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Introduction: Racial and ethnic minorities are disproportionately affected by end-stage kidney disease (ESKD). ESKD patients on dialysis are at increased risk for Staphylococcus aureus bloodstream infections, but racial, ethnic, and socioeconomic disparities associated with this outcome are not well described., Methods: Surveillance data from the 2020 National Healthcare Safety Network (NHSN) and the 2017-2020 Emerging Infections Program (EIP) were used to describe bloodstream infections among patients on hemodialysis (hemodialysis patients) and were linked to population-based data sources (CDC/Agency for Toxic Substances and Disease Registry [ATSDR] Social Vulnerability Index [SVI], United States Renal Data System [USRDS], and U.S. Census Bureau) to examine associations with race, ethnicity, and social determinants of health., Results: In 2020, 4,840 dialysis facilities reported 14,822 bloodstream infections to NHSN; 34.2% were attributable to S. aureus . Among seven EIP sites, the S. aureus bloodstream infection rate during 2017-2020 was 100 times higher among hemodialysis patients (4,248 of 100,000 person-years) than among adults not on hemodialysis (42 of 100,000 person-years). Unadjusted S. aureus bloodstream infection rates were highest among non-Hispanic Black or African American (Black) and Hispanic or Latino (Hispanic) hemodialysis patients. Vascular access via central venous catheter was strongly associated with S. aureus bloodstream infections (NHSN: adjusted rate ratio [aRR] = 6.2; 95% CI = 5.7-6.7 versus fistula; EIP: aRR = 4.3; 95% CI = 3.9-4.8 versus fistula or graft). Adjusting for EIP site of residence, sex, and vascular access type, S. aureus bloodstream infection risk in EIP was highest in Hispanic patients (aRR = 1.4; 95% CI = 1.2-1.7 versus non-Hispanic White [White] patients), and patients aged 18-49 years (aRR = 1.7; 95% CI = 1.5-1.9 versus patients aged ≥65 years). Areas with higher poverty levels, crowding, and lower education levels accounted for disproportionately higher proportions of hemodialysis-associated S. aureus bloodstream infections., Conclusions and Implications for Public Health Practice: Disparities exist in hemodialysis-associated S. aureus infections. Health care providers and public health professionals should prioritize prevention and optimized treatment of ESKD, identify and address barriers to lower-risk vascular access placement, and implement established best practices to prevent bloodstream infections., (Copyright © 2023. Published by Elsevier Inc.)

Posttransplant lymphoproliferative disorder (PTLD) is a rare complication of solid organ transplant. We identified 40 patients diagnosed with PTLD between 2009 and 2020 and analyzed their presentation, treatment strategies, and outcomes. Median age at diagnosis was 52.5 years (range 21.3 to 79). Median duration of immunosuppression was 95 months (range 4 to 292). Diffuse large B cell lymphoma (n = 16, 40%) and Burkitt lymphoma (n = 6, 15%) were the most common histological subtypes. First-line therapy varied. The median number of treatment lines was 1 (range 0 to 4). Sixteen patients (40%) achieved complete response after first-line therapy. Nineteen patients (47.5%) relapsed or progressed and received salvage therapy; 45% were alive at the end of the study period (median survival 52 months; range 1 to 266; 95% confidence interval 0 to 104). Causes of death included lymphoma-related (45.5%), therapy-related (27.3%), and other (27.3%). Five (22.7%) died within 3 months of diagnosis. Pearson's r test identified disease stage (P = .045) and proliferation index (P = .005) as negative predictors of response to frontline therapy. Bone marrow involvement (P = .033) and increased age (P = .018) were significant predictors of survival. Early mortality and poor response to frontline therapy are common, outlining the need for improved treatment strategies., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Acute scrotal pain is a common problem in children. Amongst the various causes, only testicular torsion (TT) needs urgent, and arguably any, surgical intervention. However TT accounts for only approximately 25% of cases. The diagnosis of TT is currently based mainly on history and clinical examination in the UK., Objective: We sought to find the incidence of finding TT during emergency scrotal exploration in four paediatric surgical centres in the UK. We also assessed the preoperative utilisation of clinical risk scores and Doppler ultrasound (DUS) to aid in the diagnosis., Patients and Methods: A retrospective review of 50 consecutive scrotal explorations done for acute scrotal pain at four tertiary pediatric surgical centres in 2019, including the preoperative utilisation of DUS, was analysed. Additionally an online survey was also sent out to consultant members of the British Association of Paediatric Urology to gauge their threshold for exploration, use of preoperative investigations and incidence of finding TT in their practice., Results: In the four UK centres reviewed, TT was found in 24.5% (SD = 8.54) of explorations. The overall utilisation of preoperative DUS was 10%. The online survey revealed a low threshold for exploration. However 72% of respondents recalled finding TT in <50% of explorations, with just over a third reporting finding TT in only 10% of explorations. There was low utilisation of preoperative DUS and clinical risk scores., Discussion: The incidence of finding TT during exploration in this cohort is the same as the incidence of TT in a population of children presenting with acute scrotal pain. We hypothesise that this is due to low accuracy of clinical assessment, low utilisation of preoperative clinical and radiological aids and the practice of exploring torted testicular appendages. Improving awareness and training in these modalities will increase diagnostic accuracy, limiting emergency scrotal explorations to those children with a higher risk of testicular torsion. A care pathway for children presenting with acute scrotal pain is suggested () CONCLUSIONS: There is a low incidence of finding testicular torsion during paediatric scrotal explorations in the UK. There is low preoperative utilisation of clinical risk scores and Doppler ultrasound, which if utilised, could improve diagnostic accuracy., (Crown Copyright © 2020. Published by Elsevier Ltd. All rights reserved.)

