The Impact of Social Work Intervention in Alcohol-Induced Pancreatitis in Ireland: a Single-Center Experience.

AIM: To evaluate the effect on recurrent admission for alcohol-induced pancreatitis (that can be up to 48%) of a brief social work intervention for alcohol dependence in a single center in Ireland METHODS: Retrospective cohort study of patients admitted with acute alcohol-induced pancreatitis to a tertiary hospital in Ireland from January 2009 to December 2012. RESULTS: The relapse rate in the cohort of 160 patients with alcohol-induced pancreatitis was 28.1%. There was no difference in the relapse rate of those patients who received a social work intervention compared with those who did not (ANOVA, P = 0.229). The employment status was a significant risk factor for relapse (ANOVA, P = 0.027), but did not differ between those who did, and did not, receive the intervention. CONCLUSION: Although the cohort size did not allow great statistical power, it appears that our hospital's current social work intervention for alcohol-induced pancreatitis is ineffective in preventing relapse. Long-term prospective studies are required to formulate and better implement more efficacious interventions for such patients.

The relationship of retinal vessel diameter to changes in diabetic nephropathy structural variables in patients with type 1 diabetes.

AIMS/HYPOTHESIS: We examined whether retinal vessel diameter in persons with type 1 diabetes mellitus is associated with changes in subclinical anatomical and functional indicators of diabetic nephropathy. METHODS: Persons with type 1 diabetes mellitus had gradable fundus photographs and renal biopsy data at baseline and 5-year follow-up (n = 234). Retinal arteriolar and venular diameters were measured at baseline and follow-up. Central retinal arteriole equivalent (CRAE) and central retinal venule equivalent (CRVE) were computed. Baseline and 5-year follow-up renal structural variables were assessed by masked electron microscopic morphometric analyses from percutaneous renal biopsy specimens. Variables assessed included: mesangial fractional volume, glomerular basement membrane width, mesangial matrix fractional volume and glomerular basement membrane width composite glomerulopathy index. RESULTS: While controlling for other covariates, baseline CRAE was positively associated with change in the glomerulopathy index over the 5-year period. Change in CRAE was inversely related to a change in mesangial matrix fractional volume and abnormal mesangial matrix fractional volume, while change in CRVE was directly related to change in the volume fraction of cortex that was interstitium [Vv((Int/cortex))] over the 5-year period. Baseline CRAE or CRVE or changes in these diameters were not related to changes in other anatomical or functional renal endpoints. CONCLUSIONS/INTERPRETATION: Independently of other factors, baseline CRAE correlated with changes in glomerulopathy index, a composite measure of extracellular matrix accumulation in the mesangium and glomerular basement membrane. A narrowing of the CRAE was related to mesangial matrix accumulation. Changes in CRVE were related to changes in Vv((Int/cortex),) a measure of interstitial expansion in persons with type 1 diabetes mellitus.

The experience of the moment of death in a specialist palliative care unit (SPCU).

This qualitative study is unique in examining the moment of death in a SPCU and in maximizing recall by interviewing relatives early in their bereavement. Despite its traditional significance, the moment of death has been largely unexplored in a hospice setting. Twenty-nine adults including 3 teenagers from 20 families were interviewed on average 22 days (range 8-42 days) after the death in a SPCU. They provided a rich and detailed description of the moment of death often with humour. Additional themes were the importance of vigil; qualities of the staff; value of ritual and prayer and the environment of the SPCU. We cannot hear the stories of the dead. We can try to hear the stories of those who have witnessed dying. These relatives cared deeply for the individual who was dying. They observe every detail, attending to their role and observing the role of others. They are valuable witnesses.

Relatives' and staff's experience of patients dying in ICU.

