable energy (ME) requirements for maintenance and growth of entire male Bali cattle (Bos javanicus) were determined by regressing liveweight change on ME intake. Cattle were fed either a diet (DM basis) of 52.5% urea-treated rice straw plus 47.5% fresh leucaena forage (Expt 1), or fresh leucaena forage alone (Expt 2). In each experiment, liveweight change and feed intake were measured over 4 weeks, after a 1-week introductory period, and feed constituent digestibilities were measured during the final week. In Expt 1, 10 bulls between 1.5 and 3 years of age and weighing 123.7 ± 11.79 kg (mean ± s.d.) were allocated to DM intakes estimated to provide 0.75, 1.0, 1.25, 1.5, 1.75, or 2.0 times the estimated ME requirement for maintenance (based on calculations made from published CSIRO equations for tropical cattle species other than B. javanicus), with either one or two bulls per treatment. In Expt 2, the bulls were given treatments estimated to provide 0.85, 1.0, 1.4, 1.8, or 2.2 times the ME requirement for maintenance, with two bulls allocated to each treatment. The measured ME requirements for maintenance were 0.42 ± 0.369 and 0.40 ± 0.153 MJ/kg LW0.75.day (coefficient ± standard error, Expts 1 and 2, respectively). The ME requirement for ‘production’ (i.e. positive liveweight change of male Bali cattle under the specific conditions of the experiment) was calculated to be 39.2 MJ/kg liveweight gain in Expt 2. The calculated efficiency of use of dietary ME for production in Expt 2, was 0.34

The not-so-simple renal cyst

Simple renal cysts are most commonly found in the elderly, male population. The majority of simple renal cysts remain untreated, except on the rare occasion when they become complicated with hemorrhage, infection or rupture. We present the case of a 31-year-old female with a simple renal cyst which was initially treated as acute pyelonephritis. A high clinical suspicion led to the diagnosis of an infected renal cyst which was treated with antibiotic therapy and radiological drainage. There were minimal complications and the patient made an uneventful recovery.

Mortality among tuberculosis patients on treatment in Singapore

OBJECTIVE

To identify the risk factors associated with mortality among tuberculosis (TB) patients on treatment in Singapore.

DESIGN

A retrospective cohort study of 7433 TB patients notified and started on TB treatment from 2000 to 2006 was conducted. Cox regression analysis was used to determine independent risk factors for mortality.

RESULTS

Of 7433 patients who started TB treatment between 2000 and 2006, there were 884 deaths (11.9%) from any cause. Older age, male sex, being in a long-term care facility, having comorbidity, absence of cough, more than one site of TB, bacteriologically confirmed laboratory results, resistance to at least isoniazid (INH) and rifampicin (RMP) and absence of cavity were strongly associated with all-cause mortality among TB patients. A total of 203 patients (2.7%) died of TB. Risk factors for death due to TB were older age, male sex, Malay ethnicity, being in a long-term care facility, absence of cough, more than one site of TB, bacteriologically confirmed laboratory results and resistance to at least INH and RMP or to at least INH but not RMP.

CONCLUSION

It is important to identify TB patients with risk factors related to mortality so that appropriate and timely interventions can be instituted to prevent deaths among TB patients.

Is measurement of adult height useful in screening for primary angle closure?

BACKGROUND

Adult height is independently related to ocular dimensions and shorter people have shorter globes and shallower anterior chambers. We investigated the relationship between adult height and angle dimensions to explore measuring height as a possible screening test for angle closure.

METHODS

A population-based, cross-sectional survey of adult Chinese living in the Tanjong Pagar district, Singapore was conducted. Anterior chamber depth, gonioscopic angle width and height were assessed using standardized protocols.

