Assessing Complex Emergency Management with Clinical Case-Vignettes: A Validation Study

Objective

To evaluate whether responses to dynamic case-vignettes accurately reflect actual practices in complex emergency situations. We hypothesized that when obstetricians were faced with vignette of emergency situation identical to one they previously managed, they would report the management strategy they actually used. On the other hand, there is no reason to suppose that their response to a vignette based on a source case managed by another obstetrician would be the same as the actual management.

Methods

A multicenter vignette-based study was used in 7 French maternity units. We chose the example of severe postpartum hemorrhage (PPH) to study the use of case-vignettes for assessing the management of complex situations. We developed dynamic case-vignettes describing incidents of PPH in several steps, using documentation in patient files. Vignettes described the postpartum course and included multiple-choice questions detailing proposed clinical care. Each participating obstetrician was asked to evaluate 4 case-vignettes: 2 directly derived from cases they previously managed and 2 derived from other obstetricians’ cases. We compared the final treatment decision in vignette responses to those documented in the source-case by the overall agreement and the Kappa coefficient, both for the cases the obstetricians previously managed and the cases of others.

Results

Thirty obstetricians participated. Overall agreement between final treatment decisions in case-vignettes and documented care for cases obstetricians previously managed was 82% (Kappa coefficient: 0.75, 95% CI [0.62–0.88]). Overall agreement between final treatment decisions in case-vignettes and documented care in vignettes derived from other obstetricians’ cases was only 48% (Kappa coefficient: 0.30, 95% CI [0.12–0.48]). Final agreement with documented care was significantly better for cases based on their own previous cases than for others (p<0.001).

Conclusions

Dynamic case-vignettes accurately reflect actual practices in complex emergency situations. Therefore, they can be used to assess the quality of management in these situations.     

Upper Limb Evaluation and One-Year Follow Up of Non-Ambulant Patients with Spinal Muscular Atrophy: An Observational Multicenter Trial

Assessment of the upper limb strength in non-ambulant neuromuscular patients remains challenging. Although potential outcome measures have been reported, longitudinal data demonstrating sensitivity to clinical evolution in spinal muscular atrophy patients are critically lacking. Our study recruited 23 non-ambulant patients, 16 patients (males/females = 6/10; median age 15.4 years with a range from 10.7 to 31.1 years) with spinal muscular atrophy type II and 7 patients (males/females = 2/5; median age 19.9 years with a range from 8.3 to 29.9 years) with type III. The Brooke functional score was on median 3 with a range from 2 to 6. The average total vital capacity was 46%, and seven patients required non-invasive ventilation at night. Patients were assessed at baseline, 6 months, and 1 year using the Motor Function Measure and innovative devices MyoGrip, MyoPinch, and MoviPlate, which assess handgrip strength, key pinch strength, and hand/finger extension-flexion function, respectively. The study demonstrated the feasibility and reliability of these measures for all patients, and sensitivity to negative changes after the age of 14 years. The younger patients showed an increase of the distal force in the follow-up period. The distal force measurements and function were correlated to different functional scales. These data represent an important step in the process of validating these devices as potential outcome measures for future clinical trials.

Trial Registration

ClinicalTrials.gov NCT00993161     

Dysbiosis of upper respiratory tract microbiota in elderly pneumonia patients

Bacterial pneumonia is a major cause of morbidity and mortality in elderly. We hypothesize that dysbiosis between regular residents of the upper respiratory tract (URT) microbiome, that is balance between commensals and potential pathogens, is involved in pathogen overgrowth and consequently disease. We compared oropharyngeal microbiota of elderly pneumonia patients (n=100) with healthy elderly (n=91) by 16S-rRNA-based sequencing and verified our findings in young adult pneumonia patients (n=27) and young healthy adults (n=187). Microbiota profiles differed significantly between elderly pneumonia patients and healthy elderly (PERMANOVA, P<0.0005). Highly similar differences were observed between microbiota profiles of young adult pneumonia patients and their healthy controls. Clustering resulted in 11 (sub)clusters including 95% (386/405) of samples. We observed three microbiota profiles strongly associated with pneumonia (P<0.05) and either dominated by lactobacilli (n=11), Rothia (n=51) or Streptococcus (pseudo)pneumoniae (n=42). In contrast, three other microbiota clusters (in total n=183) were correlated with health (P<0.05) and were all characterized by more diverse profiles containing higher abundances of especially Prevotella melaninogenica, Veillonella and Leptotrichia. For the remaining clusters (n=99), the association with health or disease was less clear. A decision tree model based on the relative abundance of five bacterial community members in URT microbiota showed high specificity of 95% and sensitivity of 84% (89% and 73%, respectively, after cross-validation) for differentiating pneumonia patients from healthy individuals. These results suggest that pneumonia in elderly and young adults is associated with dysbiosis of the URT microbiome with bacterial overgrowth of single species and absence of distinct anaerobic bacteria. Whether the observed microbiome changes are a cause or a consequence of the development of pneumonia or merely coincide with disease status remains a question for future research.     

