Hypoglycaemia risk among a hospitalised stroke patient cohort: a case for increased vigilance in glucose monitoring.

We conducted a retrospective cohort study involving a review of the records of 112 patients consecutively admitted with acute stroke or transient ischaemic attack (TIA) to all three district general hospitals in one Health and Social Care Trust in Northern Ireland from 1 January to 15 April 2008. Glucose results for each of the first 5 days of hospital admission were ascertained. We compared interventions and clinical outcome between patients who experienced hypoglycaemia (glucose<4.0 mmol/l) in the first 5 days, and patients with higher glucose results. Our results indicated that 11 (10%) patients experienced incidents of hypoglycaemia ranging from 1.8 to 3.9 mmol/l. None of the individuals affected had received intravenous or subcutaneous insulin. Only two of the hypoglycaemic episodes involved patients with a history of diabetes mellitus. Two patients experienced episodes of hypoglycaemia on 2 or more days. Six patients experienced hypoglycaemia at the lower threshold of glucose<3.5 mmol/l and this was not associated with a history of diabetes. A history of diabetes mellitus prompted near patient glucose testing, but among patients without diagnosed diabetes, glycaemia was under-monitored. The test that most frequently indicated hypoglycaemia was a routine electrolyte profile tested in the hospital laboratory. Patients in the first 5 days after stroke have a small risk of hypoglycaemia. There is a need for greater vigilance in the monitoring of glucose among patients admitted to hospital with stroke or TIA.

Hyperglycaemia monitoring and management in stroke care: policy vs. practice.

AIM: To evaluate the extent to which hyperglycaemia was monitored and managed among patients admitted to hospital with acute stroke and transient ischaemic attack. METHODS: We conducted a retrospective cohort study involving a review of the records of 112 patients consecutively admitted with acute stroke or transient ischaemic attack to all three district general hospitals in one Health and Social Care Trust in Northern Ireland from 1 January to 15 April 2008. Glucose results for each of the first 5 days of hospital admission were ascertained. We compared interventions, clinical outcome and discharge planning between patients who experienced glucose ≥ 7.8 mmol/l in the first 5 days, and patients with lower glucose results. RESULTS: The daily prevalence rate of hyperglycaemia > 7.8 mmol/l across the first 5 days ranged from 24 to 34%. A total of 41 (37%) patients experienced hyperglycaemia on at least one occasion during the first 5 days. A history of diabetes mellitus prompted near patient glucose testing, but, among patients without diagnosed diabetes, glycaemia was under-monitored. Hyperglycaemia was a persisting trend, was under-treated and under-reported to general practitioners. Elevated glucose results failed to influence higher rates of fasting plasma glucose tests and BMI assessment. CONCLUSIONS: There is a need for greater vigilance in the detection of hyperglycaemia and undiagnosed diabetes mellitus among patients admitted to hospital with stroke or transient ischaemic attack.

Cytokines and their inhibitors in orf virus infection.

The epitheliotropic parapoxvirus, orf virus, can repeatedly infect sheep skin. A specific immune response is generated as reinfections induce smaller lesions with quicker resolution times than primary lesions. Cyclosporin-A treatment abrogates this partial immunity. Cytokine mRNAs detected in lesion biopsies include the transcripts for IL-1 beta, IL-3 GM-CSF, TNF-alpha and, less reproducibly, IFN-gamma. CD4+ T-cells predominate in afferent lymph draining the site of infection, and are the major source of GM-CSF and IFN-gamma. IL-1 beta and IL-8 are also detected. The orf virus genome contains a homologue of mammalian vascular endothelial growth factor that may enhance virulence and a vaccinia virus E3L-like gene which may inhibit the anti-viral effect of the interferons. A GM-CSF inhibitory activity has also been discovered and has been 'chased' into a 10 kb DNA segment of the orf virus genome. These studies indicate that orf virus may temporarily avoid host immunity by a combination of acute, rapid infection and replication in the epidermis and by producing virulence factors that inhibit protective proteins of the host immune and inflammatory response.

Genomic analysis of a transposition-deletion variant of orf virus reveals a 3.3 kbp region of non-essential DNA.