RESULTS

Data were available for 996 persons. Shorter people had shallower anterior chamber depth (2.35 mm for persons <144 cm vs 2.72 mm for persons >170 cm, P=0.008) and smaller gonioscopic angles (22 degrees for <144 cm vs 30 degrees for >170 cm, P=0.079). After controlling for age and gender, adult height was significantly related to anterior chamber depth (P=0.008) but not significantly related to gonioscopic angle width (P=0.079). Female sex and age > or = 50 years used together correctly identified 45/66 (68.2%) individuals with an occludable angle (sensitivity 68.2%, specificity 61.3%). Fewer people, 41/66 (62.1%), were correctly identified when height <160 cm was added to female sex and age 50 > or = years (sensitivity was 62.1% and specificity was 64.7%).

CONCLUSIONS

Shorter adult height is significantly associated with a shallower anterior chamber depth, but the addition of height contributed little to demographics (age and gender) as the preliminary screening criteria to identify individuals at risk of an occludable angle.

A national study of the epidemiology of pneumococcal disease among hospitalised patients in Singapore: 1995 to 2004

INTRODUCTION

Infections with Streptococcus pneumoniae cause significant morbidity and mortality. In this study, we describe the epidemiology of pneumococcal disease based on hospitalisation rates for all age groups in Singapore. This is important for evaluating prevention and control strategies of pneumococcal disease.

METHODS

We conducted a retrospective study of hospitalisation cases admitted to all public and private hospitals from 1995 to 2004. 4,275 hospitalisation records were extracted, based on the International Classification of Diseases, Ninth Revision (ICD-9) codes for pneumococcal disease. We analysed the demographics, type of pneumococcal disease, length of stay and case fatality of these cases.

RESULTS

Our study showed that the mean annual hospitalisation rate for pneumococcal disease was 10.9 per 100,000 population from 1995 to 2004. The mean annual hospitalisation rate was highest in the young and the elderly.

CONCLUSION

Baseline information on the epidemiology of pneumococcal disease is important for the formulation and evaluation of a national prevention and control programme.

Splenic artery aneurysm rupture in pregnancy

Rupture of a splenic artery aneurysm, commonly associated with pregnancy is a rare and catastrophic event. We report here a case of a patient in her second pregnancy who presented with a short history of left hypochondriac and epigastric pain, followed by collapse at 32 weeks gestation. Sudden fetal distress lead to emergency caesarean delivery when splenic artery aneurysm rupture was diagnosed. With timely involvement of multidisciplinary personnel both mother and baby survived and had an uneventful recovery.

Effects of sampling standardization on estimates of Phanerozoic marine diversification

Global diversity curves reflect more than just the number of taxa that have existed through time: they also mirror variation in the nature of the fossil record and the way the record is reported. These sampling effects are best quantified by assembling and analyzing large numbers of locality-specific biotic inventories. Here, we introduce a new database of this kind for the Phanerozoic fossil record of marine invertebrates. We apply four substantially distinct analytical methods that estimate taxonomic diversity by quantifying and correcting for variation through time in the number and nature of inventories. Variation introduced by the use of two dramatically different counting protocols also is explored. We present sampling-standardized diversity estimates for two long intervals that sum to 300 Myr (Middle Ordovician-Carboniferous; Late Jurassic-Paleogene). Our new curves differ considerably from traditional, synoptic curves. For example, some of them imply unexpectedly low late Cretaceous and early Tertiary diversity levels. However, such factors as the current emphasis in the database on North America and Europe still obscure our view of the global history of marine biodiversity. These limitations will be addressed as the database and methods are refined.

Characterization of three infectious bronchitis virus isolates from China associated with proventriculus in vaccinated chickens

Outbreaks of an avian disease in infectious bronchitis-vaccinated chickens in China have led to the characterization of coronaviral isolates Q1, J2, and T3, which were isolated from proventricular tissues of the affected young layer flocks. Serologic analysis revealed that they could induce high titers of infectious bronchitis virus (IBV) antibodies in inoculated specific-pathogen-free (SPF) chickens in indirect enzyme-linked immunosorbent assay but were not neutralized by antisera specific to the IBV serotype M41 and the Australian T strain. In a pathogenicity experiment, the clinical signs and related gross lesions resembling those of field outbreaks were reproduced in SPF chickens, and viruses were reisolated from the damaged tissues, including trachea, proventriculus, duodenum, and cecal tonsil. Sequence data demonstrated the complete S1 amino acid sequences of these isolates were almost identical despite recovery from geographically different areas in China and had 47.3%-82.3% similarity in comparison with the 47 published S1 sequences. On the basis of genotyping and limited serology, the three isolates, which were responsible for field outbreaks of the disease, might be a new IBV variant.

