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Obesity has grown into a major public health problem over the last few decades. Numerous research studies have focused on understanding the genetic, nutritional, and environmental causes of obesity and developing effective preventive strategies. In addition, there has been a growing attempt by the media to make the public more aware of this problem. However, the occurrence of obesity continues to rise to epidemic proportions in all age groups in this country and the overall global prevalence is climbing steadily. [ABSTRACT FROM AUTHOR]

(1) Background: Group psychotherapy improves therapeutic process, fosters identification with others, and increases illness awareness; (2) Methods: In 40 weekly group sessions held in an acute psychiatric ward during one year, we retrospectively evaluated the inpatients' participation and the demographic and clinical variables of the individuals hospitalized in the ward, the group type according to Bion's assumptions, the main narrative themes expressed, and the mentalization processes by using the Mentalization-Based Therapy-Group Adherence and Quality Scale (MBT-G-AQS); (3) Results: The "working" group was the prevailing one, and the most represented narrative theme was "treatment programs"; statistically significant correlations were found between the group types according to Bion's assumptions and the main narrative themes (Fisher's exact, p = 0.007); at our multivariate linear regression, the MBT-G-AQS overall occurrence score (dependent variable) was positively correlated with the number of group participants (coef. = 14.87; p = 0.011) and negatively with the number of participants speaking in groups (coef. = -16.87, p = 0.025); (4) Conclusion: our study suggests that the group shows consistent defense mechanisms, relationships, mentalization, and narrative themes, which can also maintain a therapeutic function in an acute ward.

Neutrophils are specialized innate immune cells known for their ability to fight pathogens. However, the mechanisms of neutrophil trafficking to lymph nodes are not fully clear. Using a murine model of dermal infection with Leishmania parasites, we observe a transient neutrophil influx in draining lymph nodes despite sustained recruitment to the infection site. Cell-tracking experiments, together with intravital two-photon microscopy, indicate that neutrophil recruitment to draining lymph nodes occurs minimally through lymphatics from the infected dermis, but mostly through blood vessels via high endothelial venules. Mechanistically, neutrophils do not respond to IL-1β or macrophage-derived molecules. Instead, they are guided by the C5a-C5aR1 axis, using L-selectin and integrins, to extravasate into the draining lymph node parenchyma. We also report that C5, the C5a precursor, is locally produced in the draining lymph node by lymphatic endothelial cells. Our data establish and detail organ-specific mechanisms of neutrophil trafficking., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: The goal of this study was to describe outcomes and associated characteristics of patients who were intubated during the initial (3/2020-4/2020) New York City surge of the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic, during which time we were confronted by an unknown and unprecedented respiratory distress syndrome with extremely high degrees of morbidity and mortality. Our secondary aim was to analyze our physician's rapidly evolving approaches to COVID-19 airway management., Methods: A retrospective cohort analysis of all patients intubated at two emergency departments (EDs) for COVID-19 suspected respiratory failure. In addition, a survey was done to analyze clinician airway management trends and attitudes as they evolved during that period., Results: Ninety-five patients met inclusion criteria for the study. Primary outcomes looked at the spectrum of mortality outcomes ranging from died on arrival (DOA) to the ED, died in the ED (DED), died an inpatient (DIH), and survival to discharge. Overall mortalitywas 71.6% with an average age of 62.7 years. Female sex, as a demographic, was associated with higher rates of survival to discharge at 42.3% when compared to males at 23.2% ( P  < 0.001). Mean age was 70.8 years DOA, 65.6 years DED, 62.9 years DIH, and 60.0 years for survivors ( P  = 0.0037). Initial lactate levels were 8.15 mmol/L DED, 3.56 mmol/L DIH, and 2.61 mmol/L survivors ( P  < 0.0001). Initial creatinine levels were 3.38 mg/dL DED, 1.94 mg/dL DIH, and 1.77 mg/dL survivors ( P  = 0.0073). D-dimer levels were 7520.5 ng/mL DED, 5932.4 ng/mL DIH, and 1133.9 ng/mL survivors ( P  = 0.0045). Physician survey respondents reported high levels (69%) of laryngeal edema and prolonged post intubation hypoxia (>50% of time) and >80% remained concerned for their safety. There was a dramatic shift from early (73% of time) to late intubation strategies (67% of time) or non-invasive approaches (28% of time) as the first surge of the pandemic evolved., Conclusion: Our findings demonstrate that several demographic, clinical and laboratory parameters correlated with mortality in our cohort of patients intubated during the initial phase of the COVID-19 pandemic. These included male sex, advanced age, high levels of initial lactic acidosis, elevated D-dimer, and chronic kidney disease/acute kidney injury. In contrast, presenting respiratory characteristics were not correlated with mortality. In addition, our findings demonstrate that physician attitudes and strategies related to COVID-19 airway management evolved significantly and rapidly over the initial phase of the pandemic., Competing Interests: The authors declare no conflicts of interest., (© 2021 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Neutrophils represent one of the first immune cell types recruited to sites of infection, where they can control pathogens by phagocytosis and cytotoxic mechanisms. Intracellular pathogens such as Leishmania major can hijack neutrophils to establish an efficient infection. However the dynamic interactions of neutrophils with the pathogen and other cells at the site of the infection are incompletely understood. Here, we have investigated the role of Ly6G, a homolog of the human CD177 protein, which has been shown to interact with cell adhesion molecules, and serves as a bona fide marker for neutrophils in mice. We show that Ly6G deficiency decreases the initial infection rate of neutrophils recruited to the site of infection. Although the uptake of L. major by subsequently recruited monocytes was tightly linked with the concomitant uptake of neutrophil material, this process was not altered by Ly6G deficiency of the neutrophils. Instead, we observed by intravital 2-photon microscopy that Ly6G-deficient neutrophils entered the site of infection with delayed initial recruitment kinetics. Thus, we conclude that by promoting neutrophils' ability to efficiently enter the site of infection, Ly6G contributes to the early engagement of intracellular pathogens by the immune system., (© 2021. The Author(s).)

