Outcomes of telemedicine intervention in a regional intensive care unit: a before and after study.

Telemedicine consultations in remote intensive care units (ICUs) overseas were found to be effective in reducing mortality and hospital length of stay (LOS). In Australia, there were anecdotal reports of these clinical outcomes. This retrospective before and after study assessed the improvement in patient outcomes with the implementation of a telemedicine program in a regional high dependency unit. Daily virtual consultations were conducted between the rural facility and the intensivists at the regional centre. A total of 525 patients received intensive care support between 2010 and 2015. Hospital and High Dependency Unit mortality showed no evidence of significant differences between the telemedicine group and the baseline (relative risk 1.02, 95% confidence interval [CI] 0.99-1.06, P=0.25 and relative risk 1.00, 95% CI 0.98-1.03, P=0.67 respectively). The hospital LOS was lower in the baseline group by 1.5 days. There was no significant difference in High Dependency Unit LOS. To adjust for the covariates in LOS, log linear regression analysis was performed. The telemedicine intervention, Acute Physiology and Chronic Health Evaluation II scores and inter-hospital transfers were found to contribute significantly to hospital LOS. The most important result of the study was that the proportion of inter-hospital transfers was lower in the telemedicine group (relative risk 0.88, 95% CI 0.80-0.98, P=0.03) compared to baseline. This means that critically ill patients in our regional centre can continue to receive specialist care remotely through tele-ICU consultations thus avoiding the need for patient transport. However, further study is needed to establish the benefits and risks of telemedicine intervention in ICUs in Australia.

Association between severe pandemic 2009 influenza A (H1N1) virus infection and immunoglobulin G(2) subclass deficiency.

BACKGROUND: . Severe pandemic 2009 influenza A virus (H1N1) infection is associated with risk factors that include pregnancy, obesity, and immunosuppression. After identification of immunoglobulin G(2) (IgG(2)) deficiency in 1 severe case, we assessed IgG subclass levels in a cohort of patients with H1N1 infection. METHODS: Patient features, including levels of serum IgG and IgG subclasses, were assessed in patients with acute severe H1N1 infection (defined as infection requiring respiratory support in an intensive care unit), patients with moderate H1N1 infection (defined as inpatients not hospitalized in an intensive care unit), and a random sample of healthy pregnant women. RESULTS: Among the 39 patients with H1N1 infection (19 with severe infection, 7 of whom were pregnant; 20 with moderate infection, 2 of whom were pregnant), hypoabuminemia (P < .001), anemia (P < .001), and low levels of total IgG (P= .01), IgG(1) (P= .022), and IgG(2) (15 of 19 vs 5 of 20; P= .001; mean value +/- standard deviation [SD], 1.8 +/- 1.7 g/L vs 3.4 +/- 1.4 g/L; P= .003) were all statistically significantly associated with severe H1N1 infection, but only hypoalbuminemia (P= .02) and low mean IgG(2) levels (P= .043) remained significant after multivariate analysis. Follow-up of 15 (79%) surviving IgG(2)-deficient patients at a mean (+/- SD) of 90 +/- 23 days (R, 38-126) after the initial acute specimen was obtained found that hypoalbuminemia had resolved in most cases, but 11 (73%) of 15 patients remained IgG(2) deficient. Among 17 healthy pregnant control subjects, mildly low IgG(1) and/or IgG(2) levels were noted in 10, but pregnant patients with H1N1 infection had significantly lower levels of IgG(2) (P= .001). CONCLUSIONS: Severe H1N1 infection is associated with IgG(2) deficiency, which appears to persist in a majority of patients. Pregnancy-related reductions in IgG(2) level may explain the increased severity of H1N1 infection in some but not all pregnant patients. The role of IgG(2) deficiency in the pathogenesis of H1N1 infection requires further investigation, because it may have therapeutic implications.

A prospective randomised controlled trial of nutritional supplementation in malnourished elderly in the community: clinical and health economic outcomes.

