Background The ability to diagnose and monitor asthma on the basis of noninvasive measurements of airway cellular dysfunction is difficult in the typical clinical setting. Objective Metabolomics is ...the study of molecules created by cellular metabolic pathways. We hypothesized that the metabolic activity of children with asthma would differ from healthy children without asthma. Furthermore, children having an asthma exacerbation would be different compared with children with stable asthma in outpatient clinics. Finally, we hypothesized that1 H-nuclear magnetic resonance (NMR) would measure such differences using urine samples, one of the least invasive forms of biofluid sampling. Methods Children (135 total, ages 4-16 years) were enrolled, having met the criteria of healthy controls (C), stable asthma in the outpatient clinic (AO), or unstable asthma in the emergency department (AED). Partial least squares discriminant analysis was performed on the NMR data to create models of separation (70 metabolites were measured/urine sample). Some NMR data were withheld from modeling to be run blindly to determine possible diagnostic accuracy. Results On the basis of the model of AO versus C, 31 of 33 AO samples were correctly diagnosed with asthma (94% accuracy). Only 1 of 20 C samples was incorrectly labeled as asthma (5% misclassification). On the basis of the AO versus AED model, 31 of the 33 AO samples were correctly diagnosed as outpatient asthma (94% accurate). Conclusion This is the first report suggesting that1 H-NMR analysis of human urine samples has the potential to be a useful clinical tool for physicians treating asthma.
Adult California ground squirrels,Spermophilus beecheyi beecheyi, actively confront and harass northern Pacific rattlesnakes,Crotalus viridis oreganus, which are the principal predator of ground ...squirrel pups. In this report we examine the roles of risk (snake size) and context (location of encounter and squirrel reproductive category) in rattlesnake assessment by ground squirrels. In interpreting the results, we borrow heavily from the well-developed conceptual framework applied in the analogous case of intraspecific conflict. Large and small snakes were tethered near the home burrows of male ground squirrels, and maternal and nonmaternal female ground squirrels. Ground squirrels appeared to employ assessment strategies which served to mediate the level of risk associated with confronting larger snakes. The results suggest that ground squirrels exercise greater caution when dealing with large snakes and invest more in monitoring the snake from a safe distance. Maternal squirrels, which have more at stake reproductively, spent more time and effort in snake-directed activities than did squirrels from other reproductive categories. Mothers also differentiated more strongly between large and small snakes, perhaps reflecting the greater vulnerability of their pups to larger snakes. Finally, ground squirrels discriminated between snakes found close to their home burrow and those encountered further abroad. At the home burrow, squirrels monitored the snake from a closer distance, displayed a greater willingness to confront the snake, and escalated to more dangerous levels of harassment. This assessment strategy may reflect a higher payoff to squirrels that persist in driving snakes out of the home area, thereby reducing the risk of future ambush.
The objective of this study was to estimate the prevalence of
Tritrichomonas foetus infections in Alabama (USA) beef bulls through prospective and retrospective surveys. The prospective survey ...included 240 Alabama beef bulls that were sampled between January 2005 and March 2006. Preputial smegma was collected from the 240 bulls with a dry pipette and cultured in an InPouch™ TF
T. foetus culture pouch (BioMed Diagnostics; White City, OR, USA). The samples were evaluated microscopically once a day for 6 days for growth resembling
T. foetus. To avoid false-positives due to fecal trichomonads, all suspect cultures were sent to both the Alabama Department of Agriculture Veterinary Diagnostic Laboratory in Auburn, AL, USA and the Auburn University College of Veterinary Medicine Parasitology Laboratory (Auburn, AL, USA) for polymerase chain reaction (PCR) confirmatory assays. Of the 240 bulls cultured in the prospective survey, 3 (1.25%) cultures were considered suspect on microscopic evaluation. However, PCR-based assays were negative for
T. foetus, suggesting that the samples most likely contained fecal trichomonads. The retrospective analysis included 374
T. foetus cultures performed at the Alabama Department of Agriculture Veterinary Diagnostic Laboratory between October 2002 and March 2005. Of the 374 bulls included in the retrospective analysis, only 1 (0.27%) was confirmed positive by a PCR-based assay.
