Levels of serum amyloid P-component associated with pregnancy and collagen-induced arthritis in DBA/1 (H-2q) mice

The levels of the acute-phase reactant serum amyloid P-component (SAP) were measured by quantitative rocket immunoelectrophoresis in pregnant and non-pregnant DBA/1 female mice with or without collagen-induced rheumatoid arthritis (CIA). Non-pregnant animals with CIA showed elevated SAP titres related to the severity of the disease. Pregnancy alone also caused increased SAP levels equivalent to those found in animals with established CIA but which were virgin. The clinical remission seen in arthritic animals during pregnancy was not associated with reductions in circulating SAP levels. Increasing parity, however, caused a lowering of SAP levels in animals with or without CIA compared to the primiparous individuals. Pregnancy causes a strain-dependent elevation of serum SAP which is not further elevated by CIA, thus limiting the usefulness of SAP measurements in assessment of disease progression or remission during gestation.     

Connectomic assessment of injury burden and longitudinal structural network alterations in moderate‐to‐severe traumatic brain injury

Traumatic brain injury (TBI) is a major public health problem. Caused by external mechanical forces, a major characteristic of TBI is the shearing of axons across the white matter, which causes structural connectivity disruptions between brain regions. This diffuse injury leads to cognitive deficits, frequently requiring rehabilitation. Heterogeneity is another characteristic of TBI as severity and cognitive sequelae of the disease have a wide variation across patients, posing a big challenge for treatment. Thus, measures assessing network‐wide structural connectivity disruptions in TBI are necessary to quantify injury burden of individuals, which would help in achieving personalized treatment, patient monitoring, and rehabilitation planning. Despite TBI being a disconnectivity syndrome, connectomic assessment of structural disconnectivity has been relatively limited. In this study, we propose a novel connectomic measure that we call network normality score (NNS) to capture the integrity of structural connectivity in TBI patients by leveraging two major characteristics of the disease: diffuseness of axonal injury and heterogeneity of the disease. Over a longitudinal cohort of moderate‐to‐severe TBI patients, we demonstrate that structural network topology of patients is more heterogeneous and significantly different than that of healthy controls at 3 months postinjury, where dissimilarity further increases up to 12 months. We also show that NNS captures injury burden as quantified by posttraumatic amnesia and that alterations in the structural brain network is not related to cognitive recovery. Finally, we compare NNS to major graph theory measures used in TBI literature and demonstrate the superiority of NNS in characterizing the disease.     

Pay for Performance Improves Rural EMS Quality: Investment in Prehospital Care

Objective. To evaluate the effect of a system of financial reward for emergency medical technicians (EMTs) who meet selected quality marker goals. Methods. This project was reviewed by an institutional review board (IRB) andwas found to be exempt from IRB review. Two operational andfour clinical markers were targeted for improvement. Baseline performance measurements were retrospectively measured for the preceding year, andchallenging but achievable goals for improvement were established. Operational markers included completing run reports within three hours after completion of the run andcall-to-en route (“out-of-chute”) times of less than 90 seconds for emergency calls on our first-line ambulance. Clinical markers included the use of aspirin in adults with nontraumatic chest pain, electrocardiogram (ECG) performance in adults with nontraumatic chest pain, documentation of pain assessment andintervention in patients with traumatic hip pain, anddocumentation of the time of onset of symptoms in stroke calls. Each full-time EMT could earn up to $1,000 in addition to baseline pay, with part-time EMTs eligible for prorated amounts. Results. Postincentive run reports were completed within three hours 99.7% of the time, with 21 of 24 providers meeting the goal 100% of the time. Before the incentive, reports were completed within three hours 64% of the time, with only two of 23 providers meeting the goal 100% of the time. The out-of-chute goal of less than 90 seconds was met 98.7% of the time, compared with 90.1% before the incentive. Aspirin use in adult nontraumatic chest pain improved from 68% to 96.3%, andECG performance in this group improved from 43% to 87.8%. Documentation of the time of onset of symptoms in stroke patients improved from 97% to 100%, andthe assessment of andintervention for pain in traumatic hip pain patients improved from 56% to 100%. Conclusion. Financial motivation improved targeted quality measures in this rural emergency medical service. It appears to be a useful adjuvant to traditional quality improvement mechanisms.     