BACKGROUND & AIMS: Malnutrition is common in sick elderly people on admission to hospital and in the community. We conducted a randomised controlled trial to determine if nutritional supplementation after discharge from hospital improved nutritional status and functional outcomes, or reduced health-care costs. METHODS: Elderly malnourished subjects were randomised to 8 weeks of supplementation or no supplementation post discharge, and followed up for 24 weeks. Weight, body mass index, anthropometrics, handgrip strength, quality of life and requirements for health-care professionals' services and social services were measured throughout the study. RESULTS: Nutritional status improved significantly from baseline to week 24 in the intervention group (P<0.05), but not in the control group. There was no significant difference in nutritional status between groups at week 24. Handgrip strength improved significantly in the intervention group during supplementation, and was significantly different from that of the control group at week 8, but decreased thereafter. There was no significant difference in quality of life or health economic outcomes between groups at week 24. CONCLUSIONS: In already malnourished elderly subjects, it may be too late to expect to improve function or quality of life or to reduce health-care costs simply by providing nutritional supplements after hospitalisation. Prevention is key. All elderly patients should be nutritionally assessed as part of their routine care, and appropriate intervention initiated early.

The p53MH algorithm and its application in detecting p53-responsive genes.

A computer algorithm, p53MH, was developed, which identifies putative p53 transcription factor DNA-binding sites on a genomewide scale with high power and versatility. With the sequences from the human and mouse genomes, putative p53 DNA-binding elements were identified in a scan of 2,583 human genes and 1,713 mouse orthologs based on the experimental data of el-Deiry et al. [el-Deiry, W. S., Kern, S. E., Pietenpol, J. A., Kinzler, K. W. & Vogelstein, B. (1992) Nat. Genet. 1, 45-49] and Funk et al. [Funk, W. D., Pak, D. T., Karas, R. H., Wright, W. E. & Shay, J. W. (1992) Mol. Cell. Biol. 12, 2866-2871] (http://linkage.rockefeller.edu/p53). The p53 DNA-binding motif consists of a 10-bp palindrome and most commonly a second related palindrome linked by a spacer region. By scanning from the 5' to 3' end of each gene with an additional 10-kb nucleotide sequence appended at each end (most regulatory DNA elements characterized in the literature are in these regions), p53MH computes the binding likelihood for each site under a discrete discriminant model and then outputs ordered scores, corresponding site positions, sequences, and related information. About 300 genes receiving scores greater than a theoretical cut-off value were identified as potential p53 targets. Semiquantitative reverse transcription-PCR experiments were performed in 2 cell lines on 16 genes that were previously unknown regarding their functional relationship to p53 and were found to have high scores in either proximal promoter or possible distal enhancer regions. Ten (approximately 63%) of these genes responded to the presence of p53.

Patterns of prescribing of nutritional supplements in the United Kingdom.

BACKGROUND AND AIMS: A large number of prescriptions are issued for nutritional supplements under British National Formulary classifications 9.4.1 (foods for special diets) and 9.4.2 (enteral feeds), but little is known about the characteristics of the patients who receive them. We used the General Practice Research Database to examine patterns of prescribing of these supplements. METHODS: We selected patients who had been prescribed supplements under classifications 9.4.1 and 9.4.2 during 1996-1997. Descriptive statistics were used to examine how prescribing varied. RESULTS: 28644 patients received prescriptions during 1996-1997. Among the 27413 (96%) patients prescribed supplements for oral use, 14750 received supplements for enteral nutrition alone, 8122 received supplements for special diets alone and 4541 had both types of supplement. 51% of patients receiving supplements for special diets were <18 years. The commonest diagnoses among such children were milk intolerance (24%) and malnutrition (17%). 94% of patients receiving supplements for enteral nutrition were adult, 52% of whom had cancer or cardiovascular disease. Only 4% of patients had weight and height recorded prior to first prescription. CONCLUSIONS: The GPRD provides valuable information on the characteristics of patients prescribed nutritional supplements. But because only limited data are available on their nutritional status prior to supplementation, it is hard to assess whether general practitioners are prescribing these supplements appropriately.

Two approaches for consolidating results from genome scans of complex traits: selection methods and scan statistics.