Introduction: Coronavirus disease 2019 (COVID-19) caused a disproportionate number of patients to seek emergency care at hospitals in New York City (NYC) during the initial crisis. Our urban emergency department (ED), a member of the NYC public hospital system had to process the increased volume while also differentiating our patients' critical needs. We established a forward treatment area (FTA) directly in front of the ED to accomplish these goals from March 23-April 16, 2020., Methods: A clinical greeter evaluated patients 18 years and older who presented to the walk-in entrance of the ED where they were screened for COVID-19-like complaints. If they did not appear critically ill and could ambulate they were directed into the FTA. Clinical and non-clinical staff worked in concert to register, evaluate, and process patients with either a disposition of directly home or into the ED for further care., Results: A total of 634 patients were seen in the FTA from March 23-April 16, 2020. Of the 634 patients evaluated, 135 (21%) were referred into the ED for further evaluation, of whom 81 (12.7% of the total) were admitted. These patients were disproportionately male (91 into the ED and 63 admitted) and tended to have a higher heart rate (105.4 vs 93.7), a higher respiratory rate (21.5 vs 18.1), and lower oxygen saturation (93.9% vs 97.8%)., Conclusion: A forward treatment area is an effective method to rapidly screen and process an increased volume of COVID-19 patients when resources are limited. This treatment area helped decompress the ED by being rapidly deployable and effectively screening patients for safe discharge home.

Neutrophils are rapidly recruited to sites of infection, where they kill invading pathogens. However, they may also act as early temporary shelters, favoring subsequent pathogen dissemination in the host. We find that TLR7 sensing of the protozoan Leishmania parasite in neutrophils is essential for early parasite load regulation. Neutrophil effector functions, including reactive oxygen species (ROS) and neutrophil extracellular trap formation, are decreased in the absence of TLR7, resulting in higher parasite load and selective parasite replication in Tlr7 -/- neutrophils. Leishmania-infected Tlr7 -/- mice develop a chronic unhealing lesion, despite Th1 cell differentiation, and we show that Tlr7 -/- neutrophils alone mediate this effect. Conversely, topical treatment with a TLR7 agonist early in infection induces smaller lesion development than in untreated mice. Collectively, these findings highlight that parasite TLR7 triggering in neutrophils regulates early innate functions with major consequences on subsequent disease evolution, opening avenues for possible treatment strategies., Competing Interests: Declaration of Interests The authors declare no competing interests., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

