Septic arthritis in a native joint due to Anaerococcus prevotii

A 37-year-old injecting drug user presented with signs and symptoms of septic arthritis. Staphylococcus aureus was grown from his blood cultures. Despite treatment with flucloxacillin and fusidic acid his condition continued to deteriorate. Echocardiography showed no signs of endocarditis. Culture of his knee aspirate grew Anaerococcus prevotii after 5 days of incubation. Metronidazole was added to his treatment regime. A collection of pus (800 ml) was drained from the right thigh and A prevotii was isolated. His condition improved gradually and he was subsequently transferred to a drug rehabilitation unit after completing his antibiotic course. The importance of anaerobic streptococci in septic arthritis, as a very rare cause, is highlighted.

Recombinant human acid [alpha]-glucosidase: major clinical benefits in infantile-onset Pompe disease

BACKGROUND

Pompe disease is a progressive metabolic neuromuscular disorder resulting from deficiency of lysosomal acid alpha-glucosidase (GAA). Infantile-onset Pompe disease is characterized by cardiomyopathy, respiratory and skeletal muscle weakness, and early death. The safety and efficacy of recombinant human (rh) GAA were evaluated in 18 patients with rapidly progressing infantile-onset Pompe disease.

METHODS

Patients were diagnosed at 6 months of age and younger and exhibited severe GAA deficiency and cardiomyopathy. Patients received IV infusions of rhGAA at 20 mg/kg (n = 9) or 40 mg/kg (n = 9) every other week. Analyses were performed 52 weeks after the last patient was randomized to treatment.

RESULTS

All patients (100%) survived to 18 months of age. A Cox proportional hazards analysis demonstrated that treatment reduced the risk of death by 99%, reduced the risk of death or invasive ventilation by 92%, and reduced the risk of death or any type of ventilation by 88%, as compared to an untreated historical control group. There was no clear advantage of the 40-mg/kg dose with regard to efficacy. Eleven of the 18 patients experienced 164 infusion-associated reactions; all were mild or moderate in intensity.

CONCLUSIONS

Recombinant human acid alpha-glucosidase is safe and effective for treatment of infantile-onset Pompe disease. Eleven patients experienced adverse events related to treatment, but none discontinued. The young age at which these patients initiated therapy may have contributed to their improved response compared to previous trials with recombinant human acid alpha-glucosidase in which patients were older.

Radical vaginal trachelectomy as a fertility-sparing procedure in women with early-stage cervical cancer-cumulative pregnancy rate in a series of 123 women

OBJECTIVE

To analyse the fertility rates, complications and recurrences in a group of women who have undergone radical vaginal trachelectomy and pelvic lymphadenectomy for early-stage cervical cancer.

DESIGN

An observational series.

SETTING

A Gynaecological Oncology Centre.

POPULATION

One hundred and twenty-three consecutive women who underwent radical vaginal trachelectomy and pelvic lymphadenectomy for early-stage cervical cancer.

METHODS

Data were collected prospectively. MAIN OUTCOME MEASURES Complications, recurrences, pregnancies and live births are presented as percentages of the total population. Fertility is presented as a 5-year cumulative rate, with women attempting to conceive as the denominator.

RESULTS

A total of 123 women were followed up for an average of 45 months. Eleven (8.9%) had completion treatment (two radical hysterectomies and nine chemoradiotherapy) at the time of initial treatment. There were three recurrences (2.7%) among the women who did not have completion treatment and two (18.2%) in those who did. There were 6 perioperative and 26 postoperative complications. Sixty-three women attempted pregnancy. There were 55 pregnancies in 26 women and 28 live births in 19. Three women had continuing pregnancies. The 5-year cumulative pregnancy rate among women trying to conceive was 52.8%. All but two women were delivered by classical caesarean section and seven (25.0%) babies were born at 31+6 weeks or less.

CONCLUSIONS

For selected women with early-stage cervical cancer, radical vaginal trachelectomy and pelvic lymphadenectomy are fertility-sparing options, with a low incidence of recurrence and acceptable cumulative conception rates. Complications are few, although there is a high premature labour and miscarriage rate among pregnant women.