This work has two purposes: (i) empirically selecting levels of significance that maximize the fraction of markers close to a gene (hit rate) when performing linkage analyses of simulated data and (ii) evaluating the utility of a previously reported scan statistic on the same data. Genotype data were simulated from a trait model of seven susceptibility genes. For purpose (i), five statistics were evaluated on all marker loci in fifty replicates; two-point lod and heterogeneity lod scores maximized over dominance (mlod, mhlod), a multi-allelic TDT test, an affected sib-pair test (ASP), and a model-free test on all sib-pairs (ALL_SIBS). Within each replicate the fraction of markers (hit rate) significant at specified levels of significance and also (a) within fifty markers of, or (b) on the same chromosome as a major gene was calculated. For purpose (ii), scan statistics of length 15 were calculated for each chromosome and their empirical significance levels estimated on the basis of 500 replicates generated under no linkage. The scan statistic was applied to the mhlod scores from one replicate (Replicate 5). Empirical p-values for the scan statistic were determined by computing mhlod scores on 500 replicates of simulated null data. For purpose (i), significance levels between 0.001 and 0.01 had the greatest hit rate for all five methods and both criteria. For criterion (a) at the 0.001 level of significance, both mlod and mhlod displayed the highest hit rates, approximately 0.4 for each. For criterion (b), all methods but ALL_SIBS and ASP had hit rates ranging between 0.4 and 0.5. For purpose (ii), the scan statistic proved equally or more powerful than the single-locus statistic for two of the seven susceptibility genes while the remaining five genes were not detected.

Optical mapping of BAC clones from the human Y chromosome DAZ locus.

The accurate mapping of clones derived from genomic regions containing complex arrangements of repeated elements presents special problems for DNA sequencers. Recent advances in the automation of optical mapping have enabled us to map a set of 16 BAC clones derived from the DAZ locus of the human Y chromosome long arm, a locus in which the entire DAZ gene as well as subsections within the gene copies have been duplicated. High-resolution optical mapping employing seven enzymes places these clones into two contigs representing four distinct copies of the DAZ gene and highlights a number of differences between individual copies of DAZ.

Prevalence of malnutrition on admission to four hospitals in England. The Malnutrition Prevalence Group.

AIMS: The primary objective was to estimate prevalence of malnutrition on admission to four hospitals. Secondary objectives included assessing the relationship between nutritional status and length of hospital stay, numbers of new prescriptions, new infections and disease severity. METHODS: We entered eligible patients according to predefined quotas for elective and emergency admissions to 23 specialties. We measured height, weight, Body Mass Index and anthropometrics, and recorded history of unintentional weight loss. Patients who had lost > or = 10% of their body weight, had a Body Mass Index <20, or had a Body Mass Index <20 with one anthropometric measurement <15th centile were considered malnourished. RESULTS: Of 1611 eligible patients, 761 did not participate; 269 were too ill; 256 could not be weighed; and 236 refused consent. Eight hundred and fifty were subsequently evaluated. Prevalence of malnutrition on admission was 20%. Length of stay, new prescriptions and infections and disease severity were significantly higher in the malnourished. CONCLUSIONS: One patient in every five admitted to hospital is malnourished. Although this figure is unacceptably high, it may underestimate true prevalence. Malnutrition was associated with increased length of stay, new prescriptions and infections. Malnutrition may also have contributed to disease severity.

Setting standards using integrated care pathways.

An integrated care pathway is a tool that can help to deliver clinical governance objectives if implemented well. Key factors of successful implementation are: effective project management; communication and training; and top-down and bottom-up support for the process.

Outcomes of undernutrition in patients in the community with cancer or cardiovascular disease.

Public health concern has tended to focus on the dangers of obesity, but there is evidence that undernutrition may also pose a risk to physical and mental well-being, particularly in those who are already ill. Using the General Practice Research Database (see office for Population Censuses and Surveys, 1995), we followed up 10,128 men and women aged 18 years and over who had been diagnosed with cancer or cardiovascular disease to examine whether nutritional status, as indicated by BMI, affected rates of use of health care resources and mortality. In both diagnostic groups, patients with a BMI below 20 kg/m2 had higher rates of consultation with GP, higher rates of prescription and higher death rates during the follow-up period compared with those with a BMI of 20-< 25 kg/m2. In men and women with cardiovascular disease, poor nutritional status was associated with a sharply increased risk of hospital admission. Patients whose BMI was 30-< 40 kg/m2 also tended to have increased rates of GP consultation and prescription, and if they were under the age of 65 years, they had an increased risk of death. The results of the present study suggest that in men and women with cancer or cardiovascular disease, even minor degrees of undernutrition are associated with a marked increase in morbidity and mortality.

