Pattern recognition receptors and genetic risk for rsv infection: value for clinical decision‐making?

Respiratory syncytial virus (RSV) causes respiratory tract infections, especially among young infants. Practically, all infants are infected during epidemics and the clinical presentation ranges from subclinical to fatal infection. Known risk factors for severe RSV infection include prematurity, age of <2 months, underlying chronic lung or heart diseases, serious neurological or metabolic disorders, immune deficiency (especially a disorder of cellular immunity), crowded living conditions, and indoor smoke pollution. Twin studies indicate that host genetic factors affect susceptibility to severe RSV infection. Pattern recognition receptors (PRRs) are the key mediators of the innate immune response to RSV. In the distal respiratory tract, RSV is recognized by the transmembrane Toll-like receptor 4 (TLR4) and adapter proteins, which lead to production of proinflammatory cytokines and subsequent activation of the adaptive immune response. Surfactant proteins A and D are able to bind both RSV and TLR4, modulating the inflammatory response. Genetic variations in TLR4, SP-A, and SP-D have been associated with the risk of severe RSV bronchiolitis, but the results have varied between studies. Both the homozygous hyporesponsive 299Gly genotype of TLR4 and the non-synonymous SP-A and SP-D polymorphism influence the presentation of RSV infection. The reported relative risks associated with these markers are not robust enough to justify clinical use. However, current evidence indicates that innate immune responses including pattern recognition receptors (PRRs) and other components in the distal airways and airspaces profoundly influence the innate immune responses, playing a key role in host resistance to RSV in young infants. This information is useful in guiding efforts to develop better means to identify the high-risk infants and to treat this potentially fatal infection effectively.     

Three decision‐making tasks in cocaine‐dependent patients: do they measure the same construct?

Aims. Substance-abusing populations perform poorly on decision-making tasks related to delay and risk. These tasks include: (1) the Delay Discounting Procedure (DDP), in which choices are made between smaller-sooner and later-larger rewards, (2) the Gambling Task (GT), in which choices are made between alternatives varying in pay-off and punishment, and (3) the Rogers Decision-Making Task (RDMT) in which subjects choose between higher or lower probability gambles. We examine the interrelationship among these tasks.
Design. A test battery was created which included the DDP, GT and RDMT, as well as measures of impulsivity, intellectual functioning and drug use.
Setting. Subjects completed the test battery at an outpatient center, prior to beginning 12 weeks of treatment.
Participants. Thirty-two treatment-seeking cocaine dependent individuals (primarily African-American males) participated.
Findings. Performance on the GT was significantly correlated with performance on the DDP ( r = 0.37; p = 0.04). Reaction times on the RDMT correlated with performance on the GT ( r = 0.36, p = 0.04) and DDP ( r = 0.33, p = 0.07), but actual choices on the RDMT did not ( p > 0.9 for both). While no significant relationships were observed between task performance and impulsivity, IQ estimate was positively correlated with both the GT ( r = 0.44, p = 0.01) and RDMT ( r = 0.41, p = 0.021). Split half reliability data indicated higher reliability when using only data from the latter half of the GT ( r = 0.92 vs. r = 0.80).
Conclusions. These data offer preliminary evidence of overlap in the decision-making functioning tapped by these tasks. Possible implications for drug-taking behavior are discussed.     

Can a decision‐making model be justified in the management of hepatocellular adenoma?

During recent years, there was a great development in the area of hepatocellular adenomas (HCA), especially regarding the pathological subtype classification, radiological imaging and management during pregnancy. This review discusses the current knowledge about diagnosis and treatment modalities of HCA and proposes a decision-making model for HCA. A Medline search of studies relevant to epidemiology, histopathology, complications, imaging and management of HCA lesions was undertaken. References from identified articles were hand-searched for further relevant articles.     

Care for older adults with dementia: PACE day care or residential dementia care units?

BackgroundPersons with dementia (PwD) are at greater risk for various adverse health outcomes, and the best care model remains to be determined. This study aimed to compare the physical and neurocognitive performance of PwD in the Program of All-inclusive Care for the Elderly (PACE) and residential dementia care units.MethodsThis was a case-control study comparing outcomes between care recipients of PACE services (PC group) and residential dementia care (RC group). Demographic characteristics, underlying diseases, physical function, cognitive function, mood status, and behavioral and psychotic symptoms of dementia (BPSDs) were assessed every 3-6 months in both groups, while frailty status and Timed Up-and-Go Test (TUGT) performance were assessed every 6 months in the PC group only.ResultsOverall, 96 participants (PC group: 25, RC group: 71; mean age: 86.4 ± 6.8 years) were enrolled with the median follow-up period of 43.6 weeks. Lower incidence of hospital admissions was noted in the PC group (0.52 ± 1.12 vs 1.38 ± 2.49 admissions/1,000 person-days, p=0.023), even though the PC group had higher multimorbidity and more severe BPSDs. During the study period, the PC group showed a significant improvement in body mass index, less physical dependence, better cognitive performance and reduced depressive mood. In addition, the PC group showed improvement in frailty, leisure hour activities, and TUGT results. However, participants in the PC group were more likely to experience BPSD deterioration (β coeff.: 0.193, 95% CI: 0.121- 0.265).ConclusionThe PACE services significantly reduced unexpected hospital admissions of PwD, facilitated the maintenance of physical independence, and improved cognitive performance and mood status. Further randomized controlled studies are needed to determine the most appropriate care model for PwD.     

Travel for HIV care in England: a choice or a necessity?

Objectives

The aims of the study were (1) to measure the distance required to travel, and the distance actually travelled, to HIV services by HIV‐infected adults, and (2) to calculate the proportion of patients who travelled beyond local services and identify socio‐demographic and clinical predictors of use of non‐local services.

Methods

The straight‐line distance between a patient's residence and HIV services was determined for HIV‐infected patients in England in 2007. ‘Local services’ were defined as the closest HIV service to a patient's residence and other services within an additional 5 km radius. Multivariable logistic regression was used to identify socio‐demographic and clinical predictors of accessing non‐local services.

Results

In 2007, nearly 57 000 adults with diagnosed HIV infection accessed HIV services in England; 42% lived in the most deprived areas. Overall, 81% of patients lived within 5 km of a service, and 8.7% used their closest HIV service. The median distance to the closest HIV service was 2.5 km [interquartile range (IQR) 1.5–4.2 km] and the median actual distance travelled was 4.8 km (IQR 2.5–9.7 km). A quarter of patients used a ‘non‐local’ service. Patients living in the least deprived areas were twice as likely to use non‐local services as those living in the most deprived areas [adjusted odds ratio (AOR) 2.16; 95% confidence interval (CI) 1.98–2.37]. Other predictors for accessing non‐local services included living in an urban area (AOR 0.77; 95% CI 0.69–0.85) and being diagnosed more than 12 months (AOR 1.48; 95% CI 1.38–1.59).

Conclusion

In England, 81% of HIV‐infected patients live within 5 km of HIV services and a quarter of HIV‐infected adults travel to non‐local HIV services. Those living in deprived areas are less likely to travel to non‐local services.