Hearing loss is a significant public health problem, and the "loss of sensory hair cells" is one of two leading causes in humans. Advanced imaging reagents are desirable for understanding the role of the surrounding support cells in the loss or regeneration of the hair cells. A styryl dye was found to exhibit NIR emission (λ em  ≈ 684 nm) with a very large Stokes shift (Δν ≈ 9190 cm -1 ), due to the incorporation of excited state intramolecular proton transfer (ESIPT) mechanism. When used to stain live zebrafish embryos, the probe was found to exhibit good selectivity in targeting neuromasts, which are sensory organs on the surface of the fish's body. The finding was verified by direct comparison with the known neuromast-labeling reagent, 4-Di-2-ASP. In contrast to the existing styryl dyes that label neuromast hair cells, the new probe labeled both neuromast hair cells and the surrounding support cells, while giving discernable signals. The study thus illustrated a useful tool to aid the developmental study of two closely related cell types on the mechanosensory sensory organ of zebrafish, which is a powerful animal model for hearing loss research., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background & Aims: Treatment programs for people who inject drugs (PWID), including prisoners, are important for achieving hepatitis C elimination targets. There are multiple barriers to treatment of hepatitis C in prisons, including access to specialist physicians, testing and antiviral therapy, short prison sentences, and frequent inter-prison transfer. We aimed to assess the effectiveness of a nurse-led model of care for the treatment of prisoners with hepatitis C., Methods: A statewide program for assessment and management of hepatitis C was developed in Victoria, Australia to improve access to care for prisoners. This nurse-led model of care is supported by telemedicine to provide decentralized care within all prisons in the state. We prospectively evaluated the feasibility and efficacy of this nurse-led model of care for hepatitis C within the 14 adult prisons over a 13-month period. The primary endpoint was sustained virological response at post-treatment week 12 (SVR12) using per protocol analysis., Results: There were 416 prisoners included in the analysis. The median age was 41 years, 90% were male, 50% had genotype 3 and 44% genotype 1 hepatitis C and 21% had cirrhosis. Injecting drug use was reported by 68% in the month prior to prison entry, 54% were receiving opioid substitution therapy, and 86% reported never previously engaging with specialist HCV care. Treatment duration was 8 weeks in 24%, 12 weeks in 59%, and 24 weeks in 17% of treatment courses. The SVR12 rate was 96% (301/313) per protocol. Inter-prison transfer occurred during 26% of treatment courses but was not associated with lower SVR12 rates. No treatment-related serious adverse events occurred., Conclusion: Hepatitis C treatment using a decentralized, nurse-led model of care is highly effective and can reach large numbers of prisoners. Large scale prison treatment programs should be considered to support hepatitis C elimination efforts., Lay Summary: There is a high burden of hepatitis C infection among prisoners worldwide. Prisoners who continue to inject drugs are also at risk of developing new infections. For this reason, the prison setting provides an opportunity to treat those people at greatest risk of infection and to stop transmission to others. We developed a new method of providing hepatitis C treatment to prisoners, in which nurses rather than doctors assessed prisoners locally at each prison site. Treatment was safe and most prisoners were cured. Such programs will contribute greatly to achieving the World Health Organization's hepatitis C elimination goals., (Crown Copyright © 2019. Published by Elsevier B.V. All rights reserved.)

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Essentials Ignorance of direct oral anticoagulants' effects on coagulation tests may be a safety issue. An electronic questionnaire was sent to prescribers in NHS Grampian with 143 respondents. We found widespread evidence of inappropriate interpretation of the clinical scenarios given. The study suggests potential for patient harm due to lack of knowledge and education is required., Summary: Background Lack of awareness of the nature of the direct oral anticoagulants (DOACs) combined with the poor correlation between routine coagulation test prolongation and the activity of these drugs represents a potential for patient harm. Objectives To establish the level of awareness of the different DOACs, and to assess whether prescribers were able to recognize the state of anticoagulation in a hypothetical patient. Methods and results An electronic questionnaire was sent by email to prescribers in our health board. Among 143 respondents, we found significant differences in awareness of the currently licensed drugs. Of the respondents, 88%, 80% and 50%, respectively, recognized rivaroxaban, dabigatran, and apixaban. When provided with a routine clinical situation, only 13.5%, 17.5% and 16.8%, respectively, recognized that the hypothetical patient was anticoagulated, and only 55-58% recognized that it was unsafe to proceed with an invasive procedure. Conclusion These results indicate a significant risk for patient harm related to lack of knowledge about this new group of frequently used drugs, and indicate that additional education and training on this subject are required., (© 2016 International Society on Thrombosis and Haemostasis.)