Problems of nutritional assessment in the community.

The present paper explores the problems associated with assessment of nutritional status in the community and reviews the literature related to this subject. The first problem is one of terminology, since a logical first step before assessment is screening, which identifies characteristics known to be associated with dietary or nutritional problems. Its purpose is to differentiate individuals who are at high nutritional risk or have poor nutritional status. There are certain factors which should alert the primary health care team to the fact that nutritional intake may be reduced and that risk of malnutrition is increased. These include disease condition, functional disabilities, inadequate or inappropriate food intake, poor dentition or difficulty swallowing, polypharmacy, alcoholism, depression, poor social circumstances or recent discharge from hospital. Patients suffering from these factors need to be identified so that screening becomes a routine part of their medical treatment. At-risk groups include the elderly, the chronically ill, those with cancer and neurological disorders, post-surgical patients and children with developmental disabilities. In the community, practice and community nurses see the majority of at-risk patients and should carry out screening. A number of screening tools have been developed for community use. Most are aimed at the elderly population, but there are others designed to assess nutritional risk in children with developmental disabilities and the general population. These are reviewed and problems of content and validity identified. Some problems associated with nutritional assessment are also reviewed.

Detection of chromosome aberrations by FISH as a function of cell division cycle (harlequin-FISH).

Chromosome aberrations are a sensitive indicator of genetic change, and the measurement of chromosome aberration frequency in peripheral blood lymphocytes is often used as a biological dosimeter of exposure (1,4). The length of time that cells are maintained in culture before cytogenetic analysis is probably the most important in vitro factor that influences both the frequency and types of aberrations that are seen following exposure to mutagens. Therefore, for accurate cytogenetic measurements of genetic damage, cells must be analyzed in their first mitosis following exposure. As cells progress through subsequent mitotic division cycles, cells with unstable types of aberrations, e.g., dicentrics and acentric fragments, are eliminated (1,3,4). Even the use of synchronized populations of cells does not guarantee that all cells analyzed will be in their first division following treatment. Small variations in growth rate after irradiation can lead to large variations in the proportion of cells that are in their first vs. a subsequent mitosis. For example, 48 h after G0 lymphocytes are stimulated to enter the cell cycle (the standard sampling time for cytogenetic analysis), up to 50% of the cells in mitosis can be in their second division cycle (10). While there are methods available to distinguish cells in different division cycles (see Introduction), they are not easily adapted for use with standard fluorescence in situ hybridization (FISH) procedures. The goal of this study was to develop a simple approach to detect aberrations by FISH whereby cells in different division cycles could be distinguished.

Automated high resolution optical mapping using arrayed, fluid-fixed DNA molecules.

New mapping approaches construct ordered restriction maps from fluorescence microscope images of individual, endonuclease-digested DNA molecules. In optical mapping, molecules are elongated and fixed onto derivatized glass surfaces, preserving biochemical accessibility and fragment order after enzymatic digestion. Measurements of relative fluorescence intensity and apparent length determine the sizes of restriction fragments, enabling ordered map construction without electrophoretic analysis. The optical mapping system reported here is based on our physical characterization of an effect using fluid flows developed within tiny, evaporating droplets to elongate and fix DNA molecules onto derivatized surfaces. Such evaporation-driven molecular fixation produces well elongated molecules accessible to restriction endonucleases, and notably, DNA polymerase I. We then developed the robotic means to grid DNA spots in well defined arrays that are digested and analyzed in parallel. To effectively harness this effect for high-throughput genome mapping, we developed: (i) machine vision and automatic image acquisition techniques to work with fixed, digested molecules within gridded samples, and (ii) Bayesian inference approaches that are used to analyze machine vision data, automatically producing high-resolution restriction maps from images of individual DNA molecules. The aggregate significance of this work is the development of an integrated system for mapping small insert clones allowing biochemical data obtained from engineered ensembles of individual molecules to be automatically accumulated and analyzed for map construction. These approaches are sufficiently general for varied biochemical analyses of individual molecules using statistically meaningful population sizes.

