Abstract S5-6: Steroid Hormone Regulation of Mammary Stem Cell Function

Background: The ovarian hormones estrogen and progesterone profoundly influence breast cancer risk, underpinning the benefit of endocrine therapies in the treatment of breast cancer. Modulation of their effects through ovarian ablation or chemoprevention strategies also significantly decreases breast cancer incidence. Conversely, there is an increased risk of breast cancer associated with pregnancy in the short-term. The cellular mechanisms underlying these observations, however, are poorly defined. We and others recently isolated mammary epithelial populations enriched for mammary stem cells (MaSCs), committed luminal progenitor and mature luminal cells from both mouse and human mammary glands. Unexpectedly, MaSCs exhibited a receptor-negative phenotype for ERα , PR and ErbB2. Given the central important of estrogen and progesterone signaling to mammary gland development and cancer, we sought to determine whether these hormones could indirectly modulate MaSC function. Methods and Results: We utilized mouse models to directly study the effects of steroid hormones on the in vivo repopulating ability of MaSCs. Ovariectomy markedly diminished MaSC number and the extent of ductal outgrowth in vivo. The relative contribution of estrogen and progesterone to the regulation of MaSC activity was next examined using hormone pellets or antagonists. MaSC activity increased in animals treated with both estrogen and progesterone. Remarkably, even three weeks of treatment with the aromatase inhibitor letrozole was sufficient to reduce the MaSC pool. The outgrowth potential of these cells was again affected, suggesting that MaSCs retain a ‘memory’ of estrogen deprivation, perhaps through perturbation of their cycling status. Indeed, cell cycle analysis revealed an increase in the percentage of MaSC-enriched cells in G0/G1 in ovariectomized glands compared to controls. This was accompanied by a profound reduction in the expression of cell cycle genes including Cyclin D1.

We further evaluated the effect of the hormonal environment on MaSC function during pregnancy, where progesterone (and prolactin) have prominent roles. Pregnancy led to a transient 11-fold increase in MaSC numbers. This was accompanied by marked elevation in the expression of the progesterone target gene RANK ligand in luminal cells, together with its receptor RANK in the MaSC-containing population. To determine whether MaSC activity is in part mediated through paracrine signals from RANK ligand, inhibitors of RANK signaling were evaluated. Treatment of virgin or pregnant mice with an anti-RANK ligand monoclonal antibody in vivo significantly impaired the clonogenic activity of the MaSC-enriched but not luminal subpopulation.

Discussion: Despite lacking the steroid hormone receptors ERα and PR, MaSCs appear to be exquisitely sensitive to hormone signaling, presumably via paracrine signaling that includes the RANK signaling pathway. The augmented MaSC pool during pregnancy suggests a cellular basis for the short-term increase in breast cancer incidence following pregnancy. Our findings further indicate that breast cancer chemoprevention may in part be achieved through suppression of MaSC function. We speculate that inhibitors of RANK and other stem cell signaling pathways could represent potential chemoprevention agents.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr S5-6.

Abstract P4-04-03: Transcriptome Analyses of Mouse and Human Mammary Cell Subpopulations Reveals Multiple Conserved Genes and Pathways

INTRODUCTION: Molecular characterization of the normal epithelial cell types that reside in the mammary gland is an important step toward understanding pathways that regulate self-renewal, lineage commitment, and differentiation along the hierarchy. We previously reported distinct stages in human mammary epithelial cell development and linked them to breast tumor subtypes previously defined by gene expression profiling. Here we determined the gene expression signatures of four distinct subpopulations isolated from the mouse mammary gland. The epithelial cell signatures were used to interrogate mouse models of mammary tumorigenesis and to compare with their normal human counterpart subsets to identify conserved genes and networks.

METHODS: RNA was prepared from freshly sorted mouse mammary cell subpopulations (mammary stem cell (MaSC)-enriched, committed luminal progenitor, mature luminal and stromal cell) and used for gene expression profiling analysis on the Illumina platform. Gene signatures were derived and compared with those previously reported for the analogous normal human mammary cell subpopulations. The mouse and human epithelial subset signatures were then subjected to Ingenuity Pathway Analysis (IPA) to identify conserved pathways.