Background: Unicompartmental knee arthroplasty (UKA) has gained popularity in patients with isolated unicompartmental osteoarthritis. To our knowledge no systematic review has assessed and compared survivorship of medial and lateral UKA. We performed a systematic review assessing medial and lateral UKA survivorship and comparing survivorship in cohort studies and registry-based studies., Methods: A search was performed using PubMed, Embase and Cochrane systems. Ninety-six eligible studies reported survivorship, of which fifty-eight reported medial and sixteen reported lateral UKA survivorship. Nineteen cohort studies and seven registry-based studies reported combined medial and lateral survivorship., Results: The five-year, ten-year and fifteen-year medial UKA survivorship was 93.9%, 91.7% and 88.9%, respectively. Lateral UKA survivorship was 93.2%, 91.4% and 89.4% at five-year, ten-year and fifteen-year, respectively. No statistical difference between both compartments was found. At twenty years and twenty-five years survivorship of medial UKA was 84.7% and 80%, respectively, but no studies reported lateral UKA survivorship at these follow-up intervals. Survivorship of cohort studies was not significantly higher compared to registry-based studies at five years (94.3 vs. 91.7, respectively, p=0.133) but was significantly higher at ten years (90.5 vs. 84.1, p=0.015)., Conclusion: This is the first systematic review that shows no difference in the five-, ten- and fifteen-year survivorship of medial and lateral UKA. We found a lower survivorship in the registry-based studies compared to cohort studies., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Identification of methionine aminopeptidase-2 (MetAP-2) as the molecular target of the antiangiogenic compound TNP-470 has sparked interest in N-terminal Met excision's (NME) role in endothelial cell biology. In this regard, we recently demonstrated that MetAP-2 inhibition suppresses Wnt planar cell polarity (PCP) signaling and that endothelial cells depend on this pathway for normal function. Despite this advance, the substrate(s) whose activity is altered upon MetAP-2 inhibition, resulting in loss of Wnt PCP signaling, is not known. Here we identify the small G protein Rab37 as a MetAP-2-specific substrate that accumulates in the presence of TNP-470. A functional role for aberrant Rab37 accumulation in TNP-470's mode of action is demonstrated using a Rab37 point mutant that is resistant to NME, because expression of this mutant phenocopies the effects of MetAP-2 inhibition on Wnt PCP signaling-dependent processes., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: In 2005, 4 Clostridium sordellii-associated toxic shock fatalities were reported in young Californian women after medical abortions. The true incidence of this rare disease is unknown, and a population-based study has never been performed. Additional clostridia-associated deaths were sought to describe associated clinical characteristics., Study Design: Population-based death certificate review and a clinical case definition for clostridial-associated toxic shock identified women with likelihood of dying from a Clostridium infection. Formalin-fixed autopsy tissues underwent immunohistochemical and polymerase chain reaction assays., Results: Thirty-eight women were suspected of having C sordellii-associated death. Five tested positive for Clostridium species: 3 for Clostridium perfringens, 1 for C sordellii, and 1 for both. Deaths occurred after the medical procedures for cervical dysplasia (n = 2), surgical abortion (n = 1), stillborn delivery (n = 1), and term live birth (n = 1). None had a medical abortion., Conclusion: C sordellii and C perfringens are associated with undiagnosed catastrophic infectious gynecologic illnesses among women of childbearing age.

Objective: To estimate if Clostridium difficile-associated disease (CDAD) is increasing in peripartum women., Study Design: Peripartum CDAD was assessed through 1) passive surveillance collecting clinical and pathology data on severe cases and 2) survey among infectious disease consultants (ICDs) in the Emerging Infections Network., Results: Ten severe cases were collected; most had associated antibiotic use. Seven women were either admitted to the ICU or underwent colectomy. Three infants were stillborn, and 3 women died. The epidemic Clostridium difficile strain was found in 2 cases. Among 798 ICDs, 419 (52%) participated in the survey. Thirty-seven respondents (9%) recalled 55 cases, mostly in the postpartum period with 21 complications, mainly due to relapse., Conclusion: Severe CDAD may be increasing in peripartum women. Clinicians should have a low threshold for testing, be aware of the potential for severe outcomes, and take steps to reduce both the risk of disease and resultant complications.

Background: Clostridium difficile is an anaerobic, spore-forming bacterium that causes a wide range of diseases of the gastrointestinal tract. It is best known for its association with uncomplicated antimicrobial-agent-associated diarrhea., Case Description: The authors describe two previously published cases of Clostridium difficile-associated disease (CDAD) to highlight its varied clinical manifestations. A 48-year-old woman had mild CDAD after receiving antibiotics after undergoing endodontic surgery. She took metronidazole, and her C. difficile infection resolved. A 31-year-old pregnant woman developed severe CDAD after receiving antibiotics for a urinary tract infection. She underwent surgery to remove part of her colon, but her condition worsened, and she died., Clinical Implications: Dentists often prescribe antimicrobial agents to treat infections. Until recently, these agents also were recommended as prophylaxis for infective endocarditis during invasive oral procedures. An important risk factor for CDAD and recurrent CDAD is antimicrobial agent exposure. Dentists should be aware of CDAD to help prevent its spread and facilitate early recognition and treatment to minimize severe outcomes.