Detection and screening of Salmonella enteritidis-infected chickens with recombinant flagellin

Screening and identification of Salmonella enteritidis in commercial poultry flocks have assumed principal roles in preventing transmission of this pathogen to humans from hen eggs. Serologic diagnosis of S. enteritidis infection in commercial flocks currently relies on laboratory-based tests for detection of antibodies to the lipopolysaccharide, whole flagella, and bacteria. We amplified a sequence from the g,m flagellin of S. enteritidis, followed by cloning, expression, and purification of the protein. The recombinant protein was first characterized by western blot and subsequently evaluated as enzyme-linked immunosorbent assay (ELISA) antigen for detection of S. enteritidis infection. A total number of 49 positive sera and 40 negative sera were tested for ELISA validation. A cutoff value of 0.14 was shown to be sufficient to discriminate the negative and positive sera. Results obtained by testing sera raised against different bacterial strains/serotypes further confirmed that this recombinant flagellin-based ELISA was indeed specific for the detection of S. enteritidis. Both sensitivity and specificity of the developed ELISA test were comparable with a commercially available test, indicating that it is a highly promising and reliable diagnostic tool for S. enteritidis infection.

Multiple tissue transformation in adult zebrafish by gene gun bombardment and muscular injection of naked DNA

The efficiency of two direct gene transfer methods, gene gun (or particle bombardment) and intramuscular injection, in transforming adult zebrafish tissues in vivo was examined by a noninvasive approach using green fluorescent protein (GFP) reporter gene driven by the ubiquitously expressed human cytomegalovirus promoter. Particle bombardment of adult zebrafish caused internalization and expression of the plasmid only in the superficial layer such as epithelial cells, pigment cells, endothelial cells, and neurons, whereas direct injection primarily transformed muscle fibers of several bundles near or around the injection site. Expression was also evident in several nonmuscle tissues, such as skin epithelia, pigment cells, blood vessel cells, and neuron-like cells. GFP expression persisted for more than 50 days with both methods. These observations indicate the potential of these methods for functional analysis of tissue-specific promoters, delivery of DNA vaccine, and muscular expression of other useful genes.

Molecular epidemiology of infectious bronchitis virus isolates from China and Southeast Asia

In order to trace the origin and evolution of avian infectious bronchitis virus (IBV) isolates in China and Southeast Asia, genomic sequencing was used for molecular characterization of 24 IBV isolates and two reference strains in comparison with the published sequences. The 5' region of the S1 genes, containing hypervariable regions I and II, and 3' region of the nucleocapsid genes, containing cytotoxic T lymphocyte epitopes, were used to construct phylogenetic trees for analysis. The results showed that the 24 isolates could be divided into three distinct groups, that is, American, Asian, and European. Some isolates formed a distinct Asian phylogenetic group, suggesting that IBV has existed for some time in Asia. Our results also showed that in vivo recombination of IBV may have occurred at a rather high frequency, contributing to the diversity of these IBV isolates. Importantly, recombination events have probably occurred between vaccine strains and field strains in the natural condition.

Case studies in osteoporosis: a problem based learning intervention for family physicians

OBJECTIVE

To develop and evaluate a practice based small group (PBSG) learning intervention on osteoporosis for primary care physicians.

METHODS

A needs assessment on osteoporosis was performed and objectives for a continuing medical education (CME) program developed by an interdisciplinary advisory committee. Nine clinical cases were developed for evaluation by CME participants with a trained facilitator and content expert using the PBSG format. The effect of the CME intervention was evaluated using a pre and post-test consisting of objective structured clinical examination stations and standardized patients.