RESULTS: The four mouse mammary cell subpopulations exhibited distinct gene signatures. Comparison of these signatures with the molecular profiles of different mouse models of mammary tumorigenesis revealed that tumors arising in MMTV-Wnt-1 and p53-/- mice were enriched for MaSC-subset genes, whereas the gene profiles of MMTV-Neu and MMTV-PyMT tumors were most concordant with the luminal progenitor cell signature. Comparison of the mouse mammary epithelial cell signatures with their human counterparts revealed substantial conservation of genes, whereas IPA highlighted a number of conserved pathways in the three epithelial subsets.

CONCLUSIONS: The conservation of genes and pathways across species further validates the use of the mouse as a model to study mammary gland development and highlights pathways that are likely to govern cell-fate decisions and differentiation. It is noteworthy that many of the conserved genes in the MaSC population have been considered as epithelialmesenchymal transition (EMT) signature genes. Therefore, the expression of these genes in tumor cells may reflect basal epithelial cell characteristics and not necessarily cells that have undergone an EMT. Comparative analyses of normal mouse epithelial subsets with murine tumor models have implicated distinct cell types in contributing to tumorigenesis in the different models.

Figures available in online version.

A serological survey of antibodies against bovine herpesvirus-1 in yak (Poephagus grunniens) in Arunachal Pradesh in India

Serum samples were collected from 254 yak (Poephagus grunniens, presently Bos grunniens) in different yak tracts of India. These samples were then screened by virus neutralisation test (VNT) and avidin-biotin enzyme-linked immunosorbent assay (AB-ELISA) to study the seroprevalence of antibodies against bovine herpesvirus type 1 (BHV-1). The overall seroprevalence in yak was found to be 41% (105) by VNT and AB-ELISA. The sex of the animal, whether it was on a farm or free-ranging and the location of the different yak tracts did not seem to have any effect on seroprevalence. However, seroprevalence was found to increase with the age of the animals, being highest in yak older than three years of age (49%). Yak generally share feeding, watering and grazing areas with other domestic and wild animals and this common ecological niche is thought to be a possible avenue of infection. This is the first time that the seroprevalence of antibodies against BHV-1 has been studied in yak in India.

A numerical study of failure mechanisms in the cemented resurfaced femur: effects of interface characteristics and bone remodelling

Failure mechanisms of the resurfaced femoral head include femoral neck fracture in the short-term and stress shielding and implant loosening in the long-term. In this study, finite element simulations of the resurfaced femur considering a debonded implant-cement interface, variable stem-bone interface conditions, and bone remodelling were used to study load transfer within the resurfaced femur and to investigate its relationship with known failure mechanisms. Realistic three-dimensional finite element models of an intact and resurfaced femur were used. Various conditions at the interface between the stem of the prosthesis and the bone were considered. Loading conditions included normal walking and stair climbing. For all stem-bone contact conditions, the tensile stresses in the cement mantle varied between 1 MPa and 5.4 MPa, except near the distal rim of the resurfacing component where they reached 5.4-7MPa. In the case of full stem-bone contact, high von Mises stresses (114-121MPa) were generated in the implant at the stem-cup junction. These stresses were considerably reduced (maximum von Mises stress, 76 MPa) where a gap was present at the stem-bone interface. Resurfacing led to strain shielding of the bone of the femoral head (20-75 per cent strain reductions) and periprosthetic bone resorption (50-80 per cent bone density reductions) for all interface stem-bone contact conditions. In the lateral femoral head and the proximal femoral shaft around the trochantric region, bone density reductions varied between 10 per cent and 50 per cent. Bone apposition was observed in the inferior-medial part of the femoral head and proximal femoral neck region. For full stem-bone contact, more load was transferred through the stem to the surrounding bone, exacerbating strain shielding. Although femoral hip resurfacing conserves bone stock at the primary operation, strain shielding and periprosthetic bone resorption might lead to eventual loosening over time. Post-operatively, the resurfacing procedure generated elevated strains (0.50-0.75 per cent strain) in the proximal femoral neck-component junction irrespective of the variation in interface conditions, indicating an initial risk of femoral neck fracture. Subsequent to bone remodelling, this strain concentration was considerably reduced (0.35-0.50 per cent strain), lowering the risk of neck fracture. In order to reduce the potential risk of neck fracture, patients should avoid activities which might induce high loading of the hip during the early post-operative period to allow the bone around the proximal femoral neck to remodel and heal.