Background: No guidelines exist for the type of mouthwash that should be used in patients at increased risk for pneumonia. In 2005, we investigated a multistate outbreak of Burkholderia cenocepacia associated with an intrinsically contaminated alcohol-free mouthwash (AFM)., Methods: We conducted a case-series investigation. We used repetitive extragenic palindromic- polymerase chain reaction typing and pulsed-field gel electrophoresis (PFGE) to characterize available Burkholderia cepacia complex (Bcc) isolates from patients and implicated AFM. Seeding studies were conducted to determine the antimicrobial activity of the AFM., Results: Of the 116 patients with Bcc infection or colonization identified from 22 hospitals with culture dates from April 7 through August 31, 2005, 105 had infections or colonizations that were due to B cenocepacia. The median age of these 105 patients was 64 years (range, 6 to 94 years), 52% were women, 55% had evidence of infection, and 2 patients died. Of 139 patient culture specimens, 83 (60%) were from the respiratory tract. Among 103 Bcc patient isolates characterized, 81 (76%) had an indistinguishable PFGE pattern compared to the outbreak strain cultured from implicated lots of unopened AFM; the species was B cenocepacia. Seeding studies showed that the contaminated AFM might have had inadequate amounts of the antimicrobial agent cetylpyridinium chloride., Conclusions: This intrinsically contaminated AFM led to a geographically dispersed outbreak of B cenocepacia. AFM without therapeutic label claims is regulated by the US Food and Drug Administration as a cosmetic rather than a drug and is therefore subject to limited quality control requirements. Clinicians should be aware that AFM is not sterile. Its use in intubated and other patients with increased risk of aspiration should be avoided.

Background: Toxins A and B are the primary virulence factors of Clostridium difficile. Since 2002, an epidemic of C difficile-associated disease with increased morbidity and mortality has been present in Quebec province, Canada. We characterised the dominant strain of this epidemic to determine whether it produces higher amounts of toxins A and B than those produced by non-epidemic strains., Methods: We obtained isolates from 124 patients from Centre Hospitalier Universitaire de Sherbrooke in Quebec. Additional isolates from the USA, Canada, and the UK were included to increase the genetic diversity of the toxinotypes tested. Isolate characterisation included toxinotyping, pulsed-field gel electrophoresis (PFGE), PCR ribotyping, detection of a binary toxin gene, and detection of deletions in a putative negative regulator for toxins A and B (tcdC). By use of an enzyme-linked immunoassay, we measured the in-vitro production of toxins A and B by epidemic strain and non-dominant strain isolates., Findings: The epidemic strain was characterised as toxinotype III, North American PFGE type 1, and PCR-ribotype 027 (NAP1/027). This strain carried the binary toxin gene cdtB and an 18-bp deletion in tcdC. We isolated this strain from 72 patients with C difficile-associated disease (58 [67%] of 86 with health-care-associated disease; 14 [37%] of 38 with community-acquired disease). Peak median (IQR) toxin A and toxin B concentrations produced in vitro by NAP1/027 were 16 and 23 times higher, respectively, than those measured in isolates representing 12 different PFGE types, known as toxinotype 0 (toxin A, median 848 microg/L [IQR 504-1022] vs 54 microg/L [23-203]; toxin B, 180 microg/L [137-210] vs 8 microg/L [5-25]; p<0.0001 for both toxins)., Interpretation: The severity of C difficile-associated disease caused by NAP1/027 could result from hyperproduction of toxins A and B. Dissemination of this strain in North America and Europe could lead to important changes in the epidemiology of C difficile-associated disease.

Despite progress in leukemia therapy, most children who experience relapse have a dismal prognosis. New, effective approaches are needed. We conducted a phase 1 study of a novel nucleoside analog, clofarabine, in pediatric patients with refractory and relapsed leukemia. Clofarabine was infused intravenously over 1 hour each day for 5 days. Six dose levels, between 11.25 and 70 mg/m(2) per day for 5 days, were studied in 25 patients. A modified 3 + 3 phase 1 design was followed with 30% dose escalation until the dose-limiting toxicity (DLT) was defined. The maximum tolerated dose (MTD) was 52 mg/m(2) per day for 5 days. At the end of infusion at MTD, clofarabine triphosphate levels in leukemia blasts varied between 6 microM and 19 microM, which resulted in complete and sustained inhibition of DNA synthesis. The DLT was reversible hepatotoxicity and skin rash at 70 mg/m(2) per day for 5 days. Twenty-five patients were treated. Five patients achieved complete remission (CR), and 3 achieved partial remission (PR), for an overall response rate of 32%. Clofarabine is well tolerated and shows significant antileukemic activity in heavily pretreated children. Multicenter phase 2 trials in pediatric acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) are ongoing.