Lung and heart-lung transplantation in patients with end-stage cystic fibrosis: the Stanford experience

BACKGROUND: Bilateral lung (BLTx) and heart-lung transplantation have gained wide acceptance as treatment of end-stage lung disease from cystic fibrosis. We reviewed our 13-year experience with thoracic transplantation for cystic fibrosis with an operative approach that favors use of cardiopulmonary bypass for BLTx. METHODS: Sixty-four patients with cystic fibrosis underwent heart-lung transplantation (n = 22, 34.4%) or BLTx (n = 42, 65.6%) between 1988 and 2000. Mean age and weight at transplantation were 29 +/- 8 years and 51 +/- 11 kg, respectively. Mean follow-up for survivors was 4.4 +/- 3.6 years. Immunosuppression regimen included cyclosporine, tapered corticosteroids, azathioprine, and induction therapy with OKT3 (murine monoclonal antibodies) or rabbit antithymocyte globulin. Cardiopulmonary bypass was used in all but 5 patients (7.8%). However, in 8 (19%) of the 42 patients having BLTx, only the grafting of the second lung was performed with cardiopulmonary bypass. RESULTS: The operative mortality rate was 1.6%. The actuarial survival rates at 1 year, 3 years, 5 years and 10 years were 93.2%, 77.7%, 61.8%, and 48.1%, respectively, with no significant difference between BLTx and heart-lung transplantation. The major hospital complications were pneumonia (n = 11, 17.2%) and bleeding (n = 8, 12.5%). Clinically significant reperfusion injury was observed in 6 patients, 3 of whom required reintubation. Freedom from acute lung rejection beyond 1 year was 47.7%. One patient underwent late retransplantation, and 4 required bronchial stenting. Obliterative bronchiolitis accounted for eight (50.0%) of 16 late deaths. CONCLUSIONS: Though postoperative bleeding and pneumonia are still of concern, satisfactory early and intermediate-term results can be expected in patients undergoing BLTx or heart-lung transplantation for cystic fibrosis. Cardiopulmonary bypass can be used for BLTx with no adverse impact on intermediate and long-term outcomes.     

Osteolytic Paget's bone disease in a young man. Rapid healing with human calcitonin therapy

Paget's bone disease is rare in young adults. Severe osteolytic Paget's bone disease in a 28-year-old man was found to respond, clinically, biochemically, and radiographically, within one month to daily subcutaneous injections of 0.5 mg of synthetic human calcitonin. After two years of therapy, he remains asymptomatic and has no biochemical evidence of Paget's bone disease while receiving injections three times a week. Despite aggressive disease, young patients may rapidly demonstrate the same beneficial response to synthetic human calcitonin therapy as has been observed in middle-aged or elderly patients with Paget's bone disease.     

Clinical significance of cardiac damage and changes in function after exercise

Acute bouts of ultraendurance exercise may result in the appearance of biomarkers of cardiac cell damage and a transient reduction in left ventricular function. The clinical significance of these changes is not fully understood. There seems to be two competing issues to be resolved. First, could prolonged endurance exercise produce a degree of cardiac stress and/or damage that results, during the short or long term, in deleterious consequences for cardiac health. Second, there is a clear need to educate those responsible for the medical care of endurance athletes about the possibility of a transient reduction in cardiac function and the appearance of cTnT/cTnI after an exercise. Minor elevations in cardiac troponins are commonplace after an endurance exercise in elite and recreational athletes and may occur alongside exercise-associated collapse. Misdiagnosis of myocardial injury and subsequent mismanagement can be unnecessarily expensive and psychologically damaging to the athlete. Diagnosis of myocardial injury after prolonged exercise should be made on the basis of all available information and not blood tests alone. The clinical significance of chronic exposure to endurance exercise is unknown. The development of myocardial fibrosis has been suggested as a long-term outcome to chronic exposure to repetitive bouts of endurance exercise and has been linked to an exercise-induced inflammatory process observed in an animal model. This hypothesis is supported by a limited number of studies reporting postmortem studies in athletes and an increased prevalence of complex arrhythmia in veteran athletes. Care is warranted in promoting this hypothesis without further detailed work, given the unequivocal link between exercise and mortality and morbidity. It would seem erroneous, however, to assume that a linear relationship exists between exercise volume and cardiac health.     

Boerhaave's syndrome: diagnosis and treatment

Boerhaave's syndrome, or postemetic rupture of the esophagus,represents one of several etiologies of esophageal perforation. Early diagnosis, which requires both a high index of suspicion and contrast esophagography, is essential for optimal outcome. Primary repair is often possible, although other techniques, such as esophageal exclusion or diversion, may be appropriate in certain circumstances.