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Effects of introducing an integrated care pathway in an acute stroke unit.

BACKGROUND AND PURPOSE: integrated care pathways are often implemented to guide acute stroke therapy and improve organisation of care, but there is not sufficient evidence to support their routine use. We sought to evaluate the effects of introducing an integrated care pathway for acute stroke. METHODS: we performed a before-and-after study. The 'before' (control) group comprised 154 consecutive stroke patients admitted to the acute stroke unit over a 9-month period. The 'after' (intervention) group comprised 197 consecutive patients admitted to the same unit over a 9-month period in the year after the introduction of the integrated care pathway. Effectiveness was assessed with a variety of measures: quality of documentation; process of care; occurrence of complications; death and discharge destination. Results were adjusted for case mix using a validated model. RESULTS: the baseline characteristics of the two groups were similar, although there were more total anterior circulation strokes (29% versus 18%, P = 0.005) and fewer partial anterior circulation strokes (30% versus 42% P = 0.04) in the intervention group. In the intervention group, we found that urinary tract infections were significantly less frequent (OR 0.37, CI 0.15-10.91) and the quality of several aspects of care (e.g. CT scanning < 48 hours) and documentation were significantly better. However, there were no significant differences in deaths, discharge destination, or length of stay between the two groups. CONCLUSION: this before-and-after study has provided further evidence that introducing an integrated care pathway for acute stroke may improve the quality of documentation and process of care, and reduce the risk of certain post-stroke complications.

Acute Disease↗

Prediction of Golgi Type II membrane proteins based on their transmembrane domains.

MOTIVATION: A major issue in cell biology today is how distinct intracellular regions of the cell, like the Golgi Apparatus, maintain their unique composition of proteins and lipids. The cell differentially separates Golgi resident proteins from proteins that move through the organelle to other subcellular destinations. We set out to determine if we could distinguish these two types of transmembrane proteins using computational approaches. RESULTS: A new method has been developed to predict Golgi membrane proteins based on their transmembrane domains. To establish the prediction procedure, we took the hydrophobicity values and frequencies of different residues within the transmembrane domains into consideration. A simple linear discriminant function was developed with a small number of parameters derived from a dataset of Type II transmembrane proteins of known localization. This can discriminate between proteins destined for Golgi apparatus or other locations (post-Golgi) with a success rate of 89.3% or 85.2%, respectively on our redundancy-reduced data sets. AVAILABILITY: See http://microarray.imb.uq.edu.au/golgi/

Algorithms↗

A reassessment of the accuracy of reinnervation by motoneurons following crushing or freezing of the sciatic or lumbar spinal nerves of rats.

The accuracy of reinnervation in peripheral nerves following second degree injuries, which do not disrupt the longitudinal continuity of the endoneurial sheaths, has been studied in rats. The sciatic nerve or lumbar spinal nerves (that is the extraspinal nerves before their fusion in the sciatic plexus) were crushed with fine watchmakers' forceps in neonatal and adult rats. In addition, the lumbar spinal nerves were frozen in a group of 5 adult rats. After allowing reinnervation to occur for 5 to 9 weeks, the motoneurons whose axons ran in the plantar nerve were labelled retrogradely with horseradish peroxidase. Their positions in the grey matter of the lumbar spinal cord were recorded and compared with those labelled from the contralateral unoperated plantar nerve. Very few errors of projection occurred after a crush lesion of the adult sciatic nerve but all the other lesions produced significant numbers of errors. The order, starting with the preparations with fewest errors was as follows (numbers in brackets = percentage of neurons misplaced): sciatic crush in adult (3%), sciatic crush in neonate (23%), spinal nerve freeze in adult (23%), spinal nerve crush in adult (35%), and spinal nerve crush in neonate (72%). It seems that a significant number of axonal growth cones cross endoneurial sheaths after crush or cryoinjuries. Explanations for the difference in observed reinnervation accuracy between young and old rats and between lesions in peripheral nerves and spinal nerves are discussed. The first is that axons in peripheral nerves in older rats have a less penetrable endoneurial membrane encasing them. The second is that the amount of misrouting is the same at all lesion sites but is much less easily detectable after sciatic lesions than spinal nerve lesions. This is because axons are organized in a 'musculotopic' manner in peripheral nerves and exchange of axon positions will occur largely between axons destined for the same peripheral target. In contrast, exchange of positions of axons in spinal nerves will lead to more overt errors because at this site axons destined for particular muscles do not lie side by side but are intermingled with axons innervating other peripheral targets.