Study Objectives: (1) To define clinical factors that could justify hospital admission among patients with community-acquired pneumonia (CAP) with risk classes of I or II. (2) To determine the positive predictive value of the pneumonia severity index as the sole indicator for detecting inappropriate hospitalizations among patients with CAP., Design: Retrospective observational study., Setting: University of Louisville Hospital and the Veterans Affairs Medical Center of Louisville, KY., Patients: Consecutive adult patients fulfilling the criteria for CAP who were admitted to the hospital between October 1997 and May 2000., Measurements and Results: The medical records of hospitalized patients with CAP having a risk class of I or II were identified and further reviewed to determine whether there existed a clinical basis to justify hospitalization. Of a total of 328 patients, 86 had a risk class of I or II. Among these, 72 had clinical factors that justified their hospital admission. These factors, in frequency of occurrence, included the following: medical conditions other than CAP that required hospitalization, 31 patients (43%); social needs, 13 patients (18%); oral intolerance, 10 patients (14%); failure of outpatient therapy, 10 patients (14%); noncompliance, 6 patients (9%); suspicion of sepsis, 1 patient (1%); and hypoxemia, 1 patient (1%). Among the 86 patients with low risk classes (ie, classes I or II), 14 were found to be inappropriately hospitalized, yielding a positive predictive value of 16%., Conclusions: The pneumonia severity index, used as the sole indicator for detecting inappropriate hospitalizations, has an unacceptably low positive predictive value. This is due primarily to the severity of comorbid conditions requiring in-hospital care in patients with a nonsevere pneumonia. According to our study, the pneumonia severity index should not be used as the sole indicator with which to define inappropriate hospitalization.

Objective: To examine the relationship between doctor-parent communication patterns and parents' perceptions that they were listened to by the doctor., Design: Cross-sectional, clinic-based survey. Before the visit, parents were asked about the strength of their desires/preferences for being listened to; after the visit, they were asked if their desires were fulfilled and to rate their satisfaction with care. Encounters were audiotaped, transcribed, and coded for parent requests for information and action and physician responses to those requests. Coding was performed using an adapted version of the Taxonomy of Requests by Patients (TORP). Physician responses to parental requests for information were coded as brief, moderate, or prolonged fulfillment or as partially fulfilled, ignored, or denied., Setting: Two private pediatric practices, 1 community based and 1 university based., Participants: Ten of 13 eligible physicians (participation rate, 77%) and 306 of 356 eligible parents (participation rate, 86%) who sought care for their children's respiratory illnesses. Parents were invited to participate if they spoke and read English and if their child was 2-10 years old, had a chief complaint of cold symptoms, and was seeing one of the participating physicians. Complete data were obtained for 287 doctor-parent encounters (94%)., Results: Before the visit, 74% of parents reported that they considered it necessary for the physician to listen to their ideas about their child's illness. Among these parents, 62% (n = 130) reported after the visit that the physician had listened to their ideas. As the proportion of moderate-length responses to parent requests for information increased, parents were significantly more likely to report being listened to (P <.05). Multivariate results indicated a 59% probability of parents reporting that they were listened to when given moderate-length responses, 45% when given brief responses, 39% when given prolonged responses, and 12% when requests for information were only partially fulfilled, ignored, or denied. The length of response to parent requests for information was not related to overall parent satisfaction., Conclusions: Parents who received moderate-length answers to their questions were most likely to report that they were listened to. Although it is assumed that lengthier, in-depth explanations result in higher satisfaction, this study suggests that more doctor talk does not necessarily constitute better communication.

We examined post-spill trends (1989-1998) of marine bird populations in Prince William Sound (PWS) following the Exxon Valdez oil spill (EVOS) to evaluate recovery of injured taxa. Two criteria were employed. First, we examined population trends of injured taxa only in the oiled area of PWS using regression models. Second, we examined population trends of injured taxa in the oiled area relative to the unoiled area using homogeneity of the slopes tests. We considered a population recovering if there was a positive trend using either criteria. We considered a population not recovering if there was no trend using either criteria or a negative trend in the oiled area. A significant negative trend in the oiled area relative to the unoiled area was considered a continuing and increasing effect. Most taxa for which injury was previously demonstrated were not recovering and some taxa showed evidence of increasing effects nine years after the oil spill. Four taxa (loons Gavia spp, Harlequin Duck Histrionicus histrionicus, Bufflehead Bucephala spp, and North-western Crow Corvus caurinus) showed weak to very weak evidence of recovery. None of these taxa showed positive trends in both winter and summer. Nine taxa (grebes Podiceps spp, cormorants Phalacrocorax spp, Black Oystercatcher Haematopus bachmani, Mew Gull Larus canus, Glaucous-winged Gull Larus glaucescens, terns Sterna spp, murres Uria spp, Pigeon Guillemot Cepphus columba, and murrelets Brachyramphus spp) showed no evidence of recovery during summer or winter. Four taxa (scoters Melanitta spp, mergansers Mergus spp, goldeneyes Bucephala spp, and Black-legged Kittiwaka Rissa tridactyla) showed evidence of continuing, increasing effects. We showed evidence of slow recovery, lack of recovery, and divergent population trends in many taxa which utilize shoreline and nearshore habitats where oil is likely to persist. Potential lingering spill effects and natural variability appear to be acting in concert in delaying recovery of many PWS bird populations.

