Antibody to a 63 kilodalton insect protein in ankylosing spondylitis.

Ankylosing spondylitis (AS) is associated with antibodies to a heat shock puff on drosophila chromosomes. This observation was investigated by immunoblotting using extracts of the Schneider insect cell line and HeLa cells, before and after heat shock. An insect protein of 63 kilodaltons (but no equivalent human protein) was recognised by 21 (46%) of 46 serum samples from patients with AS, one of two patients with Reiter's syndrome, four (7%) of 60 patients with systemic lupus erythematosus, and two (4%) of 50 control subjects, but not by serum samples from patients with rheumatoid arthritis (RA). Previous heat shock did not appear to affect the strength of reaction, but ML-30, a monoclonal antibody to the mycobacterial 65 kilodalton heat shock protein (hsp65), also recognised an insect protein of 63 kilodaltons by immunoblotting. Antibodies to recombinant mycobacterial hsp65 were measured by enzyme linked immunosorbent assay (ELISA) in serum samples from patients with AS and RA. IgA binding to hsp65 was increased in 41% of AS and 19% of RA serum samples, but there was no correlation with detection of antibody to the insect 63 kilodalton protein.     

Relation between length of hospital stay and costs of care for patients with community-acquired pneumonia

PURPOSE: Patients with pneumonia often remain hospitalized after becoming clinically stable, without demonstrated benefits on outcome. The purposes of this study were to assess the relation between length of hospital stay and daily medical care costs and to estimate the potential cost savings associated with a reduced length of stay for patients with pneumonia. SUBJECTS AND METHODS: As part of a prospective study of adults hospitalized with community-acquired pneumonia at a community hospital and two university teaching hospitals, daily medical care costs were estimated by multiplying individual charges by department-specific cost-to-charge ratios obtained from each hospital's Medicare cost reports. RESULTS: The median total cost of hospitalization for all 982 inpatients was $5, 942, with a median daily cost of $836, including $491 (59%) for room and $345 (41%) for non-room costs. Average daily non-room costs were 282% greater on the first hospital day, 59% greater on the second day, and 19% greater on the third day than the average daily cost throughout the hospitalization (all P <0.05), and were 14% to 72% lower on the last 3 days of hospitalization. Average daily room costs remained relatively constant throughout the hospital stay, with the exception of the day of discharge. A projected mean savings of $680 was associated with a 1-day reduction in length of stay. CONCLUSIONS: Despite institutional differences in total costs, patterns of daily resource use throughout hospitalization were similar at all institutions. A 1-day reduction in length of stay might yield substantial cost-savings.     

Economic evaluation of fluoride varnish application of daily supervision versus daily supervision and additional six-monthly intervals in Scotland (Protecting Teeth @ 3): a randomised controlled trial

BackgroundEconomic evaluations of public health interventions aid decision makers in efficient resource allocation. Our aim was to do an economic evaluation of a subintake of the Protecting Teeth @ 3 Study ([email protected]), a Scottish, 2 year, parallel group, randomised controlled trial, which explored the additional preventive value of fluoride varnish application at six-monthly intervals in nursery settings over and above daily supervised toothbrushing in nursery settings (treatment as usual).MethodsFrom Nov 21, 2012 to Aug 31, 2017, eligible children were randomly assigned to receive either fluoride varnish plus treatment as usual (fluoride varnish group) or treatment as usual in a 1:1 ratio. The economic evaluation was a within-trial, cost-utility analysis comparing the fluoride varnish group with the treatment as usual group. Cost-utility analysis was done from a National Health Service perspective. Within-trial costs included intervention and health-care resource use costs. Health outcomes were expressed in quality-adjusted life-years (QALYs) accrued over the 2 year period. The Child Health Utility 9 Dimensions questionnaire was used to obtain utility scores. Staff travel and labour costs were collected using a staff costs form. Information on other costs was requested from the trial coordinators. National reference costs were used, a discount rate of 1·5% for public health investments was adopted, multiple imputation methods for missing data were employed, sensitivity analyses done, and incremental cost-effectiveness ratios calculated. Ethical approval was from the West of Scotland Research Ethics Service. This trial is registered with EudraCT, 2012-002287-26.FindingsThe data for 534 participants from the 2014–15 intake were used in the analyses. Of these, 265 were assigned to fluoride varnish and assigned to 269 treatment as usual. The mean difference in costs between the fluoride varnish and treatment as usual group was GBP£36·64 (95% CI –48·51 to 111·47; p=0·64). The mean difference in QALYs was –0·0044 (95% CI –0·0168 to 0·0065; p=0·64). The fluoride varnish intervention had higher costs and resulted in less QALYs than that of the treatment as usual. The probability that the fluoride varnish intervention was cost-effective at the £30 000 threshold was 18·5%.InterpretationOur results indicate that there was no substantial difference in costs and QALYs between the two groups. Applying fluoride varnish in nursery settings in addition to daily supervised nursery toothbrushing seems not to be good value for money. We recommended that the funds could be used better on other more cost-effective oral health interventions.Funding[email protected] was funded by the Scottish Government.     