Surgical morbidity associated with radical trachelectomy and radical hysterectomy

OBJECTIVES

To examine intra-operative, short and longer term morbidity associated with Radical Trachelectomy (RT) within our cohort of patients, compared with conventional Radical Hysterectomy (RH).

METHODS

A retrospective case note review comprising 29 RT and 50 RH patients. Patients who required adjuvant treatment were excluded. Operative data, short-term and long-term complications were recorded. Long-term problems were included only if they had been of persistent nature.

RESULTS

The median age and follow up period for the RH group were 40 years and 60 months and for RT group 30.5 years and 25 months. There were significant differences between RH and RT groups in median operative time (260 versus 187 min), blood loss (1000 versus 400 ml), transfusion requirement (75% versus 12%), analgesic requirement (8 versus 3.5 days) and hospital stay (11 versus 6 days). Bladder hypotonia requiring prolonged catheterisation was more frequent in RH group (P = 0.004). There was no apparent difference in psychosexual problems between the two groups (17 versus 16%). Complications of deep dyspareunia (P = 0.009), excessive vaginal discharge (P = 0.01), and upper thigh parasthesia (P = 0.05) were noted to be significantly higher in the RT group. Specific problems encountered in the RT group included; dysmenorrhea (24%), irregular menstruation (17%), recurrent candidiasis (14%), cervical suture problems (14%), isthmic stenosis (10%) and prolonged amenorrhea (7%).

CONCLUSION

RT is associated with less operative and short-term morbidity compared with conventional RH. In addition to specific complications associated with RT, in our experience, there are long-term morbidities that are not as commonly observed in RH.

Tbx1 haploinsufficiency is linked to behavioral disorders in mice and humans: implications for 22q11 deletion syndrome

About 35% of patients with 22q11 deletion syndrome (22q11DS), which includes DiGeorge and velocardiofacial syndromes, develops psychiatric disorders, mainly schizophrenia and bipolar disorder. We previously reported that mice carrying a multigene deletion (Df1) that models 22q11DS have reduced prepulse inhibition (PPI), a behavioral abnormality and schizophrenia endophenotype. Impaired PPI is associated with several psychiatric disorders, including those that occur in 22q11DS, and recently, reduced PPI was reported in children with 22q11DS. Here, we have mapped PPI deficits in a panel of mouse mutants that carry deletions that partially overlap with Df1 and have defined a PPI critical region encompassing four genes. We then used single-gene mutants to identify the causative genes. We show that PPI deficits in Df1/+ mice are caused by haploinsufficiency of two genes, Tbx1 and Gnb1l. Mutation of either gene is sufficient to cause reduced PPI. Tbx1 is a transcription factor, the mutation of which is sufficient to cause most of the physical features of 22q11DS, but the gene had not been previously associated with the behavioral/psychiatric phenotype. A likely role for Tbx1 haploinsufficiency in psychiatric disease is further suggested by the identification of a family in which the phenotypic features of 22q11DS, including psychiatric disorders, segregate with an inactivating mutation of TBX1. One family member has Asperger syndrome, an autistic spectrum disorder that is associated with reduced PPI. Thus, Tbx1 and Gnb1l are strong candidates for psychiatric disease in 22q11DS patients and candidate susceptibility genes for psychiatric disease in the wider population.

Comparison of haloacetic acids in the environment of the Northern and Southern Hemispheres