Stabled horses commonly perform stereotypic patterns of weaving, where the horse shifts its weight from side to side often swinging its head. Ten warm-blood types, of which five were known to reliably weave, were housed in similar 12x12 ft wooden loose boxes in a single stable block surrounding a courtyard. Each horse was exposed to each of five stable designs. These were: the conventional front top-half of the door open only with a view of the stable courtyard (F); front half-door open and a similar half-door open at the back of the stable with a view to the surrounding fields (FB); back open only (B); front and one-side panel open with a view into the adjacent stable (FS); and front, back and both sides open (All4). During observation days, horses were brought in from the field at 0830 h, fed concentrate at 0930 h, fed haylage at 1005 h and turned out at 1600 h. Behaviour was recorded from 0900 to 1040 h, 1200 to 1300 h and 1500 to 1600 h. Weaving was most common prior to feeding in the morning and prior to putting out to pasture in the afternoon. There was a significant effect of stable design on weaving, with less weaving in the FS and All4 designs than the F treatment. There was also a significant effect of stable design on repetitive nodding, though in this case, FB, B, FS and All4 designs each reduced nodding compared with the F treatment. The effect of stable design can be explained in a number of ways. Firstly, it could be the novelty of the environmental change, though there was no evidence in this study of an increase in stereotypy with prolonged exposure to the new stable designs. Secondly, opening windows may increase opportunities for environmental interaction, and the expression of new activities may compete with stereotypic behaviour for the horse's time. Thirdly, the open windows may allow expression of specific activities such as environmental monitoring or social interaction that are denied by the conventional stable.

Background: Nosocomial transmission of Mycobacterium tuberculosis is a global public-health concern. Although early clinical recognition of M. tuberculosis in hospital inpatients is critical for effective infection control, such recognition may be difficult in patients with HIV infection. To find out whether M. tuberculosis bacteraemia frequently goes unrecognised, we did a prospective blood-culture survey in an infectious-diseases hospital in Thailand and a general hospital in Malawi., Methods: Consecutive febrile (> or = 37.5 degrees C axillary or > or = 38.0 degrees C orally) hospital inpatients (aged > or = 18 years) were enrolled; blood was obtained for mycobacterial culture and HIV testing. Simple diagnostic tests, such as chest radiographs and sputum smears, were ordered by clinicians as deemed necessary, and were carried out with existing local resources., Findings: Of 344 patients enrolled, 255 (74%) were HIV infected, the median age was 33 years (range 18-87), and 208 (61%) were male. 34 (10%) patients had M. tuberculosis bacteraemia; five of these patients were already on antituberculosis therapy. Only HIV-infected patients had M. tuberculosis bacteraemia. Of the 29 patients with M. tuberculosis bacteraemia who were not already receiving antituberculosis therapy, 13 (45%) had an abnormal chest radiograph or a positive sputum smear. 16 (55%) patients had no additional diagnostic test results to indicate M. tuberculosis infection; 18 (81%) of these had a cough., Interpretation: In less developed countries where both M. tuberculosis and HIV infections are prevalent, M. tuberculosis bacteraemia may frequently go unrecognised among febrile hospital inpatients.

Metastatic spread to cervical lymph nodes is a major determinant of outcome in head and neck cancer. One hundred and ninety-six lymph nodes dissected from fresh surgical specimens from 24 patients with primary head and neck squamous cell carcinoma (SCC) were bisected. Messenger RNA (mRNA) extracted from one half and from a segment of the primary tumour was amplified by reverse transcriptase (RT)-polymerase chain reaction (PCR) with primers flanking the fifth intron of human type II keratin K5. DNA bands resolved by agarose gel electrophoresis were confirmed as specific transcripts by sequencing. The other half of each node was fixed in formalin for histology and, in selected nodes, for immunohistology for cytokeratins. Of 153 nodes suitable for analysis, 14 nodes contained metastatic tumour detected by light microscopy and also tested positive for K5 mRNA by RT-PCR. Fifty-six nodes were histologically negative for tumour but positive for K5 mRNA, and 83 nodes were negative for both histology and K5 mRNA. Extracts of the primary tumour always reacted positively for K5 by RT-PCR, whereas lymph nodes from patients without malignancies, and blood lymphocytes from a healthy volunteer reacted negatively. RT-PCR designed to detect the presence of processed transcripts of type II keratin K5 in stratified squamous epithelial cells may be a sensitive technique to detect the presence of viable and potentially metastatic carcinoma cells in lymph nodes draining head and neck SCC.