Effect of nutritional status on use of health care resources by patients with chronic disease living in the community.

The prevalence of malnutrition in patients with chronic disease living in the community in the UK is around 8%. Whether such patients experience greater morbidity and mortality or make increased use of health care resources is unknown. The aim of this study was to investigate how the use of health care resources by patients with chronic disorders of the respiratory, gastrointestinal and neurological systems varied by nutritional status. We used longitudinal data, collected since 1987, which formed part of the General Practice Research Database in the UK. Subjects were 11 357 men and women aged 18 years or over. Main outcomes were consultation rates in general practice, prescription rates, hospital referral rates, hospital admission rates and mortality. Consultation and prescription rates were lowest amongst patients whose body mass index (BMI) was between 20 and 25. Rates were higher in patients whose BMI was below 20, or 25 and above. There was no statistically significant relation between rate of hospital outpatient referral and nutritional status, but both hospital admission rate and mortality were greatest in those people whose BMIs were below 20 and declined as BMIs increased. In patients with differential use of health care resources in both primary care and hospital practice, and with differences in mortality.

The effect of aging on the immune response: influence of phosphatidylcholine-containing lipid on IgD-receptor expression and antibody formation.

It was reported previously that IgD-receptors (IgD-R) are expressed on both CD4+ and CD8+ human T cells and CD4+ murine T cells after exposure to oligomeric IgD, certain cytokines, or various pharmacological agents, as shown by rosetting with IgD-coated erythrocytes. Enhancement of antibody production is observed in mice after injection of oligomeric IgD and is mediated by these IgD-R+ T cells, while injection of monomeric IgD inhibits both IgD-R upregulation and augmentation of antibody responses induced by simultaneously injected oligomeric IgD. The effects of oligomeric IgD on IgD-R upregulation are lacking in aged mice. However, the oligomeric IgD induced enhanced antibody production can be transferred to aged mice with IgD-R+ T cells from young donors suggesting that the environment of the aged mouse supports the effector function of IgD-R+ T cells. We now report, in addition, that exposure to phosphatidylcholine (PC) and a PC-containing lipid mixture, AL721, is effective in causing IgD-R upregulation on T cells from both young and aged mice, and young humans. This effect can also be demonstrated in mice in vivo after administration of AL721. Moreover, this agent causes a two-fold enhancement of antibody production, as measured by PFC/spleen, to 4-hydroxy-5-iodo-3-nitrophenyl(acetyl)-Brucella abortus (NIP-BA) and NIP-horse red blood cells (RBC) in young and aged mice. There is no difference in the baseline membrane fluidity of lymphocytes from aged and young mice. Although PC causes an increase in membrane fluidity of lymphocytes from both young and old mice, and from humans, this effect on fluidity is not prevented by a protein kinase inhibitor, while PC's effect on IgD-R upregulation is prevented by the inhibitor. Moreover, no correlation was observed between IgD-R upregulation and membrane fluidity changes induced by AL721 administered in vivo. To evaluate the role of IgD-R induction in the augmentation of antibody production by phospholipids, the effect of monomeric IgD was investigated. The augmenting effect of AL721 on antibody production was prevented by a single injection of monomeric IgD at the time of antigen administration. We conclude that (1) PC-containing lipid mixtures are effective in enhancing antibody production in aged mice, (2) induction of IgD-R is responsible for the augmenting effects of AL721 on antibody production, and (3) monomeric IgD not only blocks the upregulation of IgD-R, as shown previously, but also the augmenting effect of previously upregulated IgD-R on T cells by preventing their interaction with surface IgD+ B cells.

Prevalence of malnutrition in patients in general practice.