Molecular Cloning of a Lobster Gαq Protein Expressed in Neurons of Olfactory Organ and Brain

Abstract: We have isolated from an American lobster ( Homarus americanus ) olfactory organ cDNA library a clone, hGα_q, with >80% identity to mammalian and arthropod Gα_q sequences. In brain and olfactory organ, hGα_q mRNA was expressed predominantly in neurons, including virtually all the neuronal cell body clusters of the brain. Gα_q protein was also expressed broadly, appearing on western blots as a single band of 46 kDa in brain, eyestalk, pereiopod, dactyl, tail muscle, olfactory organ, and aesthetasc hairs. These results suggest that hGα_q plays a role in a wide variety of signal transduction events. Its presence in the olfactory aesthetasc hairs, which are almost pure preparations of the outer dendrites of the olfactory receptor neurons, the expression of a single hGα_q mRNA species (6 kb) in the olfactory organ, and the localization of hGα_q mRNA predominantly in the olfactory receptor neurons of the olfactory organ strongly suggest that one function of hGα_q is to mediate olfactory transduction.     

Changes in Neuronal Dopamine Homeostasis following 1-Methyl-4-phenylpyridinium (MPP+) Exposure

1-Methyl-4-phenylpyridinium (MPP⁺), the active metabolite of the neurotoxin 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine, selectively kills dopaminergic neurons in vivo and in vitro via a variety of toxic mechanisms, including mitochondrial dysfunction, generation of peroxynitrite, induction of apoptosis, and oxidative stress due to disruption of vesicular dopamine (DA) storage. To investigate the effects of acute MPP⁺ exposure on neuronal DA homeostasis, we measured stimulation-dependent DA release and non-exocytotic DA efflux from mouse striatal slices and extracellular, intracellular, and cytosolic DA (DA_cyt) levels in cultured mouse ventral midbrain neurons. In acute striatal slices, MPP⁺ exposure gradually decreased stimulation-dependent DA release, followed by massive DA efflux that was dependent on MPP⁺ concentration, temperature, and DA uptake transporter activity. Similarly, in mouse midbrain neuronal cultures, MPP⁺ depleted vesicular DA storage accompanied by an elevation of cytosolic and extracellular DA levels. In neuronal cell bodies, increased DA_cyt was not due to transmitter leakage from synaptic vesicles but rather to competitive MPP⁺-dependent inhibition of monoamine oxidase activity. Accordingly, monoamine oxidase blockers pargyline and l-deprenyl had no effect on DA_cyt levels in MPP⁺-treated cells and produced only a moderate effect on the survival of dopaminergic neurons treated with the toxin. In contrast, depletion of intracellular DA by blocking neurotransmitter synthesis resulted in ∼30% reduction of MPP⁺-mediated toxicity, whereas overexpression of VMAT2 completely rescued dopaminergic neurons. These results demonstrate the utility of comprehensive analysis of DA metabolism using various electrochemical methods and reveal the complexity of the effects of MPP⁺ on neuronal DA homeostasis and neurotoxicity.     

Increase in proteinase activity in the cellular slime mould Polysphondylium pallidum induced by bacteria

Abstract Polysphondylium pallidum strain PPHU8 grown in association with bacteria contains aspartic and cysteine proteinases. When myxamoebae were grown in axenic medium the contribution of cysteine proteinases was much lower. The proteinase activity could be altered by addition of heat-killed bacteria to axenically growing cells. This was detected as an increase in the specific activity towards N -benzoyl-L-prolyl-L-phenylalanyl-L-arginine- p -nitroanilide, a cysteine proteinase substrate, and by the appearance of cysteine proteinase bands after electrophoretic analysis. The changes were inhibited by cycloheximide, azide and dinitrophenol. All the available evidence suggests that they are due to the de novo synthesis of cysteine proteinases.     

Structural characterization of glycosphingolipids from the eggs of Schistosoma mansoni and Schistosoma japonicum

The granulomatous pathology in human intestinal schistosomiasisis induced primarily by the egg antigens of schistosome, a parasitictrematode. Glycolipids and glycoproteins were extracted fromthe eggs of the two major species which infect human, Schistosomamansoni and Schistosoma japonicum, for structural characterizationbased on highly sensitive mass spectrometric analysis coupledwith chemical derivatization. Here, we demonstrate that a seriesof uniquely multifucosylated glycosphingolipids constitute themajor egg glycolipids of S.mansoni but not of S.japonicum. TheS.mansoni glycosphingolipids were found to be extended by varyingnumbers of an unusual repeating unit,     

Metabolite profiles of Stachybotrys isolates from water-damaged buildings and their induction of inflammatory mediators and cytotoxicity in macrophages

The metabolite profiles of 20 Stachybotrys spp.isolates from Finnish water-damaged buildings were compared with their biological activities. Effects of purified compounds on cytotoxicity and production of inflammatory mediators such as nitric oxide, IL-6 and TNFα in murine RAW264.7 macrophage cells were studied. The 11isolates belonging to the satratoxin-producing chemotype were highly cytotoxic to the macrophages. The isolates inducing inflammatory mediators all belonged to the atranone-producing chemotype, but pure atranones B, and D did not elicit a response in the bioassay. Altogether, cytotoxicity ofStachybotrys sp. isolates appear to be related to satratoxin production whereas the specific component inducing inflammatory responses in atranone-producing isolates remains obscure. This revised version was published online in June 2006 with corrections to the Cover Date.