Neuronal nicotinic acetylcholine receptors (NAChRs) are pentameric ligand-gated ion channel receptors which exist as different functional subunit combinations which apparently subserve different physiological functions as indicated by molecular biological and pharmacological techniques. It is possible to design and synthesize novel compounds that have greater selective affinities and efficacies than nicotine for different NAChRs, which should translate into different behavioral profiles and therapeutic potentials. Examples of NAChR agonists studied are nicotine, SIB-1508Y, SIB-1553A and epibatidine. These compounds have different degrees of selectivity for human recombinant NAChRs, different neurotransmitter release profiles in vitro and in vivo and differential behavioral profiles. Preclinical studies suggest that SIB-1508Y is a candidate for the treatment of the motor and cognitive deficits of Parkinson's disease, whereas SIB-1553A appears to have potential as a candidate for the treatment of Alzheimer's disease. Epibatidine has a strong analgesic profile, however the ratio between pharmacological activity and undesirable effects is so low that it is difficult to envisage the use of this compound therapeutically. Nicotine has a broad profile of pharmacological activity, for instance demonstrating activity in models for cognition and analgesia. As for epibatidine, the adverse effects of nicotine severely limits its therapeutic use in humans. The discovery of subtype-selective NAChR agonists such as SIB-1508Y and SIB-1553A provides a new class of neuropsychopharmacological agents with better therapeutic ratios than nonspecific agents such as nicotine.

Purpose: To determine the adequacy of documenting the preoperative evaluation for cataract surgery using criteria derived from published practice guidelines., Methods: In 1990, 1139 surgeries that were performed on 1139 patients at ten institutions of the Academic Medical Center Consortium were reviewed for completeness of documentation of the preoperative evaluation. Criteria for completeness were derived from the American Academy of Ophthalmology Preferred Practice Pattern on cataract evaluation and the Agency for Health Care Policy and Research-sponsored guidelines., Results: Twenty-six percent of charts lacked documentation of at least one of four basic elements of the preoperative evaluation. These four elements are (1) vision in the surgical eye; (2) vision in the fellow eye; (3) evaluation of the fundus, macula, or visual potential in the surgical eye: and (4) presence of some form (general or specific) of functional visual impairment. If, as stated in the guideline, a specific deficit in visual functioning should be identified, then 40% of charts fail to meet criteria., Conclusion: Documentation of the ocular preoperative assessment for cataract surgery is inadequate in more than one quarter of cases. The relation between lack of documentation and incompleteness of the examination is unknown. Improved documentation is needed to better measure and enhance the quality of care.

Following an extensive literature review of Accident and Emergency (A & E) nursing from 1985-1993, the authors focused upon triage. A wide range of issues related to triage and its use in A & E departments are examined. An appendix is included to clarify major research finds in this area. Many of the claims made regarding triage require further investigation.

On completing a wide ranging review of literature related to Accident and Emergency (A & E) nursing, the authors chose to focus upon grief support. The literature ranges from personal experiences to large scale research. A table of studies is included to clarify major research findings in this area. The article concludes by recommending long term support for bereaved relatives and research to demonstrate the value of support for relatives in the community.

A case is presented of a highly aggressive malignant meningioma with its associated imaging findings. The case report is followed by a brief review of recognized findings of malignant meningiomas versus their benign counterparts and the accuracy of such findings in differentiating malignant from benign meningiomas.

Oviductal fluids (OF) were collected at 24 hour intervals from 27 does. Fluids were collected from all does during estrus and subsequent pregnancy or pseudopregnancy. After collecting OF for 15 days from all does maintained at 21 degrees C and 45% relative humidity (RH), approximately one-half of the does were then subjected to heat stress (33.20+/-0.75 degrees C and 65.4+/-2.3% RH). Oviductal fluid was then collected for 5 days from heat stressed estrous does (HSER), after which all does (both control and HSER) were mated to fertile bucks. Human chorionic gonadotropin was administered to each doe to insure ovulation. Fluids were compared between HSER and heat stressed pregnant rabbits (HSPR) and control estrous (NHER) and pregnant rabbits (NHPR) for volume, pH, various protein concentrations, and total protein content. Fluid volume decreased due both to heat stress and pregnancy. Heat stress increased pH, whereas pregnancy resulted in a decrease. Protein concentration of OF from HSER declined due to heat stress. Protein concentration of OF from NHPR increased prior to breeding, peaking at day 3 of pregnancy, then declined to initial levels. While from HSPR there was also a tendency to have a similar increase, the peak in protein concentration was on day 4 and then decreased on day 5. Total protein content (concentration x volume) of OF from HSER decreased due to heat stress. Total protein content from HSPR and NHPR had similar changes with or without heat stress, although the total protein content from OF of HSPR was less (except for day 3) for the entire 5 day period studied. Relative percentages of albumin decreased and postalbumin increased during the first day of pregnancy (NHPR). These trends were reversed (a relative increase in albumin and a decrease in postalbumin) in OF from HSPR.