During infections, interactions between host immune cells and the pathogen occur in distinct anatomical locations and along defined time scales. This can best be assessed in the physiological context of an infection in the living tissue. Consequently, intravital imaging has enabled us to dissect the critical phases and events throughout an infection in real time in living tissues. Specifically, advances in visualizing specific cell types and individual pathogens permitted tracking the early events of tissue invasion of the pathogen, cellular interactions involved in the induction of the immune response as well the events implicated in clearance of the infection. In this respect, two vantage points have evolved since the initial employment of this technique in the field of infection biology. On the one hand, strategies acquired by the pathogen to establish within the host and circumvent or evade the immune defenses have been elucidated. On the other hand, analyzing infections from the immune system's perspective has led to insights into the dynamic cellular interactions that are involved in the initial recognition of the pathogen, immune induction as well as effector function delivery and immunopathology. Furthermore, an increasing interest in probing functional parameters in vivo has emerged, such as the analysis of pathogen reactivity to stress conditions imposed by the host organism in order to mediate clearance upon pathogen encounter. Here, we give an overview on recent intravital microscopy findings of host-pathogen interactions along the course of an infection, from both the immune system's and pathogen's perspectives. We also discuss recent developments and future perspectives in extracting intravital information beyond the localization of pathogens and their interaction with immune cells. Such reporter systems on the pathogen's physiological state and immune cell functions may prove useful in dissecting the functional dynamics of host-pathogen interactions. © 2019 The Authors. Cytometry Part A published by Wiley Periodicals, Inc. on behalf of International Society for Advancement of Cytometry., (© 2019 The Authors. Cytometry Part A published by Wiley Periodicals, Inc. on behalf of International Society for Advancement of Cytometry.)

The Consolidated Clinical Document Architecture (C-CDA) is the primary standard for clinical document exchange in the United States. While document exchange is prevalent today, prior research has documented challenges to high quality, effective interoperability using this standard. Many electronic health records (EHRs) have recently been certified to a new version of the C-CDA standard as part of federal programs for EHR adoption. This renewed certification generated example documents from 52 health information technologies that have been made publicly available. This research applies automated tooling and manual inspection to evaluate conformance and data quality of these testing artifacts. It catalogs interoperability progress as well as remaining barriers to effective data exchange. Its findings underscore the importance of programs that evaluate data quality beyond schematron conformance to enable the high quality and safe exchange of clinical data.

Objectives: Resuscitation often requires rapid vascular access via central venous catheters. Chest radiography is the reference standard to confirm central venous catheter placement and exclude complications. However, radiographs are often untimely. The purpose of this study was to determine whether dynamic sonographic visualization of a saline flush in the right side of the heart after central venous catheter placement could serve as a more rapid confirmatory study for above-the-diaphragm catheter placement., Methods: A consecutive prospective enrollment study was conducted in the emergency departments of 2 major tertiary care centers. Adult patients of the study investigators who required an above-the-diaphragm central venous catheter were enrolled during the study period. Patients had a catheter placed with sonographic guidance. After placement of the catheter, thoracic sonography was performed. The times for visualization of the saline flush in the right ventricle and sonographic exclusion of ipsilateral pneumothorax were recorded. Chest radiography was performed per standard practice., Results: Eighty-one patients were enrolled; 13 were excluded. The mean catheter confirmation time by sonography was 8.80 minutes (95% confidence interval, 7.46-10.14 minutes). The mean catheter confirmation time by chest radiograph availability for viewing was 45.78 minutes (95% confidence interval, 37.03-54.54 minutes). Mean sonographic confirmation occurred 36.98 minutes sooner than radiography (P< .001). No discrepancy existed between sonographic and radiographic confirmation., Conclusions: Confirmation of central venous catheter placement by dynamic sonographic visualization of a saline flush with exclusion of pneumothorax is an accurate, safe, and more efficient method than confirmation by chest radiography. It allows the central line to be used immediately, expediting patient care., (© 2015 by the American Institute of Ultrasound in Medicine.)

