The Adverse Effects of Physical Restraint Use among Older Adult Patients Admitted to the Internal Medicine Wards: A Hospital-Based Retrospective Cohort Study.

OBJECTIVES: To evaluate the negative effect of physical restraint use on the hospital outcomes of older patients. DESIGN: A retrospective cohort study. SETTING: Internal medicine wards of a tertiary medical center in Taiwan. PARTICIPANTS: Subjects aged 65 years and over who were admitted during April to Dec 2017 were recruited for study. MEASUREMENTS: Demographic data, geriatric assessments (polypharmacy, visual impairment, hearing impairment, activities of daily living before and after admission, risk of pressure sores, change in consciousness level, mood condition, history of falls in the previous year, risk of malnutrition and pain) and hospital conditions (admission route, department of admission, length of hospital stay and mortality) were collected for analysis. RESULTS: Overall, 4,352 participants (mean age 78.7±8.7 years, 60.2% = male) were enrolled and 8.3% had physical restraint. Results of multivariate logistic regression showed that subjects with physical restraints were at greater risk of functional decline (adjusted odds ratio 2.136, 95% confidence interval 1.322-3.451, p=0.002), longer hospital stays (adjusted odds ratio 5.360, 95% confidence interval 3.627-7.923, p<0.001) and mortality (adjusted odds ratio 4.472, 95% confidence interval 2.794-7.160, p<0.001) after adjustment for covariates. CONCLUSION: The use of physical restraints during hospitalization increased the risk of adverse hospital outcomes, such as functional decline, longer length of hospital stay and mortality.

Predictive Effect of Malnutrition on Long-Term Clinical Outcomes among Older Men: A Prospectively Observational Cohort Study.

OBJECTIVES: To determine whether nutritional status can predict 3-year cognitive and functional decline, as well as 4-year all-cause mortality in older adults. DESIGN: Prospectively longitudinal cohort study. SETTING AND PARTICIPANTS: The study recruited 354 men aged 65 years and older in the veteran's retirement community. MEASURES: Baseline nutritional status was evaluated using the Mini-Nutritional Assessment-Short Form (MNA-SF). Cognitive function and Activities of Daily Living (ADL) function were determined by the Mini-Mental State Examination (MMSE) and the Barthel Index, respectively. Three-year cognitive and functional decline were respectively defined as a >3 point decrease in the MMSE scores and lower ADL scores than at baseline. Univariate and multivariable logistic regression analyses were conducted to identify nutritional status as a risk factor in poor outcome. The Kaplan-Meier method and Cox proportional regression models were used to estimate the effect of malnutrition risk on the mortality. RESULTS: According to MNS-SF, the prevalence of risk of malnutrition was 53.1% (188/354). Multivariate logistic regression found risk of malnutrition significantly associated with 3-year cognitive decline (Adjusted odds ratio [OR] 2.07, 95% Confidence Interval [CI] 1.05-4.08, P =0.036) and functional decline (Adjusted OR 1.83, 95% CI 1.01-3.34, P =0.047) compared with normal nutritional status. The hazard ratio (HR) for all-cause mortality was 1.8 times higher in residents at risk of malnutrition (Adjusted HR 1.82, 95% CI 1.19-2.79, P =0.006). CONCLUSIONS: Our results provide strong evidence that risk of malnutrition can predict not only cognitive and functional decline but also risk of all-cause mortality in older men living in a veteran retirement's community. Further longitudinal studies are needed to explore the causal relationship among nutrition, clinical outcomes, and the effect of an intervention for malnutrition.

Retrospective Review of Documentation Practices of Hepatitis B Immunoglobulin, Birth Dose, and Vaccination at the Hospital of Birth, in Thai Nationals and Migrants in Northern Thailand.