BACKGROUND: Intensive care units (ICUs) exist to support patients through acute illness that threatens their life. Although ICUs aim to save life, they are also a place where a significant proportion of patients die with international mortality rates ranging from 15% to 24%. AIM: To explore the experience of relatives and staff of patients dying in ICU using qualitative approach. DESIGN: Consecutive patients were identified who were dying in the ICU. The researcher met the families prior to the patient's death. The ICU nurse and doctor most involved were interviewed within 48 h of the death. The families were interviewed 2 weeks later. Interviewees described their experience of the patient's dying and death. Recruitment until data saturation and thematic analysis occurred concurrently. RESULTS: Ten families, nurses and doctors were interviewed in relation to 10 patients. In caring for the patients who are dying in the ICU and their families, nurses practice to their satisfaction with creativity and autonomy, although concerned about continuity of care at handover. Families appreciate kindness and regular sensitive communication. Families would like more contact with the ICU doctors. Limiting access to the patient according to ICU protocol is distressing for relatives. Doctors struggle with decision making, determining prognosis and witnessing the grief of relatives. Some doctors wish to have a greater part in care of the dying patient. CONCLUSION: Distress among nurses reported in the ICU literature and attributed to disenfranchisement by doctors was not evident. In contrast, some doctors struggle to practice what they value. Adherence to ICU protocols needs flexibility when a patient is dying.

The life shortening effects of treatment with doxorubicin and/or local irradiation on a cohort of young C3Hf/Sed mice.

The long-term consequences of treating a cohort of C3Hf/Sed mice in early life with either local-field single dose radiation, systemic doxorubicin, or both, are reported in this study. Significant life shortening was observed in all treatment groups. Median survival times (days) from time of treatment were: control, 690; 35 Gy, 560; 70 Gy, 460; 5 mg/kg doxorubicin, 580; 10 mg/kg doxorubicin, 350; 35 Gy + 5 mg/kg doxorubicin, 510; 70 Gy + 10 mg/kg doxorubicin, 310. Mice receiving hind limb irradiation died principally from induced sarcomas in a dose dependent fashion (80% after 70 Gy and 55% after 35 Gy). Those treated with doxorubicin alone showed an increase in the actuarial incidence of spontaneous malignancies but died mainly from non-malignant causes. Histological examination did not reveal any characteristic cardiac, renal or pulmonary lesions. Doxorubicin did not increase the rate of development of radiation induced sarcomas in mice treated with combined modality.

Common symptoms in advanced cancer.

The relief of physical and psychological symptoms is an essential part of palliative care. Advanced cancer is an acute process; because the clinical picture changes rapidly, symptoms must be reassessed regularly, and a careful history is essential. Defining the relationship of the symptoms to the disease can defuse fear and encourage a sense of control in patients and their families. We review the pathophysiology, causes, prevalence, consequence, and management of common symptoms in advanced cancer.

Doppler echocardiographic evidence of left ventricular diastolic dysfunction in ankylosing spondylitis.

Although cardiac involvement in the form of conduction abnormalities or aortic regurgitation occurs in 5 to 10% of patients with ankylosing spondylitis, few studies have assessed left ventricular (LV) function. This study assesses the prevalence of both systolic and diastolic LV dysfunction and other cardiac abnormalities in patients with ankylosing spondylitis who have no clinical cardiac manifestations. Fifty-nine patients (49 men and 10 women, mean age 42 +/- 10 years) underwent full clinical examination, electrocardiography, 24-hour Holter monitoring and 2-dimensional, M-mode and Doppler echocardiography. Mean disease duration was 17 +/- 9 years (range 1 to 42). Seventeen patients had evidence of noncardiac extraarticular manifestations. Precordial examination was normal in all. An age- and sex-matched control group of 44 healthy subjects was also studied. On echocardiography, abnormal LV diastolic function was detected in 12 patients (20%). Prolonged isovolumic relaxation time, prolonged deceleration time, reduced rate of descent of flow velocity in early diastole (EF slope) and reversal of the early and late peak transmitral diastolic flow velocities (E/A ratio) were noted in 9 patients. In 3 patients there was an increased E/A ratio, reduced deceleration time and increased EF slope. Mild aortic regurgitation and mitral regurgitation was seen in 1 and 3 patients, respectively. No abnormalities of left atrial size, LV systolic or diastolic dimensions or wall thicknesses were noted. There was no correlation between the presence of LV diastolic dysfunction and age, disease severity, disease duration, or the presence of extraarticular manifestations.(ABSTRACT TRUNCATED AT 250 WORDS)

Embolism of cerebral tissue to lungs: report of two cases and review of the literature.