Investigation of human mammary stem and progenitor subpopulations from BRCA1 mutation carriers and noncarriers

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Background: We have previously isolated discrete populations of mouse mammary epithelial cells (MECs) and defined a population that expresses ‘basal’ markers and is highly enriched for mammary stem cells. This subset was ‘triple negative’ for ER, PR and ErbB2 expression and is reminiscent of the basal subtype of breast cancer, suggesting that the mammary stem cell may be the ‘cell of origin’ for this poor prognosis group. Since tumors arising in BRCA1 mutation carriers often exhibit a ‘basal’ phenotype, we hypothesized that the mammary stem cell pool is aberrant in these women. Our objective was to define the human MEC hierarchy and evaluate the functional characteristics of MECs from BRCA1± and normal breast tissue. Methods: Single cell suspensions prepared from fresh human BRCA1± and normal breast tissue were sorted by flow cytometry. Hematopoietic (CD45+, CD235a+) and endothelial (CD31+) cells were removed, and the remaining viable ‘lineage minus’ (Lin-) MECs fractionated based on cell surface markers. These subpopulations were evaluated by immunostaining, RNA profiling, in vitro culture in Matrigel and in vivo xenotransplantation into ‘humanised’ mammary fat pads of immunocompromised mice. Results: Lin- cells fractionated with α6-integrin (CD49f) and epithelial cell adhesion molecule (EpCAM) revealed three discrete MEC subpopulations. A stem/progenitor population that preferentially yields breast outgrowths in vivo has been identified. These subpopulations gave rise in vitro to colonies that were either large and heterogenous or small and homogenous. Only the latter differentiated into milk-producing cells when exposed to lactogenic stimuli. Immunostaining confirmed their origins from myoepithelial and luminal progenitor cells respectively. Intriguingly, BRCA1± MECs exhibited perturbed in vitro growth properties when compared to normal controls. Conclusions: Our studies provide evidence for a human MEC hierarchy, a model to interrogate the perturbation noted in pre-neoplastic tissue derived from BRCA1 mutation carriers and the identification of the cell of transformation in BRCA1 associated breast cancer. These findings may have implications on developing prevention strategies for hereditary breast cancer.

No significant financial relationships to disclose.

Phenotypic progression in X-linked retinitis pigmentosa secondary to a novel mutation in the RPGR gene

PURPOSE

To report phenotypic progression for a novel mutation in the RPGRgene causing X-linked retinitis pigmentosa (RP), and describe the phenotype in affected males and females.

METHODS

Bidirectional fluorescent sequencing analysis was used to screen for mutations in RPGR. Five affected males and eight affected females from two English families underwent refraction, ETDRS visual acuity, OCT imaging, and Goldmann visual field testing.

RESULTS

DNA analysis identified a novel c.350G>A sequence change in exon 5 of RPGR. The change segregated with disease in both families. For affected males there was a significant correlation between age and visual acuity (r=-0.91, P=0.034), and a non-significant correlation between age and visual field area (r=-0.56, P=0.4). For affected females, there was a significant correlation between age and visual acuity (r=-0.8, P=0.018), and between age and visual field area (r=-0.94, P=0.005). All affected females were highly myopic. No correlation between retinal thickness, and either age or sex was noted.

CONCLUSION

This novel mutation in RPGRcauses X-Linked RP with complete penetrance in males and females. Affected females are highly myopic but retain better visual function than affected males. The phenotypic data can be used to provide a mutation-specific visual prognosis, and may also help recognition of the genotype.