RESULTS

Fifty-four family physicians participated in 4 pilot PBSG learning sessions. The program format, content, and participant satisfaction was highly rated (> 3.35:4.0). Participants expected the program to have a significant effect on the practices (3:40:4.0). Ninety-eight percent of participants improved their pretest scores, with a mean increase of 13% (range 1-36%).

CONCLUSION

Based on our experience, we advocate the use of PBSG learning interventions as an effective and acceptable method of providing CME by rheumatologists for their family physician colleagues. This format appears to be associated with a significant effect on knowledge, skills, and behavior as assessed by our study.

Antibody and cellular immune responses of swine following immunisation with plasmid DNA encoding the PRRS virus ORF's 4, 5, 6 and 7

The objectives of this study was to investigate the role of DNA vaccines in the generation of an immune response and that elicited against individually encoded proteins of PRRSV. The genomic regions encoding ORF s 4, 5, 6 and 7 of the PRRS virus vaccine strain were cloned into the mammalian expression vector pc DNA 3.1 (+). Inoculations with the recombinant plasmids resulted in detection of PRRS virus-specific antibodies in 71 per cent of the immunized animals by ELISA, virus neutralization and/or Western blotting assays. In addition, cellular immune responses were detected in 86 per cent of the immunized pigs by interferon gamma assay and/or proliferation assay. Pigs in the control group had no detectable immune response to PRRS virus. The results obtained demonstrated that DNA immunization against PRRS virus results in the production of both humoral and cell mediated immune responses in pigs. The results also indicate that neutralization epitopes for PRRS virus are present on the viral envelope glycoproteins encoded by ORF 4 and ORF 5.

Characterization of antibody response to porcine reproductive and respiratory syndrome virus ORF5 product following infection and evaluation of its diagnostic use in pigs

The sensitivity and specificity of recombinant open reading frame 5 products used in the Western blotting assay for confirmation of porcine reproductive and respiratory syndrome virus (PRRSV) serologic status were evaluated. The recombinant antigen-based assays were specifically compared with a commercial enzyme-linked immunosorbent assay (ELISA) for PRRSV antibodies using 1) PRRSV antibody-negative reference sera (n = 30), 2) naturally infected pig sera (n = 40), 3) sequential sera obtained from 24 experimentally infected pigs, and 4) sera submitted to 3 state diagnostic laboratories (n = 200). The recombinant antigen assay yielded an average increased sensitivity of 10% over the commercial PRRSV ELISA. The negative controls (group 1 sera) showed no difference between the 2 assays. This comparison confirmed that the recombinant antigen-specific assay was more sensitive than the commercial ELISA and is well suited for routine confirmation of the presence of PRRSV antibodies.

Early social-emotional, language, and academic development in children with hearing loss. Families with and without fathers

As a group, children with significant hearing loss are at greater risk than other children for outcomes far below their potential, despite the institution of various educational approaches at increasingly earlier ages. Research suggests some benefits of early intervention for deaf children and their families. However, there remains a paucity of research into how family variables may affect child outcomes. The present study investigated the effect of paternal presence or absence on the social-emotional, language, and academic outcomes of 22 deaf and hard of hearing children ages 43-83 months. The children had graduated anywhere from 9 to 47 months earlier from an early intervention program for deaf and hard of hearing children 3 years of age or younger. Results indicated that children whose father is present have significantly better academic and language outcomes than those without a father present. Possible explanations for the findings are discussed, as well as implications of these findings for services offered by early intervention programs.

A hemi-nested, allele specific, whole blood PCR assay for the detection of the factor V Leiden mutation

We describe a novel hemi-nested, allele specific whole blood PCR assay for detection of the factor V Leiden mutation associated with the plasma defect, activated protein C resistance. This assay utilizes 5 microliters of whole blood without prior DNA extraction. The hemi-nested design, employing an outer primer pair in combination with nested, allele specific primers obviates the need for restriction enzyme digestion. PCR reactions are analysed directly on agarose or polyacrylamide minigels. The assay confirmed the genotypes of 50 individuals previously categorized by PCR and Mn11 digestion, and has been subsequently utilized in the genotyping of 445 individuals referred for thrombosis studies.