Comparison of primary angioplasty and pre-hospital fibrinolysis in acute myocardial infarction (CAPTIM) trial: a 5-year follow-up

AIMS

The CAPTIM (Comparison of primary Angioplasty and Pre-hospital fibrinolysis In acute Myocardial infarction) study found no evidence that a strategy of primary angioplasty was superior in terms of 30-day outcomes to a strategy of pre-hospital fibrinolysis with transfer to an interventional facility in patients managed early at the acute phase of an acute myocardial infarction. The present analysis was designed to compare both strategies at 5 years.

METHODS AND RESULTS

The CAPTIM study included 840 patients managed in a pre-hospital setting within 6 h of an acute ST-segment elevation myocardial infarction. Patients were randomized to either a primary angioplasty (n = 421) or a pre-hospital fibrinolysis (rt-PA) with immediate transfer to a centre with interventional facilities (n = 419). Long-term follow-up was obtained in blinded fashion from 795 patients (94.6%). Using an intent-to-treat analysis, all-cause mortality at 5 years was 9.7% in the pre-hospital fibrinolysis group when compared with 12.6% in the primary angioplasty group [HR 0.75 (95% CI, 0.50-1.14); P = 0.18]. For patients included within 2 h, 5 year mortality was 5.8% in the pre-hospital fibrinolysis group when compared with 11.1% in the primary angioplasty group [HR 0.50 (95% CI, 0.25-0.97); P = 0.04], whereas it was, respectively, 14.5 and 14.4% in patients included after 2 h [HR 1.02, (95% CI 0.59-1.75), P = 0.92].

CONCLUSION

The 5-year follow-up is consistent with the 30-day outcomes of the trial, showing similar mortality for primary percutaneous coronary intervention and a policy of pre-hospital lysis followed by transfer to an interventional center. In addition, for patients treated within 2 h of symptom onset, 5-year mortality was lower with pre-hospital lysis.

Prevalence and types of aggressive behaviour among adults with intellectual disabilities

BACKGROUND

Aggressive behaviours represent major obstacles to the integration into society of individuals with intellectual disability (ID) and pose significant management issues for carers.

METHODS

The present study assessed the prevalence and severity of five types of aggressive behaviours in 3165 adult men and women with ID receiving services from three rehabilitation agencies in Québec by surveying their carers using the Modified Overt Aggressive Scale.

RESULTS

The 12-month prevalence of aggressive behaviour was 51.8%: 24% property damage, 37.6% verbal, 24.4% self-oriented and 24.4% physical aggression, and 9.8% sexually aggressive behaviour, most of which being mild in severity. Only 4.9% of individuals displayed aggressive behaviour leading to injury of the victim. Few gender differences were observed.

CONCLUSIONS

The capacity to document and assess the types as well as the severity of aggressive behaviour is thus critical, not only to better understand the correlates of various types of behaviours but also to orient intervention programmes whether they be prevention, assessment, monitoring or management of aggressive behaviour.

Insulin and glycemic responses in healthy humans to native starches processed in different ways: correlation with in vitro alpha-amylase hydrolysis

The aim of the study was to elucidate how extracted starches submitted to food processing (or not) can influence plasma insulin and glucose responses in healthy subjects. Native starches from wheat, manihot, smooth peas, or mung beans were tested either raw, as starch gels (boiled and cooled), or cooked and cooled after a preliminary industrial processing: extrusion cooking for wheat, tapioca for manihot, and noodles for mung beans. Eighteen healthy subjects randomly assigned received three different starches under one form of conditioning. All products were submitted to in vitro alpha-amylolysis. Raw manihot starch produced the lowest (p less than 0.05) metabolic responses. Cooking significantly (p less than 0.01) increased plasma responses. However, cooked mung bean noodles gave metabolic responses similar to those of raw products. Close correlations were found between percentages of in vitro starch hydrolysis at 30 min and mean areas under the glycemic curves and the insulinemic curves (r = 0.95, p less than 0.001).