Phospholipid microspheres: a novel delivery mode for targeting antileishmanial agent in experimental leishmaniasis

Novel phospholipid microspheres were prepared from polylactic-co-glycolic acid (PLGA) and phosphatidyl ethanol amine in the molar ratio 1:71, to deliver drugs to macrophages in experimental leishmaniasis. Liposomes, well known as drug carrier systems, made from phosphatidylethanolamine, cholesterol and dicetyl phosphate in the molar ratio 7:2:1, were used as control, in order to compare the efficacies of the two carriers. As such, the membrane fluidity of the two carriers was kept at comparable levels by adjusting chemical composition. Moreover, because of the presence of mannosyl fucosyl receptors on macrophages, attempts were made to target an optically active synthetic compound dihydroindolo [2,3-a] indolizine, an antileishmanial agent, intercalated in both mannose-grafted liposomes and mannose-grafted microspheres. When tested for efficacy in lowering parasite load in the spleen, as well as in reducing the hepatic and renal changes associated with infection, the drug intercalated mannose-grafted microspheres were found to be the most active in comparison to drug intercalated liposomes or to the free drug. Thus, mannose-grafted microspheres may have possible application in the clinics not only in visceral leishmaniasis, but also in other macrophage-associated disorders.

Expression, purification, crystallization and preliminary crystallographic analysis of recombinant pteridine reductase of Trypanosoma cruzi

The recombinant version of Trypanosoma cruzi pteridine reductase was expressed in Escherichia coli, purified to homogeneity from the soluble fraction of bacterial extract by metal-chelate affinity chromatography and crystallized in the presence of the cofactor (NADPH) and an inhibitor (methotrexate) at 295 K using sodium acetate as precipitant. The crystals are trigonal, belonging to space group P3(1) (or P3(2)), with unit-cell parameters a = 74.35, c = 179.96 A under cryogenic conditions. The asymmetric unit contains a tetramer, with a corresponding V(M) of 2.3 A(3) Da(-1)and a solvent content of 46%. Native data have been collected to 2.1 A resolution using Cu Kalpha X-rays.

Antibacterial activity of Bergenia ciliata rhizome

The methanol extract of Bergenia ciliata (tested at 200--1000 microg/disc) showed a wide spectrum of concentration-dependent antibacterial activity.

Perceived risks of joint infection following intra-articular corticosteroid injections: a survey of rheumatologists

There are no clear published data on the risks of bacterial arthritis following intra-articular corticosteroid injections. Forty rheumatologists were given a detailed questionnaire; 32 (response 80%) completed questionnaires were analysed. On the basis of recalled cases of post-injection joint infection we estimate this risk to be low, at 4.6/100,000 injections.

Tele-rheumatology: telephone follow up and cyberclinic

This paper reviews here the main practical applications of telemedicine with particular reference to telephone care by health professionals to patients. A pilot project of out-patient telephone follow-up service for continuity of ambulatory rheumatology patients is described and recommendations are provided for those keen to develop such a service. In a later section newer technologies such as the potential practical applications of the internet and e-mail are described with the setting up of a cyber project for rheumatology and osteoporosis patients. It is noted that despite enthusiasm and development of such new projects, conventional clinicians need further longer term observation to grasp the advantages and pitfalls before more widespread use of telemedicine becomes commonplace.

A review of accident and emergency attendances for non-traumatic musculo-skeletal complaints