Two patients with head injury and pulmonary emboli of brain tissue are described. Both patients developed persistent bleeding with elevations of prothrombin time, partial thromboplastin time, and decreased platelet counts. Postmortem examination identified multiple skull fractures, subdural and subarachnoid blood, cortical tears, and intraparenchymal hemorrhages. Lacerations of dural venous sinuses were documented in each case. Multiple pulmonary arteries contained plugs of cerebral tissue, including fragments of cerebral and cerebellar cortex, and white matter. The literature concerning brain tissue emboli is reviewed. In neonates, three patients who survived longer than 1 hour were found to have evidence of persistent hemorrhage. Among both children and adults, our two cases are the only ones reported with associated clotting abnormalities. Brain tissue embolism in neonates occurs after difficult vaginal deliveries, often in conjunction with the use of forceps. Tears of the tentorium cerebelli or falx cerebri have been documented at postmortem examination in the majority of these cases. By contrast, brain tissue embolism in children and adults occurs in association with severe closed or penetrating head injury. In several cases, as in the two reported here, postmortem examination has demonstrated a large cerebral venous defect as the probable site of entry of brain tissue into the systemic circulation.

Mobile lipid accumulation in necrotic tissue of high grade astrocytomas.

Multiple samples from 42 astrocytomas were investigated ex vivo by 1H MR spectroscopy followed by histological assessment. MR visible lipids were detected in 27 of 32 grade 4 astrocytomas. These lipids were heterogeneously distributed within the tumours. Their amount correlated positively with the amount of histologically detected necrosis. Mobile lipids were also observed in grade 4 astrocytoma samples without necrosis, as well as in one of three grade 3, two of three grade 2 and two of four grade 1 astrocytomas. The clinical significance of MR visible lipids, their cellular location, and their possible biological bases are discussed.

Losartan may modulate erythropoietin production.

Erythropoietin (Epo) is distinct amongst haematopoietic hormones, in that it is produced remote from the bone marrow. The tissue oxygen pressure required to trigger the Epo gene under physiological conditions is uniquely sited at a restricted area in the kidney termed the critmeter. Angiotensin II (Ang II) increases sodium reabsorption and hence oxygen consumption at any given bloodflow rate; therefore, it may affect the balance of renal oxygen supply vs. demand and hence Epo production. The purpose of this study was to determine whether Epo production is modulated by the renin-angiotensin system (RAS). Twenty normal subjects on a controlled sodium and protein diet had glomerular filtration rate (GFR) and renal plasma flow (RPF)assessed by standard methods of inulin and para-aminohippurate clearance, respectively, at baseline, hourly after the administration of losartan (25 mg) and after each 30 minute period of the infusion of Ang II at doses of 0.5, 1.5 and 2.5 ng/kg/minute. The baseline GFR was 115+/-4.0 ml/minute/1.73 m2, RPF 650+/-29 ml/minute/1.73 m2 and Epo 12.4+/-0.8 U/L. In spite of a marked increase in filtration fraction (FF) with Ang II, no changes in serum Epo levels were observed at two hours(11.7+/-1.3 U/L, p=n.s. compared with baseline). After the administration of losartan, there was a variable effect on FF, but a strong correlation of the change in serum Epo concentration and the change in FF(r=0.648, p=0.002), suggesting that the RAS may modulate Epo production.

A comparison between tensile and shear adhesive strength of meat-myosin junctions.

A model meat-myosin gel junction was used to compare the adhesive strength of binding junctions when subject to tensile or shear forces. This comparison was made on junctions cooked to 80°C with three different alignments of muscle fibres with respect to the junction plane. Tensile adhesive strength (TAS) and shear adhesive strength (SAS) did not differ significantly when fibres in both of the bound pieces of meat were perpendicular to the plane of the myosin gel function (90°/90° junction). However, SAS was higher than TAS if the muscle fibres in one or both of the meat pieces were parallel to the plane of the junction. This suggests that tensile failure of binding junctions is the more likely mode of failure. Differences between SAS and TAS in any one junction orientation were small compared to the effect of muscle fibre orientation with respect to the junction; both TAS and SAS were highest for 90°/90° junctions and lowest when muscle fibres in both meat pieces were parallel to the junction (0°/0° junctions).