Epidemiological survey of childhood burn injuries in France

Among domestic injuries in children, skin burns deserve special attention because they can lead to severe residual lesions. Their frequency has been reported to range from 3 to 8 per cent of all childhood injuries, but few epidemiological data have been collected in France. This study was undertaken to improve our knowledge of this public-health problem. A 20-item epidemiological questionnaire developed by the SFETB was used to collect prospective data on childhood burn injuries managed over a 12-month period in 14 burn centres and 18 paediatric surgery units in France. Of the 937 patients included in the study, 606 were contributed by burn centres and 331 by paediatric surgery units. Descriptive analysis and tests for correlations between several parameters showed that the typical burn-injury patient was a boy (61.6 per cent) with a mean age of 47 months, who suffered a scald burn (64.1 per cent) in the kitchen (56.2 per cent). The bathroom (13.6 per cent) was found to be an especially dangerous room because of the presence of hot water taps (shower, bathtub) and the high risk of an immersion injury. Burns due to ignition of volatile substances (16.95 per cent) were less common, but caused seven of the 11 deaths recorded in this survey. Most burn injuries were superficial lesions (59 per cent) covering less than 10 per cent of the body surface (56.2 per cent). However, grafting was required in 35 per cent of patients. Epidemiological surveys provide objective information on hazardous agents and on the settings in which burns are most likely to occur. They are essential for the development of appropriate preventive strategies, which are still receiving insufficient emphasis in the European Economic Community (EEC).

The pathological basis of temporal lobe epilepsy in childhood

OBJECTIVE

To characterize the pathologic findings of temporal lobe epilepsy (TLE) in children undergoing temporal lobectomy for refractory seizures and to correlate these findings with clinical presentation.

METHODS

The authors reviewed the charts of all children who underwent anterior temporal lobectomy for refractory TLE from 1979 through 1999. A new neuropathologic analysis was performed blinded to clinical features and outcome.

RESULTS

Twenty-two children met inclusion criteria. Mean age at onset of epilepsy was 3 years, 7 months (range 1 month to 10 years). Mean age at surgery was 10 years, 11 months (range 1 to 18 years). All patients had complex partial seizures, 48% with secondary generalization. Most had daily seizures. Auras were reported in 45% of patients. Post-resection follow-up averaged 5 years, 2 months (range 2 to 19 years). Seizure-free status was achieved in 41% of patients, and 14% had residual auras only. The most frequent neuropathologic abnormalities were cortical dysplasia (CD) of the temporal neocortex (14 of 22) and mesial temporal sclerosis (MTS) (12 of the 15 children with available hippocampal tissue). These two findings coexisted in seven children. MTS was associated with extra-hippocampal pathology in 8 of 12 (67%) of the cases.

CONCLUSIONS

MTS occurs frequently in association with CD in this population of children. The high incidence of dual pathology could explain the early age of seizure onset and high seizure frequency rate observed. TLE in childhood may constitute a different entity than in adults, from both the clinical and neuropathologic perspectives.

Differential membrane targeting of the secretory proteins GRA4 and GRA6 within the parasitophorous vacuole formed by Toxoplasma gondii

Following secretion into the parasitophorous vacuole, dense granule proteins, referred to as GRA proteins, are targeted to different locations including a complex of tubular membranes that are connected with the vacuolar membrane. To further define the formation of this intravacuolar network, we have investigated the secretion, trafficking and membrane association of GRA4 and GRA6 within the parasitophorous vacuole. In extracellular parasites, GRA4 and GRA6 were found exclusively in dense secretory granules where they were packaged primarily as soluble proteins. Following release into the vacuole, GRA6 was rapidly translocated to the posterior end of the parasite where, like previously reported for GRA2, it bound to a cluster of multi-lamellar vesicles that give rise to the network. In contrast, GRA4 was distributed throughout the lumen of the vacuole and only later became associated with the mature network that is found dispersed throughout the vacuole. Cell fractionation and treatment with denaturing agents established that the association of GRA4 with the network membranes was mediated by strong protein-protein interactions. In contrast, GRA6 was predominantly influenced by hydrophobic interactions, and a phosphorylated form of this protein present within the vacuole showed increased association with the network membranes. Cross-linking studies established that GRA4 and GRA6 specifically interact with GRA2 to form a multimeric complex that is stably associated with the intravacuolar network. Formation of this protein complex, which is based on both protein-protein and hydrophobic interactions, may participate in nutrient or protein transport within the vacuole.