Haloacetic acids (HAAs) are a family of compounds whose environmental concentrations have been extensively studied, primarily in Europe. Depending on the compound, their sources are believed to be both natural and anthropogenic. To better understand possible sources and contribute to the knowledge of the global distribution of these compounds, especially between the Northern and Southern Hemispheres, samples of precipitation, soils, and conifer needles were collected from Canada, Malawi, Chile, and the U.K. Precipitation samples exhibited highest HAA concentrations in collections from Canada, and lowest in those from Malawi. Malawi samples contained measurable levels of monobromoacetic acid (MBA) (56 ng/ L) unlike those from most other locations (< 9 ng/L). Soil HAA concentration levels were highest in the U.K. (e.g., 7.3 ng/g average TCA) and lowest in Malawi (0.8 ng/g average TCA), with Chile having higher levels (4.8 ng/g average TCA) than Canada (3 ng/g average TCA). Malawi soils contained small amounts of MBA (2 ng/g), in common with the two most southern of the 11 Chilean sites. Analysis of soil cores (10-cm depth sliced at 1 cm) from sites in Malawi and Chile showed that trichloroacetic acid (TCA) generally declined with depth while mono- and dichloroacetic acid (MCA and DCA) showed no trend. MCA, DCA, and TCA concentrations in archived U.K. soil samples increased by factors of 2, 4, and 5-fold over 75 years while TFA showed no consistent trend. Monochloroacetic acid (MCA) was detected in pine needles collected from Malawi. U.K. needle samples had the highest concentrations of all chloroacetic acids (CAAs): MCA, 2-18 ng/g; dichloroacetic acid (DCA), 2-38 ng/g; and trichloroacetic acid (TCA), 28-190 ng/g. Conifer needles from Canada and Chile contained CAAs at levels ranging from < 2 to 16 ng/g wet wt. Trifluoroacetic acid concentrations generally declined with increasing elevation in the samples from the Rocky Mountains in western Canada. The results indicate that concentrations of HAAs are greatest in the industrialized Northern Hemisphere but there are significant amounts of these compounds in the less industrialized Southern Hemisphere.

Development of anti-human leukocyte antigen class 1 antibodies following allogeneic islet cell transplantation

Currently there is minimal concern that islet allograft failure could result from the development of anti-human leukocyte antigen (HLA) antibodies reactive to the allograft. We report here a case of islet allograft failure where the recipient developed immunoglobulin G anti-HLA class I antibodies reactive to HLA antigens present in two of the three islet cell donors. The patient had no detectable anti-HLA antibodies prior to the transplant but these antibodies were detected approximately 4 months posttransplant. Of concern, these antibodies developed despite induction with anti-IL2R antibodies (Zenapex) prior to intraportal islet cell infusion, low-dose tacrolimus (12-hour troughs 3 to 5 ng/mL) and rapammune (target troughs 12 to 15 ng/mL). The patient was not presensitized with blood products or a previous allograft. Her husband, however, shared antigens present in one of the islet donors and the recipient could have been presensitized to her husband during her two pregnancies. This case clearly demonstrates that islet allografts can lead to development of anti-HLA antibodies, which can cause islet allograft failure, as is the case with solid organ transplants, and hence emphasizes the need to monitor for such antibodies pre- and posttransplant. Additionally it appears that currently recommended immunosuppression may not be sufficient to inhibit a humoral response to both alloantigens and autoantigens.

Trifluoroacetate profiles in the Arctic, Atlantic, and Pacific Oceans

A series of depth profiles was collected at 22 sites in the Arctic, North and South Atlantic, and Pacific Oceans to determine spatial patterns for trifluoroacetate (TFA) concentrations in the marine environment and to investigate possible natural sources of TFA. Profiles were also taken over underwater vents in the North and South Pacific and the Mediterranean Sea. At the profile sites, TFA values ranged from <10 ng/L in the Pacific Ocean to greater than 150 ng/L in the Atlantic Ocean. Samples from the Canada Basin of the Arctic Ocean exhibited variable TFA concentrations (60-160 ng/L) down to 700 m. Below this depth, in water having 14C ages exceeding 1000 years, the TFA concentrations were constant (150 ng/L). Water returning to the Atlantic through the Canadian Arctic Archipelago had constant high TFA values. Profiles from the Northern Atlantic exhibited high values at all depths but were more consistent in the Western Atlantic. The northwestern Pacific Ocean surface profile sites exhibited low TFA concentrations in the top 100 m increasing to a maximum of 60 ng/L with depth. Samples from the South Pacific Ocean site had generally low values with a few depths (>800 m) having concentrations of 50 ng/L or more. To determine if underwater vents could contribute to the TFA concentrations in the oceans, profiles were taken over three vents in the Pacific and Mediterranean Oceans. The results suggest that some deep-sea vents may be natural sources of TFA.