Variations in the tensile adhesive strength of meat-myosin junctions due to test configurations.

A model system of two thick slices of beef M. semitendinosus stuck together with a crude myosin preparation and cooked to 80°C for 1 h has been used to show the effects of testing configuration on the tensile adhesive strength (TAS) of the meat-myosin junction. TAS decreased with increasing cross-sectional area in a square cross-sectional geometry, but increasing just one dimension of a rectangular cross-section resulted in smaller, often insignificant, decreases in TAS. A hypothesis based on differences in stress distributions over the area of the adhesive joint was proposed to explain this. TAS was found to increase with increasing deformation rate, in accordance with the usual behaviour of viscoelastic materials. TAS was found to be approximately three times higher when muscle fibres in both the meat pieces forming the joint were at right angles to the junction than when one or both meat pieces contained fibres running parallel to the adhesive junction; this latter orientation, being the weaker, is therefore proposed to be the orientation that determines the initial fracture of a meat product, hence its textural properties.

The influence of varying degrees of adhesion as determined by mechanical tests on the sensory and consumer acceptance of a meat product.

The adhesion between meat pieces in meat products, varied by the addition of different concentrations of a crude myosin solution, was measured by a trained sensory panel and by two instrumental tests: tensile adhesive strength (TAS) and punch and die. A consumer trial was used to find which level of adhesion was preferred. Results from the sensory panel showed that the adhesion could be detected as highly significant (P < 0·001) differences in three tactile measurements and in the two eating qualities, ease of fragmentation and rubberines. TAS measurements gave larger differences between treatments than punch and die, and had very high correlations with ease of fragmentation and crumblines on cutting. The small consumer study revealed no overall preference for any one product. Hence, although differences in adhesion between meat pieces in a meat product are detectable subjectively and can be measured objectively by TAS tests, preference for any particular strength varies between individuals.

Families, murder, and insanity: a psychiatric review of paternal neonaticide.

Neonaticide is the killing of a newborn within the first 24 h of life. Although relatively uncommon, numerous cases of maternal neonaticide have been reported. To date, only two cases of paternal neonaticide have appeared in the literature. The authors review neonaticide and present two new case reports of paternal neonaticide. A psychodynamic explanation of paternal neonaticide is formulated. A new definition for neonaticide, more consistent with biological and psychological determinants, is suggested.

P38 MAPK contributes to resistance and invasiveness of HER2- overexpressing breast cancer.

Intrinsic or acquired resistance to the HER2-targeted therapy trastuzumab is a clinical concern in the treatment of patients with HER2-over-expressing metastatic breast cancers. We demonstrate here that multiple models of intrinsic and acquired resistance exhibit increased phosphorylation of p38 MAPK. Kinase inhibition of p38 rescued trastuzumab sensitivity in cells with acquired resistance. In addition, knockdown of p38 increased sensitivity to trastuzumab in an intrinsically resistant cell line. We previously reported that expression of growth differentiation factor 15 (GDF15) is increased in trastuzumab-resistant HER2-overexpressing breast cancer cells. In this study, we found that exogenous GDF15 or stable overexpression of GDF15 stimulated p38 phosphorylation in HER2-positive cells, suggesting a possible mechanism by which p38 is activated in resistant cells.GDF15 stable clones showed significantly increased invasiveness, which was rescued by p38 kinase inhibition, suggesting that p38 plays a role in the pro-invasive phenotype conferred by GDF15. Importantly, immunohistochemical analysis of a breast tumor tissue array indicated a significant (p=0.0053) correlation between HER2 and phosphorylated p38 specifically in GDF15-positive tissues. Our results suggest that p38 signaling drives trastuzumab resistance and invasiveness in HER2-overexpressing breast cancer. Upstream growth factor signals that have previously been implicated in trastuzumab resistance, such as GDF15, may contribute to the increased phosphorylation of p38 found in resistant cells.