Stable DNA transformation of Toxoplasma gondii using phleomycin selection

Toxoplasma gondii (Tg) is an obligate intracellular protozoan parasite that is an important opportunistic pathogen in humans. To provide additional tools for molecular genetic analysis, we have developed a set of vectors for DNA transformation in Tg based on selection with the antibiotic phleomycin (Ph). These new vectors rely on the flanking sequences from the parasite genes GRA1, GRA2 or SAG1 to drive expression of the Tn5 ble gene encoding resistance to the DNA intercalating drug Ph (PhR). Treatment of extracellular parasites was used to select stable PhR transformants by plaque formation on host cell monolayers. Transfection of linear or circular forms of the pGRA1/ble, pGRA2/ble or pSAG1/ble vectors by electroporation resulted in stable transformation with an efficiency of approx. 10(-4)/micrograms DNA. Stable transformants contained 1-5 copies of ble that were integrated at non-homologous sites in the parasite nuclear genome. Ble provides a new dominant selectable marker for safe, efficient and rapid isolation of stable DNA transformants in Tg.

Transmembrane insertion of the Toxoplasma gondii GRA5 protein occurs after soluble secretion into the host cell

The intracellular parasite Toxoplasma gondii resides within a specialized compartment, the parasitophorous vacuole (PV), that resists fusion with host cell endocytic and lysosomal compartments. The PV is extensively modified by secretion of parasite proteins, including the dense granule protein GRA5 that is specifically targeted to the delimiting membrane of the PV (PVM). We show here that GRA5 is present both in a soluble form and in hydrophobic aggregates. GRA5 is secreted as a soluble form into the PV after which it becomes stably associated with the PVM. Topological studies demonstrated that GRA5 was inserted into the PVM as a transmembrane protein with its N-terminal domain extending into the cytoplasm and its C terminus in the vacuole lumen. Deletion of 8 of the 18 hydrophobic amino acids of the single predicted transmembrane domain resulted in the failure of GRA5 to associate with the PVM; yet it remained correctly packaged in the dense granules and was secreted as a soluble protein into the PV. Collectively, these studies demonstrate that the secretory pathway in Toxoplasma is unusual in two regards; it allows soluble export of proteins containing typical transmembrane domains and provides a mechanism for their insertion into a host cell membrane after secretion from the parasite.

Targeted disruption of the GRA2 locus in Toxoplasma gondii decreases acute virulence in mice

Following invasion into the host cell, the protozoan Toxoplasma gondii secretes a variety of proteins that modify the parasitophorous vacuole. Within the vacuole, the 28-kDa dense granule protein known as GRA2 is specifically targeted to the tubulovesicular network which forms connections with the vacuolar membrane. To investigate the importance of GRA2, we derived from strain RH a mutant T. gondii line in which GRA2 was disrupted by replacement with the marker Ble (selecting for phleomycin resistance). The Deltagra2 mutant invaded and grew normally in both fibroblasts and macrophages in vitro; however, it was less virulent during acute infection in mice. The survival rate of mice inoculated with Deltagra2 was significantly higher; some infected mice survived the acute infection, whereas all mice infected with the wild-type strain RH succumbed to early death. Chronic infection by Deltagra2 was detected by positive serology, immunohistochemical detection of parasites and cysts in the brain, and reisolation of parasites by bioassay at 6 weeks postinfection. Thus, absence of GRA2 partially attenuates the virulence of T. gondii during the acute phase of infection and allows for establishment of chronic infection by the otherwise highly virulent RH strain. These results establish that GRA2 plays an important role during in vivo infection and provide a potential model for examining acute pathogenesis by T. gondii.