Introduction The diagnosis of blunt cerebrovascular injuries (BCVI) has improved with widespread adaptation of screening protocols and more accurate multi-detector computed tomography (MDCT-A) ...angiography. The population at risk and for whom screening is indicated is still controversial. To help determine which blunt trauma patients would best benefit from screening we performed a comprehensive analysis of risk factors associated with BCVI. Methods All patients with BCVI from June 12, 2000 (the date at which our institution began screening for these injuries) to June 30, 2009 were identified by the primary author (JDB) and recorded in a prospective database. Associated injuries were identified retrospectively by International Classification of Diseases, Ninth Revision (ICD-9) code and compared with similar patients without BCVI. Demographic information was also compared from data obtained from the trauma registry. Univariate analyses exploring associations between individual risk factors and BCVI were performed using Fisher's exact test for dichotomous variables and Student's t test for continuous variables. Additionally, relative risk (RR) was calculated for dichotomous variables to describe the strength of the relationship between the categorical risk factors and BCVI. Multivariate logistic regression models for BCVI, BCAI (blunt internal carotid artery injury), and BVAI (blunt vertebral artery injury) were developed to explore the relative contributions of the various risk factors. Results One hundred two patients with BCVI were identified out of 9935 blunt trauma patients admitted during this time period (1.03% incidence). Fifty-nine patients (0.59% incidence) had a BVAI and 43 patients (0.43% incidence) had a BCAI. Univariate analysis found cervical spine fracture (CSI) (RR = 10.4), basilar skull fracture (RR = 3.60), and mandible fracture (RR = 2.51) to be most predictive of the presence of BCVI ( P < .005). Independent predictors of BCVI on multivariate logistic regression were CSI (OR = 7.46), mandible fracture (OR = 2.59), basilar skull fracture (OR = 1.76), injury severity score (ISS) (OR = 1.05), and emergency department Glasgow Coma Scale (ED-GCS) (OR = 0.93): all P < .05. Conclusions Blunt trauma patients with a high risk mechanism and a low GCS, high injury severity score, mandible fracture, basilar skull fracture, or cervical spine injury are at high risk for BCVI should be screened with MDCT-A.
Older patients who experience a fragility fracture are at high risk of future fractures but are rarely tested or treated for osteoporosis. We developed a multifaceted intervention directed at older ...patients with wrist fractures (in the form of telephone-based education) and their physicians (in the form of guidelines endorsed by opinion leaders, supported by reminders) to improve the quality of osteoporosis care.
In a randomized controlled trial with blinded ascertainment of outcomes, we compared our intervention with usual care (provision of printed educational materials to patients). Eligible patients were those older than 50 years of age who had experienced a wrist fracture and were seen in emergency departments and fracture clinics; we excluded those who were already being treated for osteoporosis. The primary outcome was bisphosphonate treatment within 6 months after the fracture. Secondary outcomes included bone mineral density testing, "appropriate care" (consisting of bone mineral density testing with treatment if bone mass was low) and quality of life.
We screened 795 patients for eligibility and randomly assigned 272 to the intervention (137 patients) or control (135 patients) group. The median age was 60 years; 210 (77%) of the subjects were women, and 130 (48%) reported a previous fracture as an adult. Six months after the fracture, 30 (22%) of the intervention patients, as compared with 10 (7%) of the control patients, were receiving bisphosphonate therapy for osteoporosis (adjusted relative risk RR 2.6, 95% confidence interval CI 1.3-5.1, p = 0.008). Intervention patients were more likely than control patients to undergo bone mineral density testing (71/137 52% v. 24/135 18%; adjusted RR 2.8, 95% CI 1.9-4.2, p < 0.001) and to receive appropriate care (52/137 38% v. 15/135 11%; adjusted RR 3.1, 95% CI 1.8-5.3, p < 0.001). There were no differences between the groups in other outcomes. One patient died, and 4 others experienced recurrent fracture.
A multifaceted intervention directed at high-risk patients and their physicians substantially increased rates of testing and treatment for osteoporosis. Nevertheless, more than half of the patients in the intervention group were not receiving appropriate care 6 months after their fracture, which suggests that additional strategies should be explored. (ClinicalTrials.gov trial register no. NCT00152321.).