A group intervention which assists patients with dual diagnosis reduce their drug use: a randomized controlled trial

BACKGROUND

There is a well-recognized association between substance use and psychotic disorders, sometimes described as 'dual diagnosis'. The use of substances by people with psychosis has a negative impact in terms of symptoms, longitudinal course of illness and psychosocial adjustment. There are few validated treatments for such individuals, and those that do exist are usually impracticable in routine clinical settings. The present study employs a randomized controlled experimental design to examine the effectiveness of a manualized group-based intervention in helping patients with dual diagnosis reduce their substance use.

METHOD

The active intervention consisted of weekly 90-min sessions over 6 weeks. The manualized intervention was tailored to participants' stage of change and motivations for drug use. The control condition was a single educational session.

RESULTS

Sixty-three subjects participated, of whom 58 (92%) completed a 3-month follow-up assessment of psychopathology, medication and substance use. Significant reductions in favour of the treatment condition were observed for psychopathology, chlorpromazine equivalent dose of antipsychotics, alcohol and illicit substance use, severity of dependence and hospitalization.

CONCLUSIONS

It is possible to reduce substance use in individuals with psychotic disorders, using a targeted group-based approach. This has important implications for clinicians who wish to improve the long-term outcome of their patients.

Behavioral characterization of mouse models for Smith-Magenis syndrome and dup(17)(p11.2p11.2)

Contiguous gene syndromes (CGS) refer to a group of disorders associated with chromosomal rearrangements in which the phenotype is thought to result from altered copy number of physically linked dosage-sensitive genes. Smith-Magenis syndrome and [dup(17)(p11.2p11.2)] are CGS associated with a heterozygous deletion or duplication of band p11.2 of chromosome 17, respectively. We previously constructed animal models for these CGSs by engineering rearranged chromosomes carrying a deletion/deficiency [Df(11)17] (Del mutant) or a duplication [Dp(11)17 ] (Dup mutant) of the syntenic region on mouse chromosome 11. Here we present a behavioral analysis of these models indicating that heterozygous male mice carrying the engineered deletion or the duplication are hypoactive or hyperactive, respectively. In addition, male Dup mutant mice, but not Del mutant mice, have impaired contextual fear conditioning. Circadian rhythm studies revealed period length differences in Del mutant mice, but not Dup mutant mice. These results indicate that some of the behavioral abnormalities are gene dosage sensitive, whereas other behavioral abnormalities are specific to mice carrying the deletion or the duplication and can be observed in a sex preferential manner. Our findings suggest that there is a gene(s) present in this defined genomic interval that is responsible for behavioral abnormalities in the mouse, as has been shown for the human syntenic region.

Mice with truncated MeCP2 recapitulate many Rett syndrome features and display hyperacetylation of histone H3

Mutations in the methyl-CpG binding protein 2 (MECP2) gene cause Rett syndrome (RTT), a neurodevelopmental disorder characterized by the loss of language and motor skills during early childhood. We generated mice with a truncating mutation similar to those found in RTT patients. These mice appeared normal and exhibited normal motor function for about 6 weeks, but then developed a progressive neurological disease that includes many features of RTT: tremors, motor impairments, hypoactivity, increased anxiety-related behavior, seizures, kyphosis, and stereotypic forelimb motions. Additionally, we show that although the truncated MeCP2 protein in these mice localizes normally to heterochromatic domains in vivo, histone H3 is hyperacetylated, providing evidence that the chromatin architecture is abnormal and that gene expression may be misregulated in this model of Rett syndrome.

HLA matching for simultaneous pancreas-kidney transplantation in the United States: a multivariable analysis of the UNOS data

BACKGROUND

As the incidence of diabetic nephropathy increases, especially in minority populations, more simultaneous pancreas-kidney (SPK) transplants are being performed both in the United States and worldwide. The role of matching on SPK outcomes and organ allocation remains controversial. The purpose of this analysis was to determine the influence of HLA matching using currently employed criteria on 5-year SPK graft survival.