Molecular structure of a Toxoplasma gondii dense granule antigen (GRA 5) associated with the parasitophorous vacuole membrane

The P21 antigen of Toxoplasma gondii, defined by the monoclonal antibody TG17-113, has been described as a dense granule component, secreted in the parasitophorous vacuole during host cell invasion. The present work reports the cloning of the gene encoding the P21 antigen, for which we propose the name GRA 5. A cDNA library was screened with a rat antiserum raised against an HPLC fraction enriched in the P21 antigen. cDNA clones encoding GRA 5 were selected by antibody selection on the recombinant proteins. All these clones were incomplete at the 5' end. The 5' fragment of the longest cDNA clone isolated by this first screening was used as a probe in secondary screenings of cDNA and genomic DNA libraries. A genomic fragment containing the P21 gene and nearly full-length cDNAs have been isolated and sequenced. The gene encoding GRA 5 is 834 bp long and does not contain any intron. The deduced amino acid sequence of an open reading frame encoding 133 amino acids perfectly matched that of 5 peptides microsequenced from the native antigen. A N-terminal hydrophobic region was found to possess the characteristics of a signal peptide of 25 amino acids. A second hydrophobic domain, bordered by two hydrophilic regions strongly suggests a transmembrane region. This molecular structure is supported by ultrastructural studies showing the association of the P21 antigen with the parasitophorous vacuole membrane.

Characterization of a dense granule antigen of Toxoplasma gondii (GRA6) associated to the network of the parasitophorous vacuole

This work describes the molecular characterization of GRA6, a novel Toxoplasma gondii dense granule antigen of 32 kDa. cDNA clones encoding this protein were isolated using a rat serum directed against an HPLC fraction enriched in the protein GRA5. Cross-reactivity between GRA5 and GRA6 was demonstrated by production of sera against the recombinant GRA5 protein. A serum against a recombinant fragment of GRA6 which does not react with GRA5 allowed the localization of this antigen at the subcellular level. GRA6 is detected in the dense granules of tachyzoites, and in the parasitophorous vacuole, closely associated to the network. The gene encoding GRA6 and its flanking regions were completely sequenced from cDNA and genomic inserts. Primer extension experiments demonstrated that the cap site of the GRA6 gene was located 37 bp upstream of the 5' end of the longest cDNA insert (1600 bp). The GRA6 gene potentially encodes a 230-amino-acid polypeptide, does not contain any introns and seems to be present as a single copy in the genome of T. gondii. The deduced polypeptide contains two hydrophobic regions with the characteristics of transmembrane domains. The N-terminal domain does not fit the classical feature of a signal peptide. The central hydrophobic domain is flanked by two hydrophilic domains which contain four blocks of amino acids homologous to the GRA5 protein. The C-terminal hydrophilic region comprises 24% of glycine residues, which may indicate a structural role for GRA6 in the network.

Age, gender and quality of life

This paper addresses the effect of age and gender on the subjective quality of life of people with severe and persistent mental illness. Subjective quality of life was assessed in a group of 95 men and 70 women using the Satisfaction with Life Domains Scale (SLDS) and five open-ended questions. Although statistical analyses showed no difference between men and women on quality of life, age was systematically related to satisfaction level with older participants being more satisfied with their lives than their younger counterparts. Responses to the open-ended questions revealed that fewer of the older, more satisfied respondents expressed worries, desire for change and plans for the future. These results are discussed with respect to the links between subjective quality of life, aspirations and the rehabilitation process.