Animals↗

Epidemiologic studies of travelers' diarrhea, severe gastrointestinal infections, and cholera.

A retrospective survey, which is based on interviews conducted between 1975 and 1984 with 20,000 European tourists returning from 15 destinations in various climatic zones, demonstrates that travelers' diarrhea is the most frequent health problem encountered by travelers in the tropics. The incidence varied from 4% to 51%, depending on the destination. High-risk groups were persons younger than 30 years, adventurous travelers, and travelers with preexisting gastrointestinal illnesses. Illness acquired at various geographic regions showed only minor differences in chronology and symptomatology. The clinical course of travelers' diarrhea was usually short and mild. Additionally, by longitudinal and retrospective analyses, the incidence and prognosis of gastrointestinal infections of greater severity that were acquired after a short stay in a developing country, such as giardiasis, amebiasis, typhoid fever, and cholera, were evaluated; typhoid fever and cholera, in particular, were found to be quite rare.

Adult↗

Interaction of mitochondrial targeting signals with acidic receptor domains along the protein import pathway: evidence for the 'acid chain' hypothesis.

Mitochondrial precursor proteins with basic targeting signals may be transported across the outer membrane by sequential binding to acidic receptor sites of increasing affinity. To test this 'acid chain' hypothesis, we assayed the interaction of mitochondrial precursors with three acidic receptor domains: the cytosolic domain of Tom20 and the intermembrane space domain of Tom22 and Tim23. The apparent affinity and salt resistance of precursor binding increased in the order Tom20<Tom22 (internal)<Tim23. Precursor binding to the three acidic receptor domains and to the pure cytosolic domain of Tom70 was inhibited by excess targeting peptide, but not by an equally basic control peptide. In this membrane-free and defined system, a precursor pre-bound to the Tom70 or Tom20 domain was transferred efficiently to the Tim23 domain. Transfer was stimulated by the internal Tom22 domain and was much less efficient in the reverse direction. Precursors destined for the outer membrane bound only to Tom20, but not to the internal Tom22 or the Tim23 domain, and a precursor destined for the inner membrane bound only to the Tom20 and the internal Tom22 domain, but not to the Tim23 domain. These results suggest that specific and sequential binding of a targeting signal to strategically situated acidic receptors delivers a precursor across the outer membrane and contributes to intramitochondrial sorting of imported proteins.

Acids↗

The development of migration expectations: changes throughout the lifecourse.

This research examines how the relative influence of factors that determine an individual's expectations of moving varies throughout the lifecourse. Factors representing personal characteristics, ties to origin, and ties to potential destinations were used to discriminate between expected migrants and nonmigrants in three population subgroups representing different stages of life. These subgroups included a general adult population, a preretirement population, and an elderly population. The results indicate that personal characteristics are most influential among preretirement persons, ties to origin are most influential among the general and elderly populations, and ties to potential destinations are influential among all population subgroups.

Adult↗

Amenity retirement migration process: a model and preliminary evidence.

A heuristic model of the retirement migration process was developed and explored using survey data from 586 migrants to western North Carolina. Five distinct subgroups were investigated: those who went from part- to full-time residency; those who thought about not migrating; individuals who migrated, remained in the labor force for a short period, and then retired; people who made two retirement migrations; and destination-selecting versus destination-specific migrants.

Adult↗

A first look at retirement migration trends in 2000.