Serum amyloid A (SAA) proteins are known to be surrogate markers of sepsis, but their pathogenic roles remain poorly elucidated. Here we provide evidence to support a possible role of SAA as a pathogenic mediator of lethal sepsis. In a subset of septic patients for which serum high mobility group box 1 (HMGB1) levels paralleled the clinical scores, some anti-HMGB1 antibodies detected a 12-kDa protein belonging to the SAA family. In contrast to the most abundant SAA1, human SAA induced double-stranded RNA-activated protein kinase R (PKR) expression and HMGB1 release in the wild-type, but not toll-like receptor 4/receptor for advanced glycation end products (TLR4/RAGE)-deficient, macrophages. Pharmacological inhibition of PKR phosphorylation blocked SAA-induced HMGB1 release, suggesting an important role of PKR in SAA-induced HMGB1 release. In animal models of lethal endotoxemia and sepsis, recombinant SAA exacerbated endotoxemic lethality, whereas SAA-neutralizing immunoglobulins G (IgGs) significantly improved animal survival. Collectively, these findings have suggested SAA as an important mediator of inflammatory diseases. Highlights of this study include: human SAA is possibly only expressed in a subset of septic patients; SAA induces HMGB1 release via TLR4 and RAGE receptors; SAA supplementation worsens the outcome of lethal endotoxemia; whereas SAA-neutralizing antibodies confer protection against lethal endotoxemia and sepsis.

Background: Needle-based cricothyrotomy is a common procedure for emergency department patients requiring an emergent surgical airway. Percutaneous transtracheal jet ventilation is well studied to provide oxygenation. We propose to combine these procedures into a novel, single, and sequential procedure., Methods: This study was a prospective manikin/human cadaver procedural feasibility study performed at a medical education center. Forty-eight emergency medicine attending physicians and fellows performed the procedure on a single TraumaMan (Simulab Corporation, Seattle, WA), and 26 were randomly selected to perform the procedure on fresh, unfixed human cadavers. The procedure is as follows: 15 gauge/6F catheter-over-needle punctures cricothyroid membrane, needle is removed, and Enk oxygen flow modulator is attached to the catheter (start to oxygenation). The Enk set is detached, a guide wire introduced, and Seldinger cricothyrotomy is performed (oxygenation to cricothyrotomy). Start-to-oxygenation, oxygenation-to-cricothyrotomy, and start-to-cricothyrotomy times were recorded. Manikin procedures were verified by direct visualization, and cadaver procedures were verified by video laryngoscopy., Results: All attempts were included in data analysis, and there was a 100% first-pass success rate. For the manikin trials, median start-to-oxygenation, oxygenation-to-cricothyrotomy, and start-to-cricothyrotomy times with interquartile ranges were 11 (8.5-13), 48 (42-57), and 59 (53-69) seconds, respectively. For the cadaver trials, median start-to-oxygenation, oxygenation-to-cricothyrotomy, and start-to-cricothyrotomy times with interquartile ranges were 12 (10-15), 59 (47-76), and 71 (61-94) seconds, respectively. Student t tests showed significant differences in start-to-oxygenation and oxygenation-to-cricothyrotomy times (P < .01) within the manikin and cadaver groups., Conclusion: Percutaneous transtracheal jet ventilation and needle-based Seldinger cricothyrotomy can be performed by emergency medicine physicians, and a single, sequential procedure may significantly reduce time to oxygenation for patients already undergoing surgical cricothyrotomy., (Copyright © 2015 Elsevier Inc. All rights reserved.)

This article highlights recent advances made in U.S. Air Force Pararescue Medical Operations in relation to tactical evacuation procedures. Most of these changes have been adopted and adapted from civilian medicine practice, and some have come from shared experiences with partner nations. Patient assessment includes a more comprehensive evaluation for hemorrhage and indications for hemorrhagic control. Ketamine has replaced morphine and fentanyl as the primary sedative used during rapid sequence intubation and procedural sedation. There has been an increasing use of the bougie to clear an airway or nasal cavity that becomes packed with debris. Video laryngoscopy provides advantages over direct laryngoscopy, especially in situations where there are environmental constraints such as the back of a Pave Hawk helicopter. Intraosseous access has become popular to treat and control hemorrhagic shock when peripheral intravenous access is impractical or impossible. Revisions to patient treatment cards have improved the efficacy and compliance of documentation and have made patient handoff more efficient. These improvements have only been possible because of the concerted efforts of U.S. Air Force and partner platforms operating in Afghanistan., (Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.)