Comparison of late (62 to 140 months) degenerative changes in simultaneously implanted and explanted mitral valve positions in six patients

A Hancock porcine bioprosthesis (PB) was simultaneously implanted in each of 6 patients aged 30 to 64 years (mean 45) in the tricuspid and mitral valve positions and both PBs were explanted 62 to 140 months (mean 102) later. Cuspal degenerative changes occurred in all 12 PBs. In 5 patients, the changes were more extensive on the PBs in the mitral position than in those in the tricuspid position. Cuspal calcific deposits, as determined by radiographs of the explanted bioprostheses, occurred in 5 PBs in the mitral position and in 3 in the tricuspid position: 1 patient with calcific deposits in the PB in the mitral position had no calcific deposits in the corresponding PB in the tricuspid position; 1 patient had heavy calcific deposits in the PB in the mitral position and only mild deposits in the PB in the tricuspid position; and 3 patients had similar but mild calcific deposits in both PBs. Cuspal tears occurred in 5 of the 6 PBs in the mitral position and in no PB in the tricuspid position. Thrombus was observed on the ventricular aspects of the bioprosthetic cusps in 1 PB in the mitral position and in 4 PBs in the tricuspid position. Thus, in our 6 patients, the degenerative changes were more extensive in the PBs in the mitral position than in those in the tricuspid position. These observations indicate that wear characteristics of simultaneously implanted PBs vary according to the site of implantation.     

Left ventricular function at rest and during exercise after aortic valve replacement in patients with aortic regurgitation

To determine the effect of aortic valve replacement on reversing abnormalities of left ventricular function in patients with aortic regurgitation, radionuclide cineangiography was used to study 16 symptomatic patients with aortic regurgitation before and 6 months after aortic valve replacement. Before operation, left ventricular ejection fraction was 46 ± 3 percent at rest (normal mean ± standard error of the mean 57 ± 1 percent; P < 0.001), and decreased to 37 ± 4 percent during exercise (normal 71 ± 2 percent; P < 0.001). After operation, ejection fraction rose to 58 ± 4 percent at rest, indistinguishable from the normal value, and during exercise was 53 ± 4 percent, increased (P < 0.001) from before operation but significantly (P < 0.001) subnormal. Thus, aortic valve replacement can improve but usually does not normalize left ventricular function during exercise in symptomatic patients with aortic regurgitation.     

Interleukin-6 enhances growth factor-dependent proliferation of the blast cells of acute myeloblastic leukemia

The effects of recombinant interleukin-6 (IL-6) on the proliferation of blast precursors present in the peripheral blood of patients with acute myeloblastic leukemia (AML) was investigated. IL-6 had little effect by itself; however, it synergized with granulocyte macrophage colony- stimulating factor (GM-CSF) and interleukin-3 (IL-3) in the stimulation of AML blast colony formation. Responsiveness of blast progenitors to IL-6 was heterogeneous. On normal bone marrow cells the same synergy was observed on granulocyte and monocyte precursors (GM-CFC), while there was no significant effect on erythroid and multipotential precursors.     