As there have been no previous studies, we undertook a systematic review to determine the number and nature of musculo-skeletal complaints presenting to casualty departments, review the appropriateness of treatment and referrals to other departments and also to identify potential problem areas so as to address these. Over the review period of 40 non-consecutive days, the total attendance was 2863 patients of which 85 (2.97%) presented with musculo-skeletal complaints. The majority (691) were in the age group of 20-59 years. Most complaints were in the back (26), neck (11), chest (10), shoulder (8), knee (8). Main complaints were pain (78), tenderness (10), swelling (9), stiffness (9), reduced movements (8) or a combination thereof; the rest were miscellaneous, e.g. pyrexia, headache and paraesthesia. The majority had a duration of symptoms from 1 to 7 days. Investigations at the casualty department were radiographs (29), full blood count (6), biochemistry (6), erythrocyte sedimentation rate (ESR) (1), blood culture (1), electrocardiogram (ECG) (7), and joint aspiration (2). Advice was sought from orthopaedic (2), rheumatology or general medicine (0), or other departments (2). Casualty diagnoses were mainly non-inflammatory conditions. Treatment given included analgesics/non-steroidal inflammatory drugs (NSAIDs) (44), splints and slings (5), Tubigrip (6), and collars (5). Only two patients (2.4%) were admitted. We were pleasantly surprised to note very small numbers of patients with inflammatory conditions, possibly indicating previous optimal management in our locality. A surprising finding was the lack of any attendance with gout. More direct referrals to orthopaedic or rheumatology departments would be appropriate in some instances. As a result of this review, we decided to offer short courses on musculo-skeletal medicine for new casualty officers and we have also produced guidelines/algorithm for management which would be equally useful for general practitioners.

Orbital cellulitis caused by Fusobacterium necrophorum

PURPOSE

To report the case of a previously healthy young female who developed orbital cellulitis caused by Fusobacterium necrophorum. We are unaware of previous reports of this condition caused by the same anaerobic, gram-negative, nonsporeforming bacterium and could find no reference to it in a computer search using MEDLINE.

METHODS

Case report.

RESULTS

In the case of orbital cellulitis presented here, the patient required 3 sinus debridement operations and 30 days of intravenous antibiotics. Despite this, her vision did not fully recover.

CONCLUSION

F. necrophorum is capable of causing severe orbital disease that requires aggressive and prompt treatment to preserve sight.

Reactivity of some sugars and sugar phosphates towards gold(III) in sodium acetate-acetic acid buffer medium

The kinetics of the oxidation of some aldoses and aldose phosphates have been studied spectrophotometrically in sodium acetate-acetic acid buffer medium at different temperatures. The reactions are first order with respect to [Au(III)] and [substrate]. Both H+ and Cl- ions retard the reaction. The reactions appear to involve different gold(III) species, viz. AuCl4-, AuCl3(OH2) and AuCl3(OH)- . The results are interpreted in terms of the probable intermediate formation of free radicals and Au(II). Aldoses react with gold(III) in the order: triose > tetrose > pentose > hexose. The sugar phosphates react with gold(III) at a faster rate than the parent sugars except glucose-1-phosphate, which reacts at slower rates than glucose. A tentative reaction mechanism leading to the formation of products has been suggested.

Binding of 5-(2'-carboxyphenyl)azoquinolin-8-ol to bovine serum albumin: a spectroscopic study

Dye-protein interactions are of immense importance in dye-ligand chromatography of protein purification. In this type of interactions, the structure of the dye molecules has a significant role. However, studies on the structure of these ligands are scanty. Therefore, we have spectroscopically investigated interactions of three 5-(aryl)azoquinolin-8-ol derivatives, which could be used as potent chelate forming agents, with bovine serum albumin (BSA). Among these, the carboxy derivative, 5-(2'-carboxyphenyl)azoquinolin-8-ol (CPAQ) has been selected for resonance Raman study. It has been shown that BSA has six independent binding sites for CPAQ at pH 7.2, the binding constant being 6.2 x 10(3) M(-1). Assignments of Raman modes of bound CPAQ are also presented. It has also been shown that bound CPAQ exists exclusively in hydrazone form. Results further demonstrate that the azo group nitrogen adjacent to the phenyl ring probably participated in the formation of a BSA-CPAQ complex.

How is gout managed in primary care? A review of current practice and proposed guidelines

Twelve practices with a total list of 74,111 patients were audited; 429 patients were identified with a diagnosis of gout. A wide variation in various clinical and laboratory assessments was detected. Similar variations were also noted regarding dietary advice and medical treatment. Monitoring of patients was infrequent. As a result of this audit, guidelines are proposed to improve the diagnosis and management of gout in the community.