METHODS

We performed an analysis of all 3,316 SPK transplants performed in the United States reported to the United Network for Organ Sharing (UNOS) between December 31, 1988 and December 31, 1994. Kaplan-Meier unadjusted 1- and 5-year graft survival with log rank comparisons and Cox multivariable regression models that adjusted for 12 confounding variables were used to analyze the influence of HLA matching on outcomes.

RESULTS

Despite low-grade HLA or DR matching or high levels of common reactive groups (CREG) mismatching, 1- and 5-year allograft survival rates were 90% and 78% for kidney, and 85% and 75% for pancreas transplantation.

CONCLUSIONS

SPK transplantation is associated with excellent outcomes independent of the level of HLA matching. These data support the hypothesis that SPK transplants need not be allocated based on matching criteria, thus minimizing organ ischemia time and promoting a more racially equitable allocation for SPKs in the US today.

Differential expression of vasopressin, oxytocin and corticotrophin-releasing hormone messenger RNA in the paraventricular nucleus of the prairie vole brain following stress

Forced swimming, as an effective stressor, has been found to facilitate the development of pair bonds in male but to interfere with this behaviour in female prairie voles (Microtus ochrogaster). In the present study, we found that forced swimming differentially influenced the expression of messenger RNA for vasopressin, oxytocin and corticotrophin-releasing hormone (CRH) in the paraventricular nucleus of the hypothalamus (PVN) in the prairie vole brain. Forced swimming did not alter vasopressin mRNA labelling, but did induce a sustained decrease in oxytocin mRNA labelling and a progressive increase in CRH mRNA labelling in the PVN. The elevated CRH mRNA labelling appeared to be due to an increased number of cells synthesizing CRH mRNA and an enhanced ability of individual cells to produce CRH mRNA. Male and female prairie voles did not differ in the vasopressin, oxytocin or CRH mRNA expression either at the basal levels or in response to swimming stress. Together, these data indicate that the hypothalamic response of vasopressin, oxytocin and CRH messenger RNAs to swimming stress is regulated by distinct transcriptional factors. In addition, it seems unlikely that these changes are involved directly in the sex differences in pair bond formation.

Functional cloning of Src-like adapter protein-2 (SLAP-2), a novel inhibitor of antigen receptor signaling

In an effort to identify novel therapeutic targets for autoimmunity and transplant rejection, we developed and performed a large-scale retroviral-based functional screen to select for proteins that inhibit antigen receptor-mediated activation of lymphocytes. In addition to known regulators of antigen receptor signaling, we identified a novel adaptor protein, SLAP-2 which shares 36% sequence similarity with the known Src-like adaptor protein, SLAP. Similar to SLAP, SLAP-2 is predominantly expressed in hematopoietic cells. Overexpression of SLAP-2 in B and T cell lines specifically impaired antigen receptor-mediated signaling events, including CD69 surface marker upregulation, nuclear factor of activated T cells (NFAT) promoter activation and calcium influx. Signaling induced by phorbol myristate acetate (PMA) and ionomycin was not significantly reduced, suggesting SLAP-2 functions proximally in the antigen receptor signaling cascade. The SLAP-2 protein contains an NH2-terminal myristoylation consensus sequence and SH3 and SH2 Src homology domains, but lacks a tyrosine kinase domain. In antigen receptor-stimulated cells, SLAP-2 associated with several tyrosine phosphorylated proteins, including the ubiquitin ligase Cbl. Deletion of the COOH terminus of SLAP-2 blocked function and abrogated its association with Cbl. Mutation of the putative myristoylation site of SLAP-2 compromised its inhibitory activity and impaired its localization to the membrane compartment. Our identification of the negative regulator SLAP-2 demonstrates that a retroviral-based screening strategy may be an efficient way to identify and characterize the function of key components of many signal transduction systems.