PURPOSE: This brief report takes a look at the preliminary estimates of the number and proportion of migrants over the age of 60 who moved to and from states between 1995 and 2000 and compares these estimates with those who made the same kind of move one decade earlier. DESIGN AND METHODS: The 2000 census 1-in-100 public-use microdata sample, released in the summer of 2003, and the 1-in-20 sample from the 1990 census, were compared in this analysis. Point estimates of 100% were created for the inflows and outflows for the top 10 states in these two census decades. Net migration was also considered. RESULTS: The total estimated number of older interstate migrants increased to over 2 million during the 1995-2000 migration period. Florida declined slightly in its position as the dominant destination for a second decade, indicating a downward trend for the first time. Arizona became the second largest receiving state, next to Florida, and California approached New York's dominance as a migration origin, or sending, state. Nevada entered the top ranking retirement states for the first time. IMPLICATIONS: Long-term migration dynamics of the older population may reflect perceived shifts in quality of life in destination states. Nonetheless, the next two decades will see a substantial rise in the number of older migrants.

Aged↗

Golgi localization of glycosyltransferases: more questions than answers.

The structures of cellular oligosaccharides are determined by a series of processing reactions catalyzed by Golgi glycosidases and glycosyltransferases. While there are subtle cell type differences in Golgi enzyme subcompartmentation, in general, glycosylation enzymes are localized within the Golgi cisternae in the same sequence in which they act to modify oligosaccharide substrates. The possibility that this enzyme subcompartmentation may control the types of oligosaccharides expressed by a cell has led to an interest in the signals and mechanisms directing enzyme localization in the Golgi cisternae. All glycosidases and glycosyltransferases characterized thus far have very little sequence homology that might suggest a common Golgi retention signal, but they do share a similar domain structure. They are all type II transmembrane proteins consisting of an amino terminal cytoplasmic tail, a signal anchor transmembrane domain, a stem region, and a large luminal catalytic domain. Their lack of sequence homology suggests that these proteins' Golgi retention signals are not linear amino acid sequences, but most likely involve general characteristics or conformations of larger protein domains. The peptide sequences required for Golgi retention of the N-acetylglucosaminyltransferase I (GlcNAcTI), beta 1,4-galactosyltransferase (GalT) and alpha 2,6-sialytransferase (ST) have been extensively studied. To do this, researchers created mutant and chimeric proteins, expressed these in tissue culture cells, and localized these proteins using immunofluorescence microscopy or immunoelectron microscopy. The cell surface expression of deletion mutants suggested that the deleted sequences were necessary for Golgi retention. Then, if these sequences were fused to a non-Golgi reporter protein and this chimeric or hybrid protein was retained in the Golgi, then these sequences were also sufficient for Golgi retention. Due to differences in reporter proteins used to construct these chimeric proteins, different cell types used for protein expression, different levels of protein expression, and different methods of cell surface protein detection, these experiments have led to somewhat confusing results. However, in general, it appears that the GalT relies primarily on its transmembrane domain for Golgi retention, while the GlcNAcTI and ST have requirements for their transmembrane regions, sequences flanking these regions, and luminal stem sequences. Based on these results, two potential Golgi retention mechanisms have been proposed and are now being tested. The observation that glycosyltransferase transmembrane domains are frequently sufficient for Golgi retention has led to the first of these models, the bilayer thickness model. This model proposes that the shorter transmembrane domains of Golgi proteins prevent them from entering cholesterol-rich transport vesicles destined for the plasma membrane, and that this leads to Golgi retention. The second of these models is supported by the role of multiple protein domains in the Golgi retention of some proteins. This model, the oligomerization/ kin recognition model of Golgi retention, proposes that the formation of insoluble protein homo-oligomers or very large hetero-oligomers prevents protein movement into transport vesicles destined for later compartments. Initial work suggests that the bilayer thickness mechanism may play a role in the retention of some Golgi retained proteins; however, it is not the sole retention mechanism. Other evidence suggests that an oligomerization/kin recognition mechanism may be more common, but definitive proof for its general use in Golgi protein retention is lacking. More research is required to further elucidate the sequences and particularly the mechanisms of Golgi retention. (ABSTRACT TRUNCATED)

Animals↗

Day 14 maternal serum progesterone levels predict pregnancy outcome in IVF/ICSI treatment cycles: a prospective study.