Restriction endonuclease analysis of the DNA extracted orf virus strain NZ2, which had been serially passaged in primary bovine testis cells, revealed a population of variants that had over-grown the wild-type virus. At least three distinct mutant forms were identified in which the right end of the genome had been duplicated and translocated to the left end, accompanied by deletions of sequences at the left end. Sequencing of a single variant isolated from the heterogeneous population revealed that recombination had occurred between non-homologous sequences. In this case, 6.6 kb of DNA at the left end of the genome had been replaced by 19.3 kb from the right end. The transposition resulted in the deletion at the left end of 3.3 kb of DNA encoding three genes and the terminal sequences of a fourth gene. The three genes completely deleted were a homologue of dUTPase, a gene that encodes a protein containing ankyrin-like repeats and a homologue of the 5K gene of the vaccinia virus WR strain. Experimental inoculation of sheep showed that the genes are also non-essential in vivo, but that the size of the lesion was reduced, compared with that induced by the wild-type, and resolved more rapidly.

The establishment of a genetic map of orf virus reveals a pattern of genomic organization that is highly conserved among divergent poxviruses.

The large differences between the G+C content of the orf virus genome and those of other characterized poxviruses have precluded the use of DNA hybridization to establish a gene map of orf virus. Here we have sequenced the ends of cloned restriction endonuclease fragments of the nZ2 strain of orf virus (OV) and used the translated sequences to search protein data bases. Sequence from 15 points found high-scoring matches to data base entries, including 18 vaccinia virus (VAC) genes. We also present 2 kb of sequence from a region near the right terminus of the OV genome and show that it encodes homologs of VAC genes, F9L and F10L. The data presented here in conjunction with published and as yet unpublished data have allowed the construction of a gene map of OV on which 37 genes have been placed. Thirty-two of these genes have homologs in VAC. Alignment of the OV gene map with that of VAC revealed that each OV gene and its VAC counterpart occurred in the same order and orientation on their respective genomes. The intervals between many of the points of sequence were also found to be strikingly similar. The conserved spacing of genes between OV and VAC within the central 88.2 kb of the 139-kb OV genome is not maintained in the termini where insertion, deletion, and translocation have occurred. Parallels are drawn between the data presented here and related data from swinepox virus and capripox virus.

Identification and characterization of the orf virus type I topoisomerase.

Vaccinia virus (VV) and Shope fibroma virus (SFV), representatives of the orthopox and leporipox genera, respectively, encode type I DNA topoisomerases. Here we report that the 957-nt F4R open reading frame of orf virus (OV), a representative of the parapox genus, is predicted to encode a 318-aa protein with extensive homology to these enzymes. The deduced amino acid sequence of F4R has 54.7 and 50.6% identity with the VV and SFV enzymes, respectively. One hundred forty amino acids are predicted to be conserved in all three proteins. The F4R protein was expressed in Escherichia coli under the control of an inducible T7 promoter, partially purified, and shown to be a bona fide type I topoisomerase. Like the VV enzyme, the OV enzyme relaxed negatively supercoiled DNA in the absence of divalent cations or ATP and formed a transient covalent intermediate with cleaved DNA that could be visualized by SDS-PAGE. Both the noncovalent and covalent protein/DNA complexes could be detected in an electrophoretic mobility shift assay. The initial PCR used to prepare expression constructs yielded a mutant allele of the OV topoisomerase with a G-A transition at nt 677 that was predicted to replace a highly conserved Tyr residue with a Cys. This allele directed the expression of an enzyme which retained noncovalent DNA binding activity but was severely impaired in DNA cleavage and relaxation. Incubation of pUC19 DNA with the wild-type OV or VV enzyme yielded an indistinguishable set of DNA cleavage fragments, although the relative abundance of the fragments differed for the two enzymes. Using a duplex oligonucleotide substrate containing the consensus site for the VV enzyme, we demonstrated that the OV enzyme also cleaved efficiently immediately downstream of the sequence CCCTT.

Homologs of vascular endothelial growth factor are encoded by the poxvirus orf virus.