BACKGROUND: Vaccination remains the mainstay of prevention of hepatitis B virus (HBV) including birth dose and hepatitis B immunoglobulins (HBIGs). National estimates of vaccination coverage exclude migrants. The objective of this study is to investigate documentation practices of HBV-related infant vaccinations in Northern Thailand including migrants. METHODS: This is a retrospective review of hospital records of women who birthed infants in 2015 at Maharaj Nakorn Hospital, Chiang Mai (CM) or on the Thailand-Myanmar border, Tak. RESULTS: Of 2522 women, 987 were from CM (861 Thai nationals, 126 migrants) and 1535 were from Tak (651 Thai residence and 884 Myanmar residence). In CM, documentation for the birth dose vaccine (999 of 999, 100%) and HBIG was complete. In Tak, documentation was 1441 of 1549 (93%) for birth dose and 26 of 34 (76.5%) for HBIG, with missed opportunities including home delivery, delay in obtaining hepatitis B e-antigen status, and limitations of the records. Expanded Program of Immunization (EPI) documentation of 3 follow-up vaccinations dwindled with subsequent doses and distance, and complete documentation of 3 HBV EPI vaccines at the hospital of birth was low, 41.5% (1056 of 2547), but equitable for Thai or migrant status. CONCLUSIONS: This review provides strong support for excellent documentation of HBIG and birth dose vaccination in urban and rural settings, and in migrants, consistent with Thailand's vaccination policy and practice. Documentation of the 3 HBV EPI at the hospital of birth decreases with sequential doses, especially in families further away. Innovative data linkage is required to prove coverage and identify gaps.

Papillary thyroid cancer arising in struma ovarii.

Malignant struma ovarii is a rare clinical entity that poses a therapeutic challenge, as there is no 'gold standard' of care. We aimed to develop evaluation and treatment guidelines by reviewing presentation and outcomes of the available literature. We present a 60-year-old female with papillary thyroid carcinoma arising in a mature teratoma, and our multidisciplinary approach to care and follow-up. We examined 59 cases for characteristics, including rates of metastasis and recurrence, and response to surgical and adjuvant treatment. We found higher rates of metastasis and recurrence than traditionally reported, and found no recurrence in patients treated with oophorectomy, thyroidectomy, and I-131 radioablation. A multimodal approach to the treatment of malignant struma ovarii may improve survival and decrease risk of recurrence.

An outbreak of skin and soft tissue infection caused by Mycobacterium abscessus following acupuncture.

Although outbreaks of Mycobacterium abscessus infection have been reported, none of these reports has identified the potential sources of infection and modes of transmission. In April 2008, we identified and investigated an outbreak of M. abscessus skin and soft tissue infections following acupuncture among the patients who visited an oriental medical clinic. Active surveillance of patients who had visited the clinic was conducted to define the extent of the outbreak. Environmental cultures and a case-control study were performed to elucidate the source of infection and mode of transmission. From 1002 patients interviewed, 109 patients were identified as having suffered M. abscessus skin and soft tissue infections at acupuncture sites. A single strain of M. abscessus was isolated from the wounds of 31 patients and nine environmental samples, including a diluted glutaraldehyde solution. The case-control study revealed that a higher numbers of visits to the clinic for acupuncture (adjusted OR (aOR) 20.12; 95% CI 4.34-93.35) and the use of interferential current therapy or low-frequency therapy (aOR 36.12; 95% CI 5.54-235.44) were associated with the development of M. abscessus infection. The contaminated diluted glutaraldehyde solution that was used to disinfect the physical therapy devices may have been the source of the outbreak of M. abscessus infection in the 109 patients who underwent acupuncture.

Adipocytokines and proinflammatory mediators from abdominal and epicardial adipose tissue in patients with coronary artery disease.

OBJECTIVE: Epicardial and abdominal adipose tissues have recently been demonstrated to play inflammatory roles in coronary atherosclerosis. We sought to compare tissue adipocytokine levels of these two anatomically distinct adipose stores in patients with and without coronary artery diseases (CAD). DESIGN: Samples of abdominal and epicardial fat tissues were harvested to detect the levels of adipocytokines and proinflammatory mediators. SUBJECTS: Forty-six patients with CAD who underwent coronary artery bypass surgery and 12 non-CAD control subjects who underwent other types of open-heart surgery. MEASUREMENTS: Tissue levels of adipocytokines (adiponectin, leptin and visfatin) and proinflammatory mediators (tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6)) were determined by enzyme-linked immunosorbent assay. RESULTS: Tissue levels of TNF-alpha, IL-6, leptin and visfatin were significantly higher in CAD patients relative to control subjects. In addition, significantly higher tissue levels of these four cytokines from abdominal fat depots were found compared to those from epicardial fat in CAD patients. Conversely, in comparison with control subjects, tissue levels of adiponectin were significantly reduced in CAD patients with a significantly lower tissue levels of abdominal than epicardial fat depots demonstrated. CONCLUSION: Abdominal adiposity may play more significant role than epicardial fat in the pathogenesis of coronary atherosclerosis.