Corticosteroids do not alter the threshold for vertebral fracture

Corticosteroid use is one of the most important secondary causes of osteoporosis. Generally, it has been believed that in addition to its effect on bone mineral density (BMD), it also causes an alteration in bone quality that means that fractures occur at a lower BMD than might be expected. To establish if this is the case, we have compared the relationship between BMD and vertebral fracture in patients receiving corticosteroids with that in patients who had never received such therapy. Information was gathered on those patients who had been referred to the participating centers and had both BMD measurements and lateral thoracolumbar radiographs. In all, 452 patients (391 female) were identified; of these 82 (63 female) were receiving corticosteroids. There was no significant difference in BMD between the patients on corticosteroids and those with other suspected causes of osteoporosis. Vertebral fractures were present in 53% of patients on steroids compared with 35% of those who had no such treatment (p = 0.0035). The fractures were more likely to be multiple in patients on corticosteroids (p = 0.0042). However, if the relationship between bone density and fracture is investigated by plotting the cumulative prevalence of fracture against the bone density, measured by T score, the median BMD for fractures actually was marginally lower in patients on steroids, -2.74 (95% confidence interval [CI], -2.77 to -2.70) compared with -2.65 (95% CI, -2.66 to -2.65) in those who had not received steroids. Our results fail to support the notion that the fracture threshold is altered in patients on long-term steroids and suggest that the same diagnostic criteria should be used for osteoporosis in patients whether or not they are taking corticosteroid therapy.

Is routine synovial fluid analysis necessary? Lessons and recommendations from an audit

This audit of 408 synovial fluid samples, analysed for cell counts and crystals, revealed that crystals were present in only 25 samples (6.1%). Of these, in only three patients was the diagnosis uncertain and therefore the analysis helpful. Cell counts and types generally reflected known underlying diagnoses of inflammatory arthritis or osteoarthritis. Routine synovial fluid analysis does not contribute to diagnosis or management in established rheumatic disorders and should be performed only when the underlying cause is uncertain or in newly presenting patients. Major savings can be made by abandoning routine synovial fluid analysis.

Increased prevalence of sicca complex and fibromyalgia in patients with irritable bowel syndrome

OBJECTIVE

As many as 70% of patients with fibromyalgia complain of the symptoms of irritable bowel syndrome (IBS), but there is a clinical impression that IBS patients do not suffer from fibromyalgia as frequently. The sicca complex (dry eyes and mouth) is also commonly observed in fibromyalgia, but its prevalence in IBS has not been evaluated. Our objective was to assess the frequency of fibromyalgia and sicca complex in secondary care patients with IBS.

METHODS

Forty-six secondary care patients with IBS and 46 healthy controls were assessed by a rheumatologist for the presence of fibromyalgia and objective evidence of sicca complex (Schirmer and Rose-Bengal tests). Psychological status was also assessed (HAD questionnaire).

RESULTS

Thirteen (28%) IBS patients suffered from fibromyalgia, compared with five (11%) controls, a difference of 17% (95% confidence intervals [CI], 2-33%). Fifteen (33%) IBS patients versus three (6%) controls had sicca complex, a difference of 27% (95% CI, 11-45%).

CONCLUSIONS

These results suggest that the prevalence of fibromyalgia in IBS is approximately half that of IBS in fibromyalgia. Furthermore, sicca complex seems to be another complaint that should be added to the list of extracolonic manifestations of IBS. Study of the overlap between functional disorders presenting to different specialties may give new insights into the pathophysiology of these puzzling conditions.