A gene encoding a polypeptide with homology to mammalian vascular endothelial growth factors (VEGFs) has been discovered in the genome of orf virus (OV), a parapoxvirus that affects sheep and goats and, occasionally, humans. The gene is transcribed abundantly early in infection and is found immediately outside the inverted terminal repeat at the right end of the genome. In the NZ2 strain of OV (OV NZ2), the gene encodes a polypeptide with a molecular size of 14.7 kDa, while in another strain, OV NZ7, there is a variant gene that encodes a polypeptide of 16 kDa. The OV NZ2 and OV NZ7 polypeptides show 22 to 27% and 16 to 23% identity, respectively, to the mammalian VEGFs. The viral polypeptides are only 41.1% identical to each other, and there is little homology between the two genes at the nucleotide level. Another unusual feature of these genes is their G+C content, particularly that of OV NZ7. In a genome that is otherwise 63% G+C, the OV NZ2 gene is 57.2% G+C and the OV NZ7 gene is 39.7% G+C. The OV NZ2 gene, but not the OV NZ7 gene, is homologous to the mammalian VEGF genes at the DNA level, suggesting that the gene has been acquired from a mammalian host and is undergoing genetic drift. The lesions induced in sheep and humans after infection with OV show extensive dermal vascular endothelial proliferation and dilatation, and it is likely that this is a direct effect of the expression of the VEGF-like gene.

Rapidly destructive hip disease: clinical and imaging abnormalities.

The clinical and radiographic records of 23 patients (15 women, eight men) with rapidly destructive hip disease (RDHD) were retrospectively reviewed. Criteria for RDHD included a history of hip pain of 1-6 months duration and the radiographic appearance of a rapidly progressive atrophic form of bone destruction involving both the femoral head and the acetabulum. Radiographs of the remainder of the appendicular skeleton were assessed in 14 patients. The mean patient age was 72 years. The average time from clinical presentation to the appearance of severe hip destruction was 14 months. Five patients demonstrated similar atrophic bone destruction around other articulations. No patients had clinical or laboratory evidence of sepsis or neurologic disease. Although previous reports have suggested that RDHD is degenerative in nature, similar involvement of other articulations suggests that it may represent a focal finding of a more generalized process.

Lymphocyte-synovial cell interactions: a role for beta 1 and beta 3 integrin-mediated adhesion to cellular fibronectin.

The interactions of lymphocytes with cultured synovial cells derived from rheumatoid arthritis patients were examined. A number of lymphoid cell lines bound to these cells. The adherence of several of these lines was inhibited by antibodies to fibronectin. The adherence of the T cell leukemia Jurkat was sensitive to inhibition by antibodies to the fibronectin receptors alpha 4 beta 1 and alpha 5 beta 1. The adherence of the beta 1 integrin negative B cell line RPMI 8866 was inhibited by antibodies to the vitronectin receptor, alpha v beta 3. The interactions of several other cell lines with synovial cells appeared to be independent of this fibronectin-dependent pathway. These results indicate that multiple potential adhesion pathways for cellular interactions in the tissues may exist. The adherence to cell-associated fibronectin may play a contributory role in such processes for certain lymphocyte subsets.

In vivo recognition of orf virus early transcriptional promoters in a vaccinia virus recombinant.

The 4.4-kb BamHI-E fragment of the orf virus (OV) genome contains three discrete open reading frames designated ORF-pp, ORF-1, and ORF-3, all of which are flanked by vaccinia virus-like early transcriptional control sequences. To determine whether the vaccinia transcriptional machinery would recognize these promoters and faithfully transcribe OV genes in vivo the BamHI-E fragment was inserted into the thymidine kinase (TK) locus of vaccinia virus and the recombinant used in transcription studies. Northern blotting analysis of early RNA isolated from 143B-TK- cells infected with the recombinant virus showed that OV genes were transcribed and that the three transcripts of 0.70-(ORF-pp), 0.48- (ORF1), and 0.75-kb (ORF-3) were the same size as their counterparts in OV-infected cells. Analysis of the 5' end of transcripts by S1 nuclease and primer extension showed that the transcriptional start points (tsp) of ORF-pp, ORF-1, and ORF-3 in the recombinant were identical or within four nucleotides of the tsps of the same ORFs in OV. However, there were quantitative differences. ORF-1 was transcribed more efficiently in recombinant virus-infected cells than in those infected with OV and analysis of the putative promoter, 5'-AAAATTGTAAATGTA, showed that it was similar to the 7.5-kDa early promoter of vaccinia virus. This demonstrates that the transcriptional control sequences of OV genes are recognized by vaccinia virus transcriptional factors but that quantitative differences exist suggesting that the generically different transcriptional factors have different promoter sequence requirements for maximal transcription.