Spin cloud induced around an elastic scatterer by the intrinsic spin hall effect.

Similar to the Landauer electric dipole created around an impurity by the electric current, a spin polarized cloud of electrons can be induced by the intrinsic spin Hall effect near a spin independent elastic scatterer. It is shown that in the ballistic range around the impurity, such a cloud appears in the case of Rashba spin-orbit interaction, even though the bulk spin Hall current is absent.

Strain-induced coupling of spin current to nanomechanical oscillations.

We propose a setup which allows us to couple the electron spin degree of freedom to the mechanical motions of a nanomechanical system not involving any of the ferromagnetic components. The proposed method employs the strain-induced spin-orbit interaction of electrons in narrow gap semiconductors. We have shown how this method can be used for detection and manipulation of the spin flow through a suspended rod in a nanomechanical device.

Spin Hall effect on edge magnetization and electric conductance of a 2D semiconductor strip.

The intrinsic spin Hall effect on spin accumulation and electric conductance in a diffusive regime of a 2D electron gas has been studied for a 2D strip of a finite width. It is shown that the spin polarization near the flanks of the strip, as well as the electric current in the longitudinal direction, exhibit damped oscillations as a function of the width and strength of the Dresselhaus spin-orbit interaction. Cubic terms of this interaction are crucial for spin accumulation near the edges. As expected, no effect on the spin accumulation and electric conductance have been found in case of Rashba spin-orbit interaction.

Survival of BRCA1 negative ovarian cancer patients based on family history.

OBJECTIVE: To compare survival of ovarian cancer patients with and without a family history of breast or ovarian cancer who are known to be without mutations in BRCA1. METHODS: Patients with ovarian cancer were tested for germline mutations in BRCA1 by polymerase chain reaction amplification of DNA for single-strand conformation polymorphism and direct sequencing analysis to examine the 22 coding exons of BRCA1 in fresh and archived tumor specimens. Demographic and survival data were collected for statistical analysis. Survival data were calculated by the method of Kaplan and Meier and compared by the log-rank test. RESULTS: Of the 110 patients tested at our institution, 100 were noted to be negative for BRCA1 mutations. After exclusion of nonepithelial histologies, benign tumors, primary peritoneal carcinoma, and incomplete staging, 87 patients remained for analysis, of which 37 demonstrated a family history of breast or ovarian cancer. The two groups showed similar age at diagnosis, stage, grade, residual disease, and type of chemotherapy. Median actuarial survival was 75 months for those patients with a family history versus 70 months for those without (P = 0.73). Evaluation of patients with two or more relatives with breast or ovarian cancer also revealed no differences in survival. CONCLUSIONS: Family history of breast or ovarian cancer does not affect survival of patients with ovarian cancer in the absence of mutations in BRCA1. Previously described differences in survival among patients with BRCA1 mutations may be more related to genetic factors than to biases introduced by the presence of family history.

Regulatory CD4(+)CD25(+) T cells in tumors from patients with early-stage non-small cell lung cancer and late-stage ovarian cancer.