Mapping of a palmitoylatable band 3-binding domain of human erythrocyte membrane protein 4.2

Evidence accumulated over the years suggests that human erythrocyte membrane protein 4.2 is one of the proteins involved in strengthening the cytoskeleton-membrane interactions in the red blood cell. Deficiency of protein 4.2 is linked with a variety of hereditary haemolytic anaemia. However, the interactions of protein 4.2 with other proteins of the erythrocyte membrane remain poorly understood. The major membrane-binding site for protein 4.2 resides on the cytoplasmic domain of band 3 (CDB3). In order to carry out an initial characterization of its interaction with the CDB3, protein 4. 2 was subjected to proteolytic cleavage and gel renaturation assay, and the 23-kDa N-terminal domain was found to interact with band 3. This domain contained two putative palmitoylatable cysteine residues, of which cysteine 203 was identified as the palmitoylatable cysteine. Recombinant glutathione S-transferase-fusion peptides derived from this domain were characterized with respect to their ability to interact with the CDB3. Whereas these studies do not rule out the involvement of other subsites on protein 4.2 in interaction with the CDB3, the evidence suggests that the region encompassing amino acid residues 187-211 is one of the domains critical for the protein 4.2-CDB3 interaction. This is also the first demonstration that palmitoylation serves as a positive modulator of this interaction.

Acute inflammatory (non-purulent) arthritis concomitant with a developing breast abscess

A 34 year old female presented 7 weeks post-partum with acute diffuse arthritic manifestations and pyrexia. Extensive investigations (grossly raised erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], normal serology and others) were performed to pursue a diagnosis. Subsequently a breast abscess was diagnosed. Surgical treatment of this led to almost immediate resolution of the joint complaints and return of ESR/CRP to normal levels. This was considered a hitherto unreported case of acute non-purulent inflammatory arthritis concomitant to an existing infection elsewhere in the body. The pathogenic mechanism is unclear but speculatively toxin-mediated.

A cyberclinic in rheumatology

OBJECTIVE

To evaluate the feasibility of a rheumatology consultation and advisory service using internet and e-mail.

METHODS

We placed a detailed rheumatology proforma on our website for general practitioners to complete and e-mail to our outpatients clinic. To study its feasibility, two junior doctors interviewed and completed the proforma for 207 new patients. Based on this information, the consultant provided provisional diagnoses, work up & management plans, which were then compared with those drawn up following face-to-face assessment of the same patients in the outpatients clinic.

RESULTS

In most instances the pre- and post-examination diagnoses, work up & management plans were similar. Diagnostic concurrence was noted in 178 (86%) patients; no changes were required in x-rays and other tests requested in 129 (62%) patients; and the suggested treatment (including corticosteroid injections) remained the same in 153 (74%) patients.

CONCLUSION

Our results suggest that it is feasible to offer an e-mail or internet based outpatients consultation and advisory service in rheumatology and possibly other disciplines.

What counselling do patients with ankylosing spondylitis receive? Results of a questionnaire survey

This questionnaire survey of 71 patients with ankylosing spondylitis (members of the National Ankylosing Spondylitis Society of the UK) revealed that a substantial proportion of patients were apparently not told of several aspects of their illness by their doctors such as likely cause(s), familial clustering, role of HLA tissue typing and diet (appropriately). Only a small percentage (4.2%) were counselled to actively seek screening for close family members. As HLA B27 presence is not diagnostic of ankylosing spondylitis, and it cannot be prevented or arrested even if diagnosed at onset or early stages, routine screening of close family members cannot be justified at present.

Why do outpatients fail to keep their clinic appointments? Results from a survey and recommended remedial actions

We undertook a survey of 2555 outpatients (both new and review) to look at the reasons for high non-attendance (DNA) rates. Completed questionnaires (n = 983, 38.5% response) indicated the main reasons: forgetting or not receiving the appointment because of illness, and less often because of feeling better; transport problems; and short notice. Our remedial actions included improving the clerical system, announcing DNA rates on a regular basis in GP surgeries and in the outpatient department, introducing a tear-off slip with the appointment letter for patients to return, installing a free answerphone, active GP/consultant involvement in DNA-related problems and local publicity campaigns. A new scheme in our trust--outpatient telephone follow-up--may also help in reducing DNA rates.

An audit of post fracture rehabilitation with special emphasis on osteoporosis assessment and treatment

OBJECTIVE

To study the outcome of osteoporosis assessment and rehabilitation in post-fracture patients.

METHODS

This was a retrospective survey of the records of patients who had been referred to us from orthopaedic departments for rehabilitation after a fracture.