Protection of cattle against a natural infection of Fasciola hepatica by vaccination with recombinant cathepsin L1 (rFhCL1).

The liver fluke, Fasciola hepatica causes liver fluke disease, or fasciolosis, in ruminants such as cattle and sheep. An effective vaccine against the helminth parasite is essential to reduce our reliance on anthelmintics, particularly in light of frequent reports of resistance to some frontline drugs. In our study, Friesian cattle (13 per group) were vaccinated with recombinant F. hepatica cathepsin L1 protease (rFhCL1) formulated in mineral-oil based adjuvants, Montanide ISA 70VG and ISA 206VG. Following vaccination the animals were exposed to fluke-contaminated pastures for 13 weeks. At slaughter, there was a significant reduction in fluke burden of 48.2% in the cattle in both vaccinated groups, relative to the control non-vaccinated group, at p

Improving colon cancer screening rates in primary care: a pilot study emphasising the role of the medical assistant.

BACKGROUND: Colorectal cancer (CRC) is the third-leading cause of cancer death for both men and women in the USA. Despite consensus recommendations for screening, just over half of eligible adults nationally have undergone screening. We therefore implemented a programme to improve the rate of CRC screening. METHODS: This study was conducted in the Utah Health Research Network and the University of Utah Community Clinics, a 100 000 patient, seven-practice, university-owned system offering primary and secondary care and ancillary services including endoscopy. We focused on patients aged >or=50 who were seen between 1 January 2003 and 31 October 2006, and who were not current for CRC screening at the time of the visit. The study included a three-phase INTERVENTION: electronic medical record (EMR) reminders, physician and medical assistant (MA) education about CRC screening guidelines, and redesign of patient visit workflow with an expanded role for MAs to review patients' CRC screening status and recommend testing when appropriate. With patient agreement, the MA entered a preliminary order in the EMR, and the physician confirmed or rejected the order. The primary outcome measure was the rate of screening colonoscopy ordered for eligible patients. RESULTS: The baseline colonoscopy referral rate was 6.0%. Provider education and electronic reminders had minimal immediate impact on screening rates. Addition of the expanded MA role was associated with a sustained increase in colonoscopy referral order rate to 13.4%, a relative improvement of 123%. CONCLUSIONS: The MA can play a key role in improving CRC screening rates as part of a redesigned system of primary care.

Accumulation of glycated albumin in end-stage renal failure: evidence for the principle of "physiological microalbuminuria".

In light of the growing understanding of the toxic effects of glycated albumin and of the preferential excretion of this substance, the excretion of glycated albumin could be considered a physiologic function of the kidney. Furthermore, if the increased load of glycated albumin in diabetic patients results in glycated albumin excretion rates in the range of 20 to 200 microg/min, might this not be considered "physiologic microalbuminuria"? The hypothesis is presented that microalbuminuria composed of glycated albumin is a homeostatic renal function. Although some proteins are glycosylated for their normal physiologic function, many proteins are glycated nonenzymatically according to ambient blood glucose. Albumin is subject to nonenzymatic glycation in all humans, but at increased rates in diabetic patients. Glycated albumin induces changes in the microvasculature and glomerulus that may lead to endothelial dysfunction and diabetic nephropathy, respectively. Renal excretion of glycated albumin is enhanced compared with native albumin. To explore this potential homeostatic function of the kidney, patients with impaired renal function were studied to determine whether glycated albumin accumulates. Plasma levels of glycated albumin were determined in diabetic and nondiabetic patients on hemodialysis. Hemoglobin A1c was used as an index of the rate of nonenzymatic glycation of proteins. Hemoglobin A1c was increased in the diabetic subjects but was normal in the nondiabetic group (7.9% +/- 0.5% v 6.2% +/- 0.2%, respectively; P < 0.01). On the other hand, the glycated albumin was elevated in both groups and was not significantly different between them (1.95% +/- 0.15% in the diabetic patients v 1.75% +/- 0.14% in the nondiabetic patients; P = NS). The results of this study provide the first clinical evidence supporting the hypothesis that the excretion of glycated albumin is a homeostatic renal function.