Immunosuppression may contribute to the progression of cancer. In this study we assessed the structural and functional status of T cells from tumor specimens obtained from patients with early stage non-small cell lung cancer and late-stage ovarian cancer. Although some groups have described structural alterations in the TCR in patients with other malignancies, we did not observe decreased expression of the CD3zeta subunit in the tumor-associated T cells. However, increased percentages of CD4(+)CD25(+) T cells were observed in the non-small cell lung cancer tumor-infiltrating lymphocytes and ovarian cancer tumor-associated lymphocytes. Furthermore, these CD4(+)CD25(+) T cells were found to secrete transforming growth factor-beta, consistent with the phenotype of regulatory T cells. Despite a generalized expression of lymphocyte activation markers in the tumor-associated T-cell populations, the CD8(+) T cells expressed low levels of CD25. To determine whether expression of CD25 could be restored on the CD8 cells, tumor-associated T cells were stimulated with anti-CD3 and anti-CD28 monoclonal antibodies. After stimulation, nearly all of the CD8 T cells expressed CD25. Furthermore, despite the low levels of interleukin 2, IFN-gamma, and tumor necrosis factor-alpha secretion by the tumor-associated and peripheral blood T cells at baseline, stimulation with anti-CD3 and anti-CD28 monoclonal antibodies significantly increased the fraction of cells producing these cytokines. Thus, tumor-associated T cells from patients with early and late-stage epithelial tumors contain increased proportions of CD4(+)CD25(+) T cells that secrete the immunosuppressive cytokine transforming growth factor-beta. Furthermore, our results are consistent with previous reports showing impaired expression of CD25 on CD8(+) T cells in cancer patients. Finally, increased lymphocyte costimulation provided by triggering the CD28 receptor is able to increase CD25 expression and cytokine secretion in tumor-associated T cells. These observations provide evidence for the contribution of regulatory T cells to immune dysfunction in cancer patients.

Second-look laparotomy for epithelial ovarian cancer: a reappraisal.

Although second-look laparotomy (SSL) has been used in the management of ovarian cancer for over three decades, its current clinical use is limited. On average, over 50% of patients with a clinical complete response are noted to have disease at the time of SLL, emphasizing our lack of accurate noninvasive methods for determining pathologic response. Although findings at SLL have some prognostic significance, there is no definitive evidence that those patients undergoing SLL have improved survival, and even 50% of patients with negative findings at SLL have recurrences. The lack of survival advantage for patients enduring SLL highlights the need to identify consistently effective salvage and consolidation regimens. Few published studies provide definitive evidence regarding efficacy of treatment. Prospective, randomized, controlled trials are needed to evaluate the various therapies available. In general, the performance of SLL should be confined to those patients enrolled in clinical trials.

Accelerated healing with a mesh autograft/allodermal composite skin graft treated with silver nylon dressings with and without direct current in rats.

PURPOSE: Evaluation of the healing and persistence of a meshed composite skin graft applied without immunosuppression. METHODS: The contraction of wounds grafted with 9:1 split-thickness autograft/1.5:1 allodermal mesh composite skin grafts (auto/allo MCSGs) was investigated. No immunosuppressive agent was applied. Male ACI rats and female Lewis rats reciprocally served as allodermis graft donors and recipients. Autograft/dermal autograft and allograft/dermal allograft MCSGs were the controls. RESULTS: AT 3 months after grafting, when epithelized auto/allo MCSG wounds were measured by computerized morphometric analysis, the silver nylon (SN) dressing group displayed less contraction than the Vaseline (petroleum jelly) dressing group (p < 0.003), and direct current treatment (SNDC) was more effective than SN (p < 0.005). The histologic structures of the hair follicles appear to confine the rejection process to the allogeneic follicles of the graft. The focal nature of the rejection process and the relatively low antigenicity of the dermal matrix allowed the survival of the allodermis layer. Although direct current significantly enhanced MCSG healing, SN and SNDC were not the immunosuppressive agents that were confirmed. CONCLUSION: This type of MCSG can heal without immunosuppressive treatment.

Direct current reduces accumulation of Evans Blue albumin in full-thickness burns.