BACKGROUND: Serum progesterone has been advocated as a tool in the diagnosis of early pregnancy failure. We conducted this prospective study in order to investigate the potential value of early (14 days after oocyte recovery) serum progesterone measurement, in women undergoing IVF/ICSI and receiving rectal progesterone supplements, in relation to pregnancy outcome. METHODS: 442 women consecutively treated by IVF or ICSI had serum progesterone and bhCG levels prospectively measured 14 days after oocyte retrieval (day 0). All women received natural progesterone 400 mg rectally until the pregnancy test on day 14. Pregnant women were followed up by serial transvaginal ultrasound scans to 8 weeks gestation. RESULTS: 115 women (26%) had a viable intra-uterine pregnancy at 8 weeks gestation, 80 (18.1%) had an abnormal pregnancy (biochemical, ectopic, miscarriage) and 247 (55.9%) failed to conceive. Women with on-going pregnancies had significantly higher serum progesterone levels (median: 430, 95%CI: 390-500 nmol/l) compared to those who had either an abnormal pregnancy (72, 48-96 nmol/l; P < 0.001) or failed to conceive (33, 28-37 nmol/l; P < 0.001). Receiver-operator curve analysis demonstrated that a single serum progesterone on day 14 post-oocyte retrieval, could highly differentiate between normal and abnormal pregnancies (area under the curve = 0.927, 95%CI = 0.89-0.96; P < 0.0001). CONCLUSIONS: In spite of exogenous progesterone supplementation, serum progesterone levels, from as early as 4 weeks gestation (day 14 post-oocyte retrieval) were significantly elevated and predicted women destined to have viable intra-uterine pregnancies. These high levels are suggestive that endogenous progesterone is already sufficient in viable pregnancies and that exogenous progesterone administration will not rescue a pregnancy destined to result in a miscarriage. Single serum progesterone measurement could be a useful indicator of pregnancy outcome in women undergoing IVF or ICSI treatment.

Abortion, Spontaneous↗

Type C virus expression in lymphoma-paralysis-prone wild mice.

Wild mice trapped near Lake Casitas (LC) in southern California showed a high prevalence of infectious type C virus in the liver, spleen, and thymus within the first few weeks of life. By young adulthood about 80% of LC mice (including their genital tissues) were infected. Virus isolates from these mice cause lymphoma and lower limb paralysis under both natural and experimental conditions. Mice destined to develop paralysis showed higher levels of serum gs antigen early in life, whereas mice destined to develop lymphoma or remain free of these diseases could not be distinguished by this test. The individual variation in virus expression suggested that differences in virus type or in the immune or other host defense mechanisms greatly influenced susceptibility or resistance to indigenous type C virus-caused disease in LC wild mice.

Age Factors↗

A subtelomeric DNA sequence is required for correct processing of the macronuclear DNA sequences during macronuclear development in the hypotrichous ciliate Stylonychia lemnae.

During macronuclear differentiation in ciliated protozoa a series of programed DNA reorganization processes occur. These include the elimination of micronuclear-specific DNA sequences, the specific fragmentation of the genome into small gene-sized DNA molecules, the de novo addition of telomeric sequences to these DNA molecules and the specific amplification of the remaining DNA molecules. Recently we constructed a vector containing the modified micronuclear version of macronuclear destined DNA sequences that was correctly fragmented and telomeres were added de novo after injection into the developing macronucleus. It therefore must contain all the cis- acting sequences required for these processes. We made a series of vectors deleting different sequences from the original vector. It could be shown that at least in the case studied here no micronuclear-specific sequences are required for specific fragmentation of the genome and telomere addition. However, a short subtelomeric sequence at the 3[prime]-end is essential for these processes, whereas no specific cut seems to occur at the 5[prime]-end. In addition, we can show that the processing activity is restricted to a short period of time during macronuclear differentiation and that a preceding transcription is required for correct processing of macronuclear-destined DNA sequences. Possible mechanisms of these processes will be discussed.