High-performance liquid chromatographic determination of 4,4'-methylenedianiline in human urine.

A method is described for the determination of urinary 4,4'-methylenedianiline (MDA) by high-performance liquid chromatography (HPLC). MDA was extracted from hydrolyzed urine using C18 solid-phase extraction columns. The extract was analyzed by reversed-phase HPLC with electrochemical detection at a cell potential of 0.8 V. The method was very sensitive (detection limit 2.5 micrograms/l) and quantitation using 4,4'-ethylenedianiline as an internal standard correlated well with results by gas chromatography-mas spectrometry. Run-to-run precision (n = 25) averaged 8.9%. In analysis of more than 160 potentially exposed workers, MDA was detected in less than 20% of the urines and concentrations ranged up to 210 micrograms MDA per g of creatinine.

Surgical interruption of patellar blood supply by total knee arthroplasty.

Arterial blood supply of the patella was demonstrated in 21 cadaver knees by intraarterial injection of radiopaque contrast. When the standard medial parapatellar approach or lateral retinacular release was carried out at a distance of at least 1 cm from the margin of the patella, some steps in total knee arthroplasty caused no impairment and others jeopardized the filling of intraosseous vessels. The radial intraosseous vessels are jeopardized by osteotomy of a deformed patella or excision of fat pad. The prepatellar vessels greatly contribute to intraosseous vascularization and should be carefully preserved.

Continuous passive motion device for hand rehabilitation.

Prototypes have been designed and manufactured for a lightweight portable device which continually moves all the joints of the hand passively through a range of motion. Inflatable bag modules in the palm of the hand are ganged together to create the required range of motion. A battery-operated air pump cycles compressed air to the modules. Initial clinical experience with patients who have flexion contractures caused by burns, trauma, and Dupuytren's contractures has shown the device to be well tolerated and effective.

Infectious and non-infectious mutants of cauliflower mosaic virus DNA.

Mutants of cauliflower mosaic virus (CaMV), generated in vitro by modification of recombinant DNA plasmids containing the viral genome, either retained the ability to induce disease symptoms on turnip plants, produced less severe symptoms or failed to induce symptoms. Wild-type symptoms were produced by a variant CaMV DNA of the Cabbage S isolate that had 4 bp in open reading frame (ORF) III replaced with a 16 bp sequence. Less severe symptoms, due to a delay in symptom appearance relative to inoculation with wild-type DNA, were induced by a mutant with a frameshift mutation in ORF II (pSA103). CaMV DNA, recovered from plants infected with pSA103, contained a second mutation which restored the original translation reading frame. Nucleic acid hybridization to 'squishes' of leaf tissue from plants that had been inoculated with mutant DNAs that included DNAs modified in each of the six major ORFs of CaMV DNA revealed that only those plants that appeared diseased had detectable CaMV nucleic acid in uninoculated leaves. Replicated CaMV DNA was also not detected in non-encapsidated and virion DNA fractions from inoculated leaves of non-diseased plants.

Hip arthroplasty surgery in Manitoba: 1973-1978.

A review of all (1279) total hip arthroplasties in the Province of Manitoba, Canada, from 1973 to 1978 demonstrates an increase in the number of operations except in the very elderly. Six-week operative mortality was decreased from 2.4% to .6%, and time spent in the hospital has decreased from 54 to 40 days. Utilization of medical services by patients before and after surgery, as recorded by the Manitoba Health Services Commission, enables identification of all serious postoperative complications. Two years after surgery, 95.2% of patients were alive, and 16% had a contralateral hip arthroplasty. Fourteen patients (2.7%) required revision surgery within two years; 20 patients (4%) were readmitted to the hospital with other surgical complications, including trochanteric bursitis, osteomyelitis, pulmonary embolism, and so forth. Visits to physicians for arthritis-related problems and to chiropractors decreased in the two years after surgery compared with the two years before.