ABSTRACT BACKGROUND The Ottawa chronic obstructive pulmonary disease (COPD) Risk Scale (OCRS), which consists of 10 criteria, was previously derived to identify patients in the emergency department ...with COPD who were at high risk for short-term serious outcomes. We sought to validate, prospectively and explicitly, the OCRS when applied by physicians in the emergency department. METHODS We conducted this prospective cohort study involving patients in the emergency departments at 6 tertiary care hospitals and enrolled adults with acute exacerbation of COPD from May 2011 to December 2013. Physicians evaluated patients for the OCRS criteria, which were recorded on a data form along with the total risk score. We followed patients for 30 days and the primary outcome, short-term serious outcomes, was defined as any of death, admission to monitored unit, intubation, noninvasive ventilation, myocardial infarction (MI) or relapse with hospital admission. RESULTS We enrolled 1415 patients with a mean age of 70.6 (SD 10.6) years and 50.2% were female. Short-term serious outcomes occurred in 135 (9.5%) cases. Incidence of short-term serious outcomes ranged from 4.6% for a total score of 0 to 100% for a score of 10. Compared with current practice, an OCRS score threshold of greater than 1 would increase sensitivity for short-term serious outcomes from 51.9% to 79.3% and increase admissions from 45.0% to 56.6%. A threshold of greater than 2 would improve sensitivity to 71.9% with 47.9% of patients being admitted. INTERPRETATION In this clinical validation of a risk-stratification tool for COPD in the emergency department, we found that OCRS showed better sensitivity for short-term serious outcomes compared with current practice. This risk scale can now be used to help emergency department disposition decisions for patients with COPD, which should lead to a decrease in unnecessary admissions and in unsafe discharges.
Study objective In recent years, lean principles have been applied to improve wait times in the emergency department (ED). In 2009, an ED process improvement program based on lean methods was ...introduced in Ontario as part of a broad strategy to reduce ED length of stay and improve patient flow. This study seeks to determine the effect of this program on ED wait times and quality of care. Methods We conducted a retrospective cohort study of all ED visits at program and control sites during 3 program waves from April 1, 2007, to June 30, 2011, in Ontario, Canada. Time series analyses of outcomes before and after the program and difference-in-differences analyses comparing changes in program sites with control sites were conducted. Results In before-after models among program sites alone, 90th percentile ED length of stay did not change in wave 1 (–14 minutes 95% confidence interval {CI} –47 to 20) but decreased after wave 2 (–87 95% CI –108 to –66) and wave 3 (–33 95% CI –50 to –17); median ED length of stay decreased after wave 1 (–18 95% CI –24 to –12), wave 2 (–23 95% CI –27 to –19), and wave 3 (–15 95% CI –18 to –12). In all waves, decreases were observed in time to physician assessment, left-without-being-seen rates, and 72-hour ED revisit rates. In the difference-in-difference models, in which changes in program sites were compared with controls, the program was associated with no change in 90th percentile ED length of stay in wave 2 (17 95% CI –0.2 to 33) and increases in wave 1 (23 95% CI 0.9 to 45) and wave 3 (31 95% CI 10 to 51), modest reductions in median ED length of stay in waves 2 and 3 alone, and a decrease in time to physician assessment in wave 3 alone. Conclusion Although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared with that of control sites, which were exposed to system-wide initiatives such as public reporting and pay for performance. This study suggests that further evaluation of the effectiveness of lean methods in the ED is warranted before widespread implementation.
Abstract
The purposes of this study were: (1) to describe the snake-directed antipredator behavior of rock squirrels; (2) to assess whether rock squirrels distinguish nonvenomous gopher snakes from ...venomous rattlesnakes; (3) to compare antisnake behavior in a snake-rare urban site and a snake-abundant wilderness site as a means of assessing whether natural selection or experience has generated population differences in behavior; (4) to assess snake densities in the two study sites; (5) to compare the antisnake behavior of rock squirrels with that of their closest relatives, California ground squirrels (Spermophilus beecheyi), a species that appears to differ from rock squirrels in exhibiting marked sexual-size dimorphism; and (6) to gather additional data on sexual size dimorphism in these two ground squirrel species. We tethered nonvenomous gopher snakes (Pituophis melanoleucus) and venomous western diamondback rattlesnakes (Crotalus atrox) in the field near burrows of marked squirrels and videotaped the ensuing interactions. Rock squirrels from both urban and wilderness populations confronted snakes while waving their fluffed tails from side to side, throwing substrate at the snakes, and even attacking snakes on occasion. Survey data confirmed large differences in snake densities between the two sites. Squirrels from the snake-abundant wilderness site distinguished rattlesnakes from gopher snakes, but squirrels from the snake-rare urban site did not. Since these squirrels show similar evidence of selection from snakes, as revealed by their equivalent physiological resistance to rattlesnake venom, we attributed these behavioral differences to the effects of snake experience. Rock squirrel antisnake behavior was very similar to that of California ground squirrels. Where the two species' behavior was dissimilar, the differences may be due in part to the interspecies variation in sexual size dimorphism confirmed in this study, and to the greater number of rattlesnake species that rock squirrels encounter.