Objective: Certain patient populations may be unable to communicate their needs in the emergency department (ED) setting, and the ability to communicate varies between age groups. We aim to determine if there are differences in pain management of acute long-bone fracture (ALBF) among age groups presenting to the ED., Methods: This study was a retrospective chart review of a consecutive sample of subjects over 13 months. Fracture site, subject age, arrival time, whether pain medication was administered, and time to initial administration were recorded. Subjects were categorized into 3 groups based on age: pediatric (<18 years), adult (≥18 and <65 years), and geriatric (≥65 years)., Results: A total of 1255 patients were included in analysis. One hundred seventy-seven (78.0%) pediatric, 364 (86.5%) adult, and 486 (80.1%) geriatric patients received pain medication during their ED stay. Median and average times to initial pain medication administration with 95% confidence intervals were 44 and 52.0 minutes (45.9-58.1), 39 and 53.6 minutes (48.8-58.4), and 55 and 73.2 minutes (68.1-78.3) for pediatric, adult, and geriatric groups, respectively. A single-factor analysis of variance indicated a significant difference between the groups (P<.01). Student t tests revealed significant differences between pediatric and geriatric groups (P<.01) and adult and geriatric groups (P<.01)., Conclusions: Although most patients presenting to the ED with ALBF were geriatric, these patients were the least likely to have their pain addressed in a timely fashion. Subgroup analysis of pediatric and geriatric populations indicates significant delay, especially for those ages younger than 3 and 85 years and older. We believe that patients within these groups experience the greatest difficulty communicating their needs effectively due to age-related issues., (Copyright © 2014 Elsevier Inc. All rights reserved.)

In the tactical setting, intraosseous (IO) access has become popular to treat hemorrhagic shock when peripheral intravenous access is difficult or impractical. The traditional sites most commonly used by combat medics, corpsmen, and Pararescuemen (PJs) include the sternum and tibial tuberosity. Recent studies have shown that the humeral head (HH) is an appropriate and effective access site for IO infusion and fluid resuscitation in the clinical setting. In this procedural feasibility study, we assessed the ability of 26 U.S. Air Force PJs to perform HH IO placement on fresh, unfixed human cadavers over two consecutive cadaver lab training sessions. Following a formal didactic session, which highlighted proper patient positioning and technique, the PJs were instructed to attempt to place an IO needle using both a drill and manual driver. Once performed, correct placement was reviewed by a physician and confirmed by aspiration of bone marrow. Rates of success were calculated on first and second pass. First pass success rates were 96% and 90.5% for the drill and driver, respectively. Both devices achieved 100% success by the second pass. Military field personnel would benefit from a HH approach, especially in the care and management of patients of explosive injuries., (Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.)

Nursing telephone calls after hospital discharge are commonly adopted as a tool to improve patient satisfaction and continuity of care. Previous research, however, has been inconclusive on the impact of telephone follow-up. The purpose of this study was to comparatively examine patients who received telephone follow-up for response differences on a mail satisfaction survey and 30-day readmission rates for a large health system in southeast Texas. Telephone follow-up, patient satisfaction, and administrative billing data from 2008 to 2009 were retrospectively examined across 10 nursing units that routinely performed calls after patient discharge. Patients eligible to receive a nursing call (N = 10,559) were categorized based on responses to nursing questions or if no contact was made. Logistic regression was used to evaluate whether call data significantly predicted survey response and 30-day readmission rates. Nonparametric analysis was used to evaluate whether survey ratings varied between groups. Completion of telephone follow-up was a significant (P <  0.01) predictor of patient response to the mail survey, with 62% more patients returning surveys after contact. Completion of a nursing call with a patient who reported a physician appointment was a significant predictor (P  =  0.04) of lower 30-day readmissions. Readmission rates were 10.8% for patients who did not receive telephone follow-up compared to 9.5% for patients who received a call and who had a scheduled physician appointment. Mean nursing and overall satisfaction scores varied minimally between groups and telephone follow-up was not a significant predictor of patient satisfaction. Telephone follow-up shows significant predictive value for mail survey response and 30-day readmission rates but does not correlate with patient satisfaction scores in the hospital setting.