RESULTS

A significant number of patients had had previous fractures (n = 17) or risk factors for osteoporosis (n = 16). The mortality rate was 4%. A significant proportion of patients (9/44) who had been living in their homes required placement in residential or nursing homes and additional care after rehabilitation.

CONCLUSION

Our audit showed that post-fracture patients received optimum care, as set out in the Royal College of Physicians guidelines, but could benefit additionally from assessment and treatment of osteoporosis as set out in the Department of Health (DOH) Guidelines.

Response to low-dose interferon in chronic liver disease due to hepatitis B virus infection

BACKGROUND

Interferon is at present the only effective therapy for chronic hepatitis B virus (HBV) infection. Data regarding its efficacy in India are scant. The present study was undertaken to assess the efficacy of low-dose interferon in chronic liver disease due to HBV infection.

METHODS

Twenty four patients with histologic evidence of chronic hepatitis with or without cirrhosis, and persistent elevation of serum aminotransferases and persistent positivity for HBsAg and HBeAg for more than six months, were included. Fourteen patients were treated with interferon alpha-2b, 3 million units thrice weekly for 16 weeks; ten patients who could not afford the drug were followed up as controls without specific therapy. Patients were examined weekly for the first 4 weeks, followed by two weekly for 12 weeks and then every two months. Blood tests for viral markers and liver biochemistry were done at 0, 4, 8, 12, 16 weeks and then at two-month intervals for at least one year after therapy. Patients who cleared HBeAg were followed up for 2.2 (1-4) years for HBsAg clearance.

RESULTS

HBeAg clearance occurred in 9 patients (64%) in the interferon group, and in one control patient (p < 0.01). HBsAg clearance occurred in only one patient in the treatment group during follow up of mean 2.4 years. No patient in the control group cleared HBsAg. Patients having high ALT level at the beginning of treatment had significantly higher HBeAg clearance rate (7 of 7) than patients with low ALT levels (2 of 7; p < 0.05).

CONCLUSION

Low-dose interferon therapy is effective in attaining HBeAg, but not HBsAg, clearance in chronic HBV infection.

Spectroscopic characterization of gelonin--assignments secondary structure and thermal denaturation

Gelonin, a type 1 ribosome inactivating protein (RIP), having only one polypeptide chain, and which could be used against deadly diseases like cancer and AIDS is investigated spectroscopically through infrared (IR), diffused reflectance infrared fourier transform (DRIFT) and Raman techniques and observed vibrational modes are assigned. It is found that gelonin is having mainly alpha-helix and beta-sheet structure with some turn and disordered structure, the estimated percentage structure using Raman data being approximately 32% alpha-helix, approximately 20% beta-sheet, approximately 26% turn and approximately 22% disorder type. The temperature dependent infrared study of gelonin reveals its thermal stability, the denaturation temperature being around 60 degrees C and disordered contribution increasing with heating.

Weak association between subjective symptoms or and objective testing for dry eyes and dry mouth: results from a population based study

OBJECTIVES

To determine associations between symptoms of dry eyes and dry mouth and objective evidence of lacrimal and salivary gland dysfunction in a population based sample. To determine associations between these elements and the presence of autoantibodies.

METHODS

A cross sectional population based survey. Subjects were interviewed and examined (Schirmer-1 test and unstimulated salivary flow) for the presence of dry eyes and mouth. Antibodies (anti-Ro [SS-A], anti-La [SS-B], rheumatoid factor, antinuclear antibody) were measured.

RESULTS

341 subjects were examined. Twenty four per cent had dry eye symptoms, 29% dry mouth symptoms, and 14% both. There was only a weak association between the presence of oral or ocular symptoms and their respective test results. Associations were strongest between dry mouth symptoms and positive test results, and in subjects under 55 years of age. There was no association between the presence of autoantibodies and either symptoms or signs of dry eyes or dry mouth.

CONCLUSION

Only weak associations were found between self reported symptoms of dry eyes and dry mouth and objective measures said to define Sjögrens syndrome in the general population. The clinical significance of these symptoms in the community needs reappraisal.