Animals↗

Potential role of thyroid hormones and prolactin in the programming of photorefractoriness in turkey hens.

The domestic turkey hen is a seasonal breeder, requiring a period of short days to establish photosensitivity and a long day length to initiate egg production. The reproductive season is then limited by the onset of photorefractoriness (PR), which causes a decline, and then termination, of egg laying. In passerine birds, PR is programmed early in the reproductive season by the presence of thyroid hormones and a long photoperiod. High circulating prolactin (PRL) is thought to hasten the onset of PR. In a prior study, we reported that hens destined to have PR exhibited lower levels of thyroxine (T4) and PRL at certain points (weeks) following photostimulation than did hens destined to remain photosensitive (PS), a result opposite to what might be expected. The present study was conducted to further explore the possible relationship between circulating hormone levels and subsequent PR in the commercial turkey hen at times (days) closer to photostimulation than our previous study. Plasma levels of triiodothyronine (T3), T4, and PRL were compared in 2 subpopulations of hens identified retrospectively after 50 wk of egg production: A group of 17 hens that exhibited PR (mean onset = 27 wk of photostimulation) and a group of "good" layers that remained PS (mean production = 210 eggs/50 wk). Results showed no differences between groups in plasma T3 or T4 levels or in the T3:T4 ratio at -6, 0, 1, 3, and 7 d from photostimulation. Plasma PRL levels were significantly higher at 8 and 9 wk after photostimulation in hens that remained PS vs. those that became PR. We conclude that thyroid hormone levels around the time of photostimulation either are not actively related to programming of subsequent PR in turkeys or programming for PR in the turkey hen occurs later in the reproductive cycle than in passerine birds. We further conclude that hens that exhibit PR tend to have lower circulating PRL levels early in the reproductive season than hens that remain PS and lay at a relatively high rate.

Animals↗

Referrals to hospital-based rheumatology and orthopaedic services: seeking direction.

OBJECTIVES: While both community and hospital-based services strive to cope with the considerable burden posed by musculoskeletal disorders, multidisciplinary-led, integrated approaches are frequently lacking. It has been suggested that referrals to musculoskeletal services are frequently misdirected to an orthopaedic surgeon when non-surgical advice/intervention is warranted, reducing the efficiency of hospital-based services and potentially affecting quality of care. Triage of referrals may help to prevent this, but this system is dependent upon accurate and thorough information being provided in the referral letter. Our aim was to assess the feasibility of triage of musculoskeletal referrals to rheumatology and orthopaedic services at a large teaching hospital. METHODS: One thousand and eighty-seven consecutive referral letters to orthopaedic and rheumatology services were reviewed by a consultant rheumatologist. Letters were assessed for both basic content and the appropriate destination for that referral. In order to evaluate the accuracy of the assessor's prediction of the most appropriate destination of the referrals, the number of patients who were ultimately listed for surgical intervention was calculated in a random sample of orthopaedic referrals, 1 yr after the initial hospital appointment was requested. RESULTS: Six hundred and eighty-two referrals were to orthopaedics and 393 to rheumatology. Referrals relating to spinal pain were excluded. The content of letters was scant and no diagnosis was volunteered in 63.4% of referrals. Fifty-eight per cent of referrals to orthopaedics were considered appropriate; 27% of referrals to orthopaedics were defined as 'should definitely see a rheumatologist' (12%) or 'should probably see a rheumatologist' (15%). Fifteen per cent of referrals to orthopaedics were defined as 'could see either a surgeon or a rheumatologist'. Ninety-four per cent of referrals to rheumatology were defined as appropriate, 2% were not and 4% were defined as 'could see either a surgeon or a rheumatologist'. One year later, in a random sample of 373 of the orthopaedic referrals, 42.2% of those who were categorized as 'should see surgeon' and 9.7% of the 'should see a physician' group were listed for surgical intervention. CONCLUSIONS: Many referrals to hospital-based musculoskeletal services are likely to be misdirected. Integrated referral and care pathways are required for efficient and optimal care of patients with musculoskeletal diseases. The development of such pathways will require significant support, education and training for general practitioners.