The centralization of operations and access to treatment: total hip replacement in Manitoba.

The impact of centralized facilities on access to care was tested by studying total hip arthroplasty in the Province of Manitoba, Canada. Data from the Manitoba Health Services Commission, which insures costs of all medical services in the Province, show that the availability of this surgical procedure has increased steadily over the 1973-78 period at a rate similar to that elsewhere in North America. Although Manitoba's population is geographically dispersed, specialized orthopedic services are concentrated in two urban centers. No important difference in access to care for this condition was found between urban center residents and residents distant from the surgical facilities.

Method for Growth and Purification of Bacteriophage 643 on Streptococcus lactis ML3.

The yield of bacteriophage 643 was increased by infecting cultures of Streptococcus lactis ML3 in late-log phase growth, harvesting the infected cells, and suspending them in fresh, phosphate-buffered minimal medium. The cells lysed after this treatment and produced high titers of bacteriophage. The phage particles were dissociated from debris by 2 M NaCl and purified by differential and CsCl band centrifugation.

Pathogenesis of Charcot-Marie-Tooth disease. Gait analysis and electrophysiologic, genetic, histopathologic, and enzyme studies in a kinship.

Little has been written about the pathogenesis of pes cavus in Charcot-Marie-Tooth disease (CMT). In 12 of 22 patients in a family with known autosomal dominant CMT, a predictable pattern of progression was related to a centrifugal pattern of innervation of the extremity. The gait pattern had greater complexity than the steppage gait. Pelvic shift and elevation on the swing side were used to clear the "drop foot" from the floor. Lateral flexion of the trunk to the opposite direction was used for balance. Previous descriptions of the etiology of pes cavus did not apply to this family. The mode of development of pes cavus in CMT is not known and requires further investigation.

The DNA of bacteriophage 643: isolation and properties of the DNA of a bacteriophage infecting lactic Streptococci.

The DNA extracted from bacteriophage 643, which infects group N strains of Streptococci, could be separated into four components by electrophoresis on agarose gels. Electron microscopy established the predominant form of the DNA to be a relaxed, circular molecule of molecular weight 14.9 X 10(6). The four species observed on electrophoresis are believed to be a circular monomeric form, a linear form derived from it, a circular dimeric form, and the corresponding linear dimer. Two DNA components were demonstrated by sedimentation velocity in the analytical ultracentrifuge and by zone sedimentation in sucrose gradients. These corresponded to a circular monomeric form and a circular dimeric form; no evidence for supercoiled forms was found by sedimentation in either neutral or denaturing solvents. Bacteriophage 643 DNA was sensitive to cleavage by single-strand-specific nuclease S1 and could be labeled in vitro by the PolI-catalyzed incorporation of [alpha-32P]dATP into the molecule under conditions that did not permit nick translation, suggesting that the circular duplex molecule is interrupted by a single-stranded gap.

Helper component for aphid transmission encoded by region II of cauliflower mosaic virus DNA.

A deletion mutant of cauliflower mosaic virus (CaMV) isolate NY8153 deficient in aphid transmissibility was constructed by BAL-31 exonuclease treatment of XhoI linearized pCMS31 (a plasmid containing the entire CaMV genome cloned in the SalI site of pBR322), followed by ligation. The resulting mutant, pSA103, lacked about 100 by from the putative protein-coding region II of CaMV DNA. In turnips there was no difference in the number and appearance of starch lesions or hybridization lesions, or in the nature of symptoms in systemically infected leaves induced by pSA103 DNA, pCMS31 DNA, and NY8153 DNA. Systemic symptoms appeared later in plants infected with pSA103 (27 +/- 2 days) than in those infected with the parental pCMS31 DNA (19 +/- 2 days). Aphids fed on virus SA103-infected mustard plants were unable to transmit the virus to healthy plants while 30-70% transmission was observed from plants infected by the parent virus. Virions extracted from turnips infected with the mutant had DNA still containing the deletion. In addition, the single-stranded discontinuity in region II of NY8153 DNA was missing in this DNA. The results suggest that region II codes for a "helper component" required for aphid transmission of CaMV.