Establishment of erythropoiesis following bone marrow transplantation in a patient with congenital hypoplastic anemia (Diamond-Blackfan syndrome)

Marrow transplantation was attempted in a 13-yr-old boy with congenital hypoplastic anemia who had never responded to corticosteroid therapy. Prior to the transplant, he had received 238 transfusions, at least 12 of which were from his father. He was prepared for grafting with antilymphocyte globulin, procarbazine, and total body irradiation (1000 rads). The patient, whose red cells were Group B, then received marrow cells from his Group O, histocompatible, sister. Thereafter, reticulocytes, Group O erythrocytes, and female leukocytes appeared in the peripheral blood. Erythroid precursors were seen in the patient's marrow for the first time in his life, and all lacked fluorescent Y chromosomes. Dividing cells were all female. After initially progressing well, the patient developed interstitial pneumonia and died 55 days after the transplant. The successful erythroid graft suggested that this patient's failure to produce red blood cells was due to a defective stem cell rather than to a humoral defect, plasma inhibitor, or abnormal marrow microenvironment. It suggested further that sibling marrow may be engrafted in patients who have received multiple transfusions, even from a parent.     

Parent–Adolescent Relationship Quality and Nondisclosure as Mediators of the Association Between Exposure to Community Violence and Psychological Distress

Background

African American youth residing in urban poverty have been shown to be at increased risk for exposure to violence and for psychological symptoms, but there has been little investigation of mediating processes that might explain this association.

Objectives

This study tested the quality of parent–adolescent relationships and adolescent nondisclosure to adults as mediating mechanisms through which exposure to community violence may lead to psychological symptoms.

Methods

The current study surveyed a sample of 152 low-income urban African American early adolescents (aged 12–14). Participants completed self-report questionnaires assessing exposure to community violence, nondisclosure, parent–adolescent relationship, and psychological symptoms (i.e., internalizing and externalizing symptoms).

Results

Path analyses revealed that parent–adolescent relationship quality and nondisclosure both functioned as mediators of the relation between exposure to community violence and both internalizing and externalizing symptoms, though significant direct effects for violence exposure on externalizing symptoms remained. Decomposition of effects revealed that nondisclosure was a stronger mediator than parent–adolescent relationship quality. Results also indicated that exposure to violence can lead to externalizing (but not internalizing) symptoms first by way of parent–adolescent relationship quality and then nondisclosure.

Conclusions

Combined, these findings suggest that the development of preventive interventions designed to assist adults and parents improve communication and strengthen relationships with adolescents might reduce the negative effects of exposure to community violence on adolescent mental health.

     

Peri-operative complications in pediatric and adolescent shoulder arthroscopy

Background

Shoulder arthroscopy is not common in the pediatric and adolescent population, but the frequency may be on the rise. The purpose of the study was to determine the incidence of acute complications of arthroscopic shoulder surgery in children and adolescents.

Methods

A retrospective, cross-sectional review was performed identifying patients aged 18 years or less who underwent an arthroscopic shoulder procedure from 1997 to 2009 at Institution 1 and 2007 to 2010 at Institution 2. Exclusion criteria included open procedures and missing records. Demographic and surgical data were collected, including intra-operative and post-operative complications during the first 6 months. The complications were divided into minor (no secondary treatment) and major (secondary treatment rendered).

Results

Two hundred children, mean age 15.9 years, met criteria and 73 % were boys. All procedures were performed under general anesthesia, but 51 % included inter-scalene regional anesthesia. There were 16 (8.0 %) total complications recorded. Major complications occurred in five (2.5 %) patients, including two tendinitis/bursitis requiring injections, one broken pain pump catheter requiring an accessory incision to retrieve, one pain control readmission, and one laceration of the cephalic vein requiring ligation. Minor complications occurred in 11 (5.5 %) patients, including allergic reactions, transient dysesthesias, headaches, bronchitis, syncope, transient hypotension, and uvula swelling.

Conclusion

Although we found no seriously deleterious outcomes, it is important to recognize that an additional service was rendered for 2.5 % of children undergoing shoulder arthroscopy. The events that did occur may be preventable and this study should serve as a baseline to improve quality and safety of shoulder arthroscopy in the pediatric population.