Correspondence as Topic↗

Explaining the modern mortality decline: what can we learn from sea voyages.

During the past two decades, scholars have attempted to quanify the mortality at sea of a large number of seaborne populations. We now have estimates of death rates associated with over 13,000 voyages between 1497 and the First World War. These include voyages of Portuguese and Dutch travellers to Asian destinations; African slaves, European convicts, and free emigrants to the Americas; British convicts to Australia; British government-assisted emigrants to South Africa and Australia; and African, Indian, Chinese, and Pacific Islander indentured labourers to various destinations in the Atlantic, Indian, and Pacific Ocean regions. Whereas the death rate on slave voyages did not decline over time, the death rate of young adults and older children on non-slave voyages plummeted in the early-to-middle nineteenth century, preceding the modern mortality decline on land. Yet, the infant death rate of babies who embarked, or who were born at sea, although steadily declining, remained very much higher than infant mortality on land. The reduction in infant maritime mortality, which lagged well behind that of voyaging adults and children, thus mirrors the difficulty in reducing infant death rates on land. This paper surveys the recent literature on mortality at sea, drawing implications for our understanding of the modern mortality decline on land.

Emigration and Immigration↗

Static syndrome after cross-facial nerve transplantation.

A cross-facial nerve graft connected to buccal branches of the healthy facial nerve may carry axons destined for the orbicularis oris muscle as well as axons destined for elevators and abductors of the corner of the mouth. If this nerve graft innervates a pedicled or free muscle flap, contractions of the flap or part of it will also occur when the patient purses his lips. This results in immobilization of the corner of the mouth. On the other hand, smiling may lead to simultaneous contraction of other erroneously reinnervated muscle fibers, equally immobilizing the corner of the mouth. Electromyography in these cases shows well-reinnervated musculature. The only solution to prevent this so-called static syndrome is to transplant smaller nerves connected at more peripheral levels to smaller facial nerve branches with more specific functions.

Adolescent↗

Using talking lights to assist brain-injured patients with daily inpatient therapeutic schedule.

OBJECTIVES: To test the ability of patients with brain injury to use a patient locator and minder (PLAM) system to assist in their adherence to therapy schedules. PARTICIPANTS: Five patients with acquired brain injury who were inpatients on an acute rehabilitation floor of a rehabilitation hospital. MEASURES: The number of human prompts necessary to direct a patient to, and ensure arrival at, a scheduled therapy destination and the proportion of therapy sessions requiring no prompting was measured both before and after the introduction of the PLAM system. RESULTS: With the PLAM system, the average number of human prompts dropped by more than 50%, and the number of sessions requiring no prompting increased from 7% to 44%. CONCLUSION: The PLAM system described in this article seems feasible and useful for patients with acquired brain injury in assisting them with arrival at their therapy destinations without the assistance of staff.

Adult↗

Selection for rehabilitation: acute care discharge patterns for stroke and orthopaedic patients.

This study aimed to develop predictive models to assist clinicians working in acute care to determine which stroke and lower limb orthopaedic patients should be discharged to nursing homes, inpatient rehabilitation, or home. The subjects were 223 patients with stroke and 125 patients with lower limb orthopaedic problems, aged 60 years and over, and the 22 acute care and rehabilitation clinicians who cared for these patients. Patient status was measured within 72 hours of discharge using the Adult FIM(SM) (Guide for the Uniform Data Set for Medical Rehabilitation, 1993) and ten additional items from either the RICFAS (Rehabilitation Institute of Chicago, 1987) or developed for this research. Four mathematical models were developed to predict discharge destination using stepwise discriminant function analysis. Using between three and seven items from the FIM(SM) alone or FIM(SM) plus additional variables, these models correctly classified between 74.9% and 80.5% of patients. In conclusion, clinicians are offered a selection of models to guide their discharge destination decisions for two large groups of patients. While these models cannot replace clinical judgement, they increase the transparency of decisions. The use of objective models to guide clinical decisions are essential, particularly given increasing pressure to justify patient access to costly rehabilitation services.

Aged↗