The objective of this study was to determine the prevalence and correlates of malnutrition in patients living at home with cancer and chronic diseases. Patients (213) with cancer and 228 patients with chronic diseases were randomly selected from general practice registers. Nutritional status was determined from body mass index (BMI in kg/metre2), triceps skinfold thickness (TST), mid-arm muscle circumference (MAMC) and population centiles. Patients were classified as mildly malnourished if they had a BMI < 20 and TST or MAMC < 15th centile, moderately malnourished if they had a BMI < 18 and TST or MAMC < 5th centile, and severely malnourished if they had a BMI < 16 and TST or MAMC < 5th centile. Using these criteria, nearly 10% of patients were malnourished: 24 (5.4%) mildly, 12 (2.7%) moderately and 4 (0.01%) severely. Malnutrition was more common in patients in social classes 3.2, 4 and 5 than in social classes 1, 2 and 3.1 (P = 0.003), and in patients receiving district nurse care (P < 0.001). Malnutrition was more prevalent in cancer patients who complained of chronic or severe pain (32% vs 12%, P = 0.021) and in patients with chronic disorders who experienced mental apathy (22% vs 5%, P = 0.014). Clinicians need to be aware that malnutrition is common in patients living at home. In this study BMI proved to be a fairly good indicator of malnutrition and routine measurement of BMI would be one simple way of detecting patients who are at risk.

Relationship between humoral immunoaugmenting properties of DHEAS and IgD-receptor expression in young and aged mice.

IgD-receptors are associated with augmented antibody production in vivo and are induced on CD4+ T cells by aggregated IgD in young but not in aged mice. In the current study orally or intraperitoneally administered DHEAS was found to enhance antibody production, as measured in a plaque-forming cell assay, and also to cause an increased expression of IgD-R on T cells in both young and aged mice. IgD-R+ T cells are enumerated by rosette cell formation with IgD-coated SRBC. Since, as shown previously, the immunoaugmenting effect of IgD-R+ T cells is blocked by injection of monomeric IgD, the effect of monomeric IgD was also examined in DHEAS-pretreated mice. The inhibitory effect obtained with monomeric IgD in these studies indicates that upregulation of IgD-R by DHEAS plays an important role in the immunoenhancing effect of this hormone. In addition, no significant effect of DHEAS was obtained on contact hypersensitivity to DNCB or on proliferative responses of T cells from young or aged mice. Aged but not young mice showed increases in the numbers of Ia+ epidermal Langerhans cells after DHEAS treatment.

The Emu-bcl-2 transgene enhances antigen-induced germinal center formation in both BALB/c and SJL mice but causes age-dependent germinal center hyperplasia only in the lymphoma-prone SJL strain.

Emu-bcl-2 transgenic and littermate control BALB/c and SJL mice were immunized in the front footpads with trinitrophenylated Brucella abortus and the germinal center (GC) response in draining brachial lymph nodes was studied by staining with peanut agglutinin peroxidase and methyl green. Although the GCs induced were not larger in transgenic than in control young mice, there was a significant increase in the percentage of B cell follicles exhibiting GCs 7 to 8 days after primary and secondary antigen injections in the transgenic mice of both strains. In addition, glucocorticosteroid injected on day 7 after the primary injection caused a marked decrease in GCs in littermate controls but had no effect in the bcl-2 transgenic SJL mice. Antibody production to B. abortus was only slightly higher in transgenic than in control mice, but anti-TNP immunoglobulin M and G titers were significantly enhanced in the transgenic mice. The bcl-2 transgenic SJL mice, older than 6 months, showed the spontaneous appearance of large numbers of peanut agglutinin-binding GCs that greatly varied in size and were located without regard for the normal lymph node structure or follicle localization. This GC hyperplasia was seen in a large percent of the older transgenic SJL mice and never in similarly aged normal SJL or BALB/c mice with and without the bcl-2 transgene. Frank lymphomatous transformation of peanut agglutinin-binding germinal center-like areas was seen in lymph nodes and Peyer's patches of some of the older bcl-2 transgenic SJL mice. These results suggest that the tendency of SJL mice to develop GC-derived lymphomas synergizes with the presence of the bcl-2 transgene to cause the development of GC hyperplasia.