A simple and rapid high-performance liquid chromatographic (HPLC) method for 5-fluorouracil (5-FU) assay in plasma and possible detection of patients with impaired dihydropyrimidine dehydrogenase (DPD) activity

BACKGROUND

Dihydropyrimidine dehydrogenase (DPD) gene polymorphism may lead to severe toxicity with 5-fluorouracil (5-FU), a major anticancer drug extensively used in clinical oncology. Drug monitoring combined with early detection of patients at risk would enable timely dose adaptation so as to maintain drug concentrations within a therapeutic window. However, the best method to identify such patients remains to be determined.

OBJECTIVE

The aim of this study was to develop a rapid and simple high-performance liquid chromatographic (HPLC) method for estimating uracil/dihydrouracil (U/UH2) ratio in plasma, as an index of DPD status, and for assaying 5-FU as part of drug level monitoring.

METHOD

Assay of 5-FU, and U/UH2 detection were performed on a HPLC system equipped with UV detector. Analytes were separated at room temperature using a 5 microm particles, 25 cm RP-18 X-Terra column. The mobile-phase consisted of a KH(2)PO(4) salt solution (0.05 m) + 0.1% triethylamine (TEA) pumped at 0.4 mL/min. Detection of 5-FU and 5-bromouracil were performed at 254 nm; U and UH2 elution was monitored at 210 nm.

RESULTS

The method was sensitive and specific for assaying 5-FU within the 5-500 ng/mL concentration range, which covers exposure levels currently met in clinical practice. The method was simple, and relatively cheap, and rapid, with an analytical run time of about 30 min. Data from a patient with 5-FU toxicity suggest that the method was capable of identifying DPD metabolic phenotype in cancer patients, based on measurement of plasma U/UH2 ratio.

CONCLUSION

The method described should be suitable both for detecting patients at high risk of 5-FU toxicity, and for drug level monitoring during chemotherapy.

Intramedullary epidermoid cysts of the spinal cord. Case report

Epidermoid cysts are tumors familiar to neurosurgeons, but intramedullary epidermoid cysts are rare. The authors report the case of a 6-year-old girl presenting with progressive paraparesis. A midthoracic intramedullary mass was revealed on myelography and magnetic resonance (MR) imaging and confirmed as an intramedullary epidermoid cyst at surgery, at which time the cyst was removed. This is the fourth report documenting a purely intramedullary epidermoid cyst occurring in a child. The pathology and etiology, epidemiology, clinical features, radiology (including MR image characteristics), and surgical treatment of such rare intramedullary benign tumors are discussed. Magnetic resonance imaging reduces the delay in diagnosis of spinal cord tumors but should be guided by clinical judgment.

Molecular characterization of a dense granule antigen (Gra 2) associated with the network of the parasitophorous vacuole in Toxoplasma gondii

The monoclonal antibody (mAb) TG17.179 recognizes an excreted-secreted antigen (ESA) of 28.5 kDa named Gra 2, which is stored in the dense granules of Toxoplasma cells and secreted into the parasitophorous vacuole after host cell invasion. Screening of an expression cDNA library with TG17.179 led to the isolation of several clones, the longest one (clone L) being of 1030 bp. Clone L cDNA was found to be homologous to a previously described composite cDNA encoding a P28 protein of Toxoplasma gondii. Characterization of one genomic clone indicates that the complete GRA 2 gene is about 1.3 kb in length, including an intron of 241 bp. Northern blot and primer extension analyses confirmed the size of the mature messenger (1.1 kb). Amino acid partial sequencing of the native antigen purified by HPLC and metabolic radiolabelings of ESAs perfectly matched the primary amino acid structure deduced from the clone L cDNA. This primary translation product consists of an 185 amino acid polypeptide (19.8 kDa) including a 23 amino acid signal sequence. The presence of many serine and threonine residues may indicate an O-glycosylation. The predicted mature polypeptide shows an internal helical domain with 2 amphipathic alpha-helices. These might be involved in the association of Gra 2 with the membranous network within the parasitophorous vacuole.