An experiment was designed to determine the effect of progesterone (P) or estradiol benzoate (EB) on uterine tubal transport of ova in the cow. Intramuscular injections of P, EB, or corn oil (C) were administered to heifers 24 hours after the end of estrus. The heifers were euthanatized 60 hours after the end of estrus and the location of the ovum or zygote was determined. Venous serum levels of progesterone and estradiol-17beta were measured by radioimmunoassay. The mean uterine tube (UT) length was 23.9 cm. An ovum or zygote was recovered from 11 of 14 heifers. Serum levels of progesterone and estradiol-17beta were above normal bovine levels following the P and EB treatments, respectively. The mean UT ovum transport rates were 0.42, 0.21 and 0.23 cm/hour in the P, EB and C treatment groups, respectively. The UT ovum transport rate was increased (P<0.05) by the P treatment and EB treatment had no effect (P > 0.05) when compared with the C treatment.

Cardiac and pulmonary disease are so closely interrelated that it is often difficult to determine in young infants which is the primary offender. As illustrated in these case reports, failure to recognize the true nature of the disease process may lead to unnecessary procedures and delays which can be life-threatening. Statistically, the wheezing infant very likely is suffering from primary pulmonary disease; however, congenital cardiac abnormalities can cause pulmonary symptoms which completely dominate the clinical picture and lead to erroneous diagnoses. Although rare, the basis of cough and wheezing may be a vascular ring which encircles and compresses the trachea. Lesions associated with large left-to-right shunts, such as ventricular septal defect and patent ductus arteriosus, also can cause cough and wheezing because of bronchial compression by a large tense pulmonary artery and a distended left atrium. These same lesions also produce isolated left ventricular failure with pulmonary venous congestion and episodes of cough and wheezing. Anomalous pulmonary venour return, cor triatriatum, supravalvular mitral ring, or mitral stenosis are other lesions which can cause cough and wheezing secondary to pulmonary venous obstruction.

A single phosphoinositidase C (PIC) activity has been purified 500-fold from bovine heart cytosol to a specific activity of 3 mumol phosphatidylinositol (Ptdlns) hydrolyzed/(min.mg protein). The enzyme required Ca2+ for the hydrolysis of polyphosphoinositides or Ptdlns; PIC activity was saturable at micromolar free Ca2+ concentrations with an apparent KCa of 230nM. None of the multivalent cations tested could effectively substitute for Ca2+ in the activation of PIC, although several ions inhibited PIC activity in the presence of Ca2+. AlCl3 had a differential effect on PIC activity, stimulating Ptdlns hydrolysis while inhibiting Ptdlns-(4,5)P2 hydrolysis in a concentration-dependent manner from 1-100 microM. The effect of AlCl3 was attributed to the free ion, Al3+. Complexation of Al3+ with phosphate, citrate, fluoride, or hydroxide could block the stimulatory effect on Ptdlns hydrolysis. Only fluoride or hydroxide could partially reverse the inhibition of Ptdlns-(4,5)P2 hydrolysis by AlCl3.

Insulin, parathyroid hormone, and calcitonin are polypeptide hormones that regulate important physiological processes in target tissues. Rat genes encoding each hormone were chromosomally assigned to rat chromosome 1. Both rats and mice have two insulin genes (I and II). However, in contrast to mice in which insulin I and II are asyntenic, rat insulin I and II were both localized to chromosome 1. This study identifies a conserved syntenic group on rat chromosome 1, and implies that mouse insulin I and II genes were chromosomally separated after rats and mice diverged 20-35 million years ago.

Thirteen subjects between the ages of 50 years and 70 years were administered a daily 25,000 IU dose of retinol for 9 months. Two subjects experienced mild skin dryness, headaches, and/or alopecia. There were no significant changes in serum chemistries. High performance liquid chromatography assays for plasma retinol revealed no evidence of drug accumulation; however, there was a significant increase in the plasma concentration-versus-time curve for retinyl palmitate concentrations between the first and subsequent sampling days (P = 0.009). The mean skin retinol and retinyl palmitate concentrations in 7 retinol-treated subjects (131.7 and 15.9 ng/g, respectively) were not significantly different from those observed in 13 age-matched controls (118.9 and 25.5 ng/gm, respectively).

All cases of cardiac infarction, acute coronary insufficiency and sudden death occurring in residents of the London Borough of Tower Hamlets below age 65 were registered over nearly three years, and survivors were followed up for one year. The attack-rate in men aged 45-64 years was 1 per 100 per annum but the recurrence-rate in survivors was 1 per 100 per month. Immigrants from Asia had more than the average, and those from the Carribean one tenth of the average attack-rate. Although it was unusual for general practitioners to manage cases at home by choice, nonetheless two-thirds of the deaths happened outside hospital and half of these were not witnessed. Half of those suffering coronary heart-attacks had a previous history of coronary disease and a sizable minority were already unfit for work. Approximately half of those attacked were alive at one year.

A human liver cDNA library was screened using an oligonucleotide probe based on the amino acid sequence of human prealbumin. The cDNA insert of one positive clone was sequenced and found to contain the entire coding sequence of human prealbumin plus untranslated 5' and 3' regions. This cDNA was used to probe DNA from a panel of mouse/human somatic cell hybrids. Only those hybrids containing human chromosome 18 showed the human-specific hybridization pattern, thereby localizing the human prealbumin gene to this chromosome.