BACKGROUND: Application of direct current (DC) to a burn wound limits extension of the zone-of-stasis and reduces wound tissue edema. OBJECTIVE: To study the effects of DC on extravasation of plasma proteins after burn by using Evans blue (EB) as a marker of plasma albumin. MATERIALS AND METHODS: Male Sprague-Dawley rats with 20% total body surface area full-thickness scalds (100 degrees C/10 sec) were used as the experimental model. Burn wounds were treated with plain nylon, silver-nylon, silver-nylon and 40 microA DC, or no dressing. EB (30 mg/kg) was injected immediately or at variably delayed postburn (PB) times and accompanied by DC application at various time intervals PB. Tissue content of Evans blue was assessed at different times after injection of the dye or infliction of burn injury. RESULTS: Evans blue albumin (EBA) concentration in untreated burn wounds (307.7 microg/g tissue) was nine times greater than in unburned skin (36.5 microg/g tissue) at 48 hours PB. When animals received a DC and EB injection immediately PB, DC treatment reduced EBA concentration by 60% at any time point PB. When EB was injected immediately PB, or at variably delayed times PB, accompanied by DC immediately PB, or at variably delayed times PB, DC reduced EBA accumulation at all examined times PB by more the 50% (p < 0.001). CONCLUSION: EBA and edema fluid accumulation in burn wound change in concert after injury and show similar response to DC treatment.

The accumulation of chromosome aberrations and Dlb-1 mutations in mice with highly fractionated exposure to gamma radiation.

The dichotomy between the doses at which experimental measurements of genetic effects can be made and the doses to which people are exposed is often different by two or more orders of magnitude. This presents a significant problem when determining the effects of low doses of radiation or chemicals. The solution has usually involved extrapolating the data by curve-fitting or by applying theoretical considerations. Both approaches are unsatisfactory due to uncertainties of the assumptions used in each process. The alternative solution has been to increase the sample size enormously at the lower doses. This is impractical beyond a certain point due to the variation in the spontaneous frequency and the need to quadruple the sample size for a doubling of precision. The development of new methods for measuring stable genetic effects, however, permits a simple and effective approach to this problem: if the genetic events being detected have no effect on survival, i.e., are selectively neutral, then the effects of multiple independent treatments will be additive. If the independent treatments are identical, then the effect of each is easily calculated by dividing the total effect by the number of treatments. Here we report a limited test of this approach using mice. Chromosome aberrations induced in lymphocytes and Dlb-1 mutations induced in the small intestine were measured after daily doses of 0.64, 1.85 or 5.5 cGy 137Cs gamma rays administered for 21, 42 or 63 days. The dose response curve for chromosome translocations obtained in this way, combined with the data from single larger acute doses, shows no evidence for a threshold over a 500-fold dose range. Dlb-1 mutations were increased at each dose and time but the results do not permit reliable extrapolations. The results suggest that translocations might be useful for quantifying the effect of doses below 0.05 cGy and that the effect of dose rate and dose fractionation at much lower doses than reported here could be investigated.

Management of congenitally missing maxillary lateral incisors.

Congenitally absent maxillary permanent lateral incisors often lead to an unattractive appearance and difficulties in treatment planning. Many factors must be considered before a decision is made either to close spaces and modify the canines, or to redistribute the spaces and replace the missing teeth with prostheses. Good communication among patients, parents, dental specialists, and general practitioners is necessary.

Optimized mesh expansion of composite skin grafts in rats treated with direct current.

BACKGROUND: The purpose of this study was to determine the optimum autoepidermal and allodermal expansion ratio of each component of a meshed composite skin graft (MCSG) that would lead to successful healing. METHODS: Male Sprague-Dawley rats were used as hosts of the MCSG and donors of autologous tissue. Male ACI rats were used as donors of allodermis. MCSGs with open meshed area (autoepidermal/allodermal) of 9:1/1.5:1, 9:1/3:1, 9:1/6:1, or 6:1/6:1 were applied to full-thickness skin defects and treated with a silver nylon dressing (SN) or SN with direct current (DC). Wound size, hair regrowth, and thickness of dermal layer were evaluated at 3 months. RESULTS: MCSGs of 9:1/1.5:1, 9:1/3:1, and 6:1/6:1 mesh ratios healed completely within 3 months with no difference in wound size between SN dressing groups or DC-treated groups. Application of DC reduced MCSG contraction and stimulated regrowth of hair. CONCLUSION: Fresh autoepidermis can be expanded 6:1 on a 6:1 allodermis or 9:1 on a 3:1 allodermis and achieve successful wound healing.

Requirements of an impression material for fixed prostheses.

This article reviews the clinical and laboratory steps in taking impressions for creating fixed prostheses. Recommendations for selecting impression materials and techniques for using them are discussed. Common problems associated with impressions, and their possible causes, are also included.