Cerebral ischemia-elicited inflammatory responses are driven by inflammatory mediators produced both by central (e.g., neurons and microglia) and infiltrating peripheral immune cells (e.g., macrophage/monocyte), and contribute to the evolution of tissue injury. A ubiquitous molecule, spermine, is released from injured cells, and counter-regulates release of various proinflammatory cytokines. However, the spermine-mediated anti-inflammatory activities are dependent on the availability of fetuin-A, a liver-derived negative acute-phase protein. Using an animal model of focal cerebral ischemia (i.e., permanent middle cerebral artery occlusion, MCAo), we found that levels of fetuin-A in the ischemic brain tissue were elevated in a time-dependent manner, starting between 2 and 6 h, peaking around 24 to 48 h, and returning to baseline 72 h after MCAo. When administered peripherally, exogenous fetuin-A gained entry across the BBB into the ischemic brain tissue, and dose dependently reduced brain infarct volume at 24 h after MCAo. Meanwhile, fetuin-A effectively attenuated (i) ischemia-induced HMGB1 depletion from the ischemic core; (ii) activation of centrally (e.g., microglia) and peripherally derived immune cells (e.g., macrophage/monocytes); and (iii) TNF production in ischemic brain tissue. Taken together, these experimental data suggest that fetuin-A protects against early cerebral ischemic injury partly by attenuating the brain inflammatory response.

Overwhelming gram-negative bacterial infection and life-threatening systemic inflammation are widespread problems in critically ill emergency department patients. Currently, the treatment of these patients is largely supportive, focusing on antibiotics, fluids, hemodynamic and ventilatory support, and intensive monitoring. The only Food and Drug Administration-approved pharmaceutical agent for the treatment of sepsis is activated protein C, with its use largely relegated to the intensive care unit. The subject thus remains an active area of exploration for emergency medicine research. During sepsis and inflammation, innate immune cells release excessive amounts of proinflammatory cytokines such as tumor necrosis factor (TNF) and interleukin-1beta. If delivered early enough, anti-TNF antibodies can be an effective therapy in experimental models of septic shock. Anti-TNF antibodies have been developed for clinical use in rheumatoid arthritis and Crohn's disease. However, anti-TNF treatment for sepsis has been difficult to achieve in the clinical setting, perhaps because TNF's early release and transient appearance in the serum create a narrow therapeutic window. An alternative strategy would be to identify "late" mediators that may be clinically more accessible. High mobility group box 1 (HMGB1), a protein previously known only as a nuclear transcription factor, is now implicated as a late mediator of sepsis. Targeting late mediators of lethal systemic inflammation represents a novel approach that may widen the therapeutic window and lead to new strategies for inhibiting the deleterious effects of the inflammatory cascade. Here the authors review the studies that led to the discovery of HMGB1 as a late mediator of systemic inflammation and discuss the possibility of HMGB1 as a therapeutic target for septic patients in the emergency department.

Objectives: To characterize the homeless adult population of an urban emergency department (ED) and study the medical, psychiatric, and social factors that contribute to homelessness., Methods: A prospective, case-control survey of all homeless adult patients presenting to an urban, tertiary care ED and a random set of non-homeless controls over an eight-week period during summer 1999. Research assistants administered a 50-item questionnaire and were trained in assessing dentition and triceps skin-fold thickness., Inclusion Criteria: all homeless adults who consented to participate. Homelessness was defined as being present for any person not residing at a private address, group home, or drug treatment program. Randomly selected controls were concurrently enrolled with a 3:1 homeless:control rate., Exclusion Criteria: critically ill, injured, or incapacitated patients, or patients <21 years of age. Univariate analysis with appropriate statistical tests was used. The Mantel-Haenszel test was used to adjust for population differences., Results: Two hundred fifty-two homeless subjects and 88 controls were enrolled. Data are presented for homeless vs control patients, and all p-values were <0.01. Odds ratios (ORs) with 95% confidence intervals (95% CIs) are given where appropriate: mean age (+/-SD) = 42 +/- 10 vs 48 +/- 13; male gender 95% vs 54% (OR = 17; 95% CI = 8 to 37); history of (hx) tuberculosis 49% vs 15% (OR = 2.5; 95% CI = 1.2 to 3); hx HIV infection 35% vs 13% (OR = 3.8; 95% CI = 1.8 to 8); hx penetrating trauma 62% vs 16% (OR = 8.62; 95% CI = 4.4 to 17.1); hx depression 70% vs 15% (OR = 13.4; 95% CI = 6.7 to 27); hx schizophrenia 27% vs 7% (OR = 5.1; 95% CI = 2.0 to 14); hx alcoholism 81% vs 15% (OR = 24; 95% CI = 12 to 49); significant tooth loss (>3) 43% vs 18% (OR = 3.3; 95% CI = 1.8 to 6.4); percentage of body fat 16.5% vs 19.7%; hx social isolation (no weekly social contacts) 81% vs 11% (OR = 33.3; 95% CI = 14 to 100); mean number of ED visits/year 6.0 vs 1.6., Conclusions: In the study population homelessness was associated with a history of significantly higher rates of infectious disease, ethanol and substance use, psychiatric illness, social isolation, and rates of ED utilization.