Epstein-Barr virus (EBV)-infected cells may sustain three distinct forms of virus latency. In lymphoblastoid cell lines, six EBV-encoded nuclear antigens (EBNA1, 2, 3A, 3B, 3C, -LP), three latent ...membrane proteins (LMP1, 2A, 2B), and two nuclear RNAs (EBERs) are expressed. This form of latency, termed latency III, is also encountered in some posttrans-plant lymphoproliferative disorders. In EBV-positive cases of Hodgkin's disease, the EBERs, EBNA1, and the LMPs are expressed (latency II), whereas in Burkitt's lymphoma (BL) only the EBERs and EBNA1 have been detected (latency I). We have studied the expression of EBV proteins in 17 cases of EBV-positive endemic BL by immunohistology. Expression of LMP1 was seen in variable proportions of tumor cells in two cases and EBNA2 was detected in some tumor cells in three other cases. Also, the BZLF1 trans-activator protein was expressed in a few tumor cells in 6 cases, indicating entry into the lytic cycle. A phenotypic drift from latency I to latency III has been observed previously in some BL cell lines. Our results suggest that a similar phenomenon may occur in BL in vivo and indicate that the operational definition of EBV latencies is not easily applied to human tumors.
Study objective Although recent-onset atrial fibrillation and flutter are common arrhythmias managed in the emergency department (ED), there is insufficient evidence to help physicians choose between ...2 competing treatment strategies, rate control and rhythm control. We seek to evaluate variation in ED management practices for recent-onset atrial fibrillation and flutter patients at multiple Canadian sites and to determine whether hospital site was an independent predictor of attempted cardioversion. Methods We conducted a cross-sectional survey by health records review on an observational cohort of all eligible adult recent-onset atrial fibrillation and flutter cases, with onset of symptoms less than 48 hours, treated at 8 academic hospital EDs during a 12-month period, and evaluated the variation in practice among sites for important management strategies. Results Among the 1,068 study patients, 88.3% had atrial fibrillation and 11.7% had atrial flutter. The proportion of cases managed with rhythm control was 59.4% (interhospital range 42% to 85%) and, among these, electrocardioversion was attempted first for 44.2% (range 7% to 69%). There was variation in most management strategies, including use of rate control drugs 54.9% (range 37% to 65%), choice of procainamide as rhythm control drug 62.1% (range 15% to 89%), referral to cardiology in the ED 30.7% (range 16% to 64%), use of heparin 13.7% (range 1% to 29%), and outpatient cardiology referral 43.0% (range 30% to 65%). Adverse events were relatively uncommon and transient for patients undergoing attempts at pharmacologic (13.0%) or electrocardioversion (12.1%). Overall, 83.3% of patients were discharged home from the ED (range 73% to 90%). After controlling for 12 covariates, multivariate logistic regression found that factors independently associated with attempted cardioversion were age (odds ratio OR 0.97; 95% confidence interval CI 0.95 to 0.98), history of electrocardioversion (OR 2.73; 95% CI 1.56 to 4.80), associated heart failure (OR 0.29; 95% CI 0.09 to 0.95), and hospital site (ORs ranged from 0.38 to 3.05). Conclusion We demonstrated a high degree of variation in management approaches for recent-onset atrial fibrillation and flutter patients treated in academic hospital EDs. Individual hospital site, age, previous cardioversion, and associated heart failure were independent predictors for the use of rhythm control.
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