The purpose of this study was to investigate the role of fas antigen, a member of the TNF receptor family, in cell death after focal cerebral ischemia. Focal ischemia was induced in the Sprague-Dawley rat. Evidence for apoptosis was determined by morphology as well as the presence of DNA fragmentation by the end labeling technique (TUNEL). Immunohistochemistry was performed to detect expression of both fas and fas ligand (fasL). In a separate set of experiments, two groups of mice were studied: lpr (that have a loss of function mutation for fas) and wild type. Infarct volume was measured at 24 hr as well as evidence for apoptosis. Twenty-four hours after ischemia, there was evidence for apoptosis based on morphological criteria as well as the TUNEL technique in the rat. Immunohistochemistry demonstrated increased expression of both fas and fasL in the ischemic region, with maximal staining occurring between 24-48 hr for both. Twenty-four hours after ischemia in the mice, there was evidence of apoptosis in both groups, however, the mutant mice (lpr) had significantly smaller infarcts as compared to the wild type. There was no difference in the cerebrovasculature of the two groups of mice. These data support the hypothesis that apoptosis plays a role in the pathophysiology of focal cerebral ischemia. Furthermore, these data suggest that fas-mediated apoptosis contributes to this process., (Copyright 2000 Wiley-Liss, Inc.)

The goal of this study was to determine whether aurintricarboxylic acid (ATA), an endonuclease inhibitor known to inhibit apoptosis, could ameliorate cell damage in a gerbil model of transient ischemia. Transient ischemia was induced in gerbils by bilateral carotid artery occlusion for a period of 5 minutes. Four micrograms of ATA was administered intraventricularly 1 hour before ischemia, and the brains were assessed histologically 1 week later to quantitate cell loss in the vulnerable CA-1 subsector of the hippocampus. In a separate set of experiments, 4 microg of ATA was administered intraventricularly 1 hour before ischemia and the brains were assessed for evidence of DNA fragmentation by the TUNEL method. There was only a 16% cell loss compared with nonischemic controls in animals pretreated with ATA that was significantly less (p < 0.05) than the 48% cell loss in animals pretreated with saline alone. TUNEL-positive cells were first evident at 3 days and were still present at 7 days subsequent to ischemia. Maximal staining occurred at 4 days. Pretreatment with ATA virtually eliminated TUNEL staining at 4 days. These results support the hypothesis that the delayed cell death secondary to transient ischemia is, in part, apoptotic. Furthermore, ATA afforded significant neuronal protection and prevented DNA fragmentation.

Bilateral Wilms' tumors in children are not uncommon but in the adult are quite rare. A two-mutation theory of oncogenesis has been proposed in which a prezygotic gene mutation and a postzygotic mutation lead to the development of Wilms' tumor. However, the recent discovery of a postzygotic deletion within the 11p13 band of chromosome 11 in adult cases of Wilms' tumor may explain the rarity of the bilateral form in later years. Early diagnosis is difficult because of the nonspecificity of signs and symptoms. Computer tomography, ultrasonography, and arteriography are important modalities in the earlier diagnosis of adult Wilms' tumor. Because of the rarity of these tumors, no definitive guidelines for treatment have emerged. However, a multidisciplinary approach incorporating surgery, chemotherapy and/or radiation therapy has been used most often but with varying success. This report documents the second case of bilateral adult Wilms' tumor presenting as perinephric hematomas which partially resolved.