TNFalpha inhibits insulin's antiapoptotic signaling in vascular smooth muscle cells

Tumor necrosis factor alpha (TNFalpha) interferes with insulin signaling in adipose tissue and may promote insulin resistance. Insulin resistance is associated with vascular injury, but little is known about the interaction of TNFalpha and insulin in the vasculature. By activating the Insulin receptor (IR) --> IRS-1 --> phosphatidylinositol-3-kinase (PI3K) --> Akt-pathway, insulin protects vascular smooth muscle cells (VSMC) from undergoing apoptosis. We therefore investigated the effect of TNFalpha on insulin's antiapoptotic signaling in rat aortic VSMC. Insulin induced rapid tyrosine-phosphorylation of the IR and IRS-1 and caused a 2.8-fold increase of IRS-1-bound PI3K. TNFalpha had no effect on insulin-induced tyrosine-phosphorylation of IR or IRS-1, but inhibited insulin-stimulated IRS-1/PI3K-association by 84%. Insulin-induced phosphorylation of Akt downstream of PI3K was inhibited by TNFalpha in a similar pattern. We next examined the effect of TNFalpha on insulin's protective actions on H(2)O(2)-induced apoptosis. Insulin alone prevented 72.8% of H(2)O(2)-induced apoptosis, which was significantly inhibited by TNFalpha. TNFalpha alone did not induce apoptosis. In contrast, TNFalpha had no effect on PDGF-induced antiapoptotic signal transduction via Akt. Thus, TNFalpha selectively interferes with insulin's antiapoptotic signaling in VSMC by inhibiting the association of IRS-1/PI3K and the downstream activation of Akt.

Initial results of ultrasound screening for aneurysm of the abdominal aorta in Western Australia: relevance for endoluminal treatment of aneurysm disease

BACKGROUND

Increased life expectancy in men during the last thirty years is largely due to the decrease in mortality from cardiovascular disease in the age group 29--69 yr. This change has resulted in a change in the disease profile of the population with conditions such as aneurysm of the abdominal aorta (AAA) becoming more prevalent. The advent of endoluminal treatment for AAA has encouraged prophylactic intervention and fueled the argument to screen for the disease. The feasibility of inserting an endoluminal graft is dependent on the morphology and growth characteristics of the aneurysm. This study used data from a randomized controlled trial of ultrasound screening for AAA in men aged 65--83 yr in Western Australia for the purpose of determining the norms of the living anatomy in the pressurized infrarenal aorta.

AIMS

To examine (1) the diameters of the infra-renal aorta in aneurysmal and non-aneurysmal cases, (2) the implications for treatment modalities, with particular reference to endoluminal grafting, which is most dependent on normal and aneurysmal morphology, and (3) any evidence to support the notion that northern Europeans are predisposed to aneurysmal disease.

METHODS

Using ultrasound, a randomized control trial was established in Western Australia to assess the value of a screening program in males aged 65--83 yr. The infra-renal aorta was defined as aneurysmal if the maximum diameter was 30 mm or more. Aortic diameter was modelled both as a continuous (in mm) and as a binary outcome variable, for those men who had an infra-renal diameter of 30 mm or more. ANOVA and linear regression were used for modelling aortic diameter as a continuum, while chi-square analysis and logistic regression were used in comparing men with and without the diagnosis of AAA.

FINDINGS

By December 1998, of 19,583 men had been invited to undergo ultrasound screening for AAA, 12,203 accepted the invitation (corrected response fraction 70.8%). The prevalence of AAA increased with age from 4.8% at 65 yr to 10.8% at 80 yr (chi(2)=77.9, df=3, P<0.001). The median (IQR) diameter for the non-aneurysmal group was 21.4 mm (3.3 mm) and there was an increase (chi(2)=76.0, df=1, P<0.001) in the diameter of the infra-renal aorta with age. Since 27 mm is the 95th centile for the non-aneurysmal infra-renal aorta, a diameter of 30 mm or more is justified as defining an aneurysm. The risk of AAA was higher in men of Australian (OR=1.0) and northern European origin (OR=1.0, 95%CL: 0.9, 1.2) compared with those of Mediterranean origin (OR=0.5, 95%CL: 0.4, 0.7).

CONCLUSION

Although screening has not yet been shown to reduce mortality from AAA, these population-based data assist the understanding of aneurysmal disease and the further development and use of endoluminal grafts for this condition.

Segregation analysis of cancer in families of glioma patients

A small proportion of brain tumors are attributed to a genetic predisposition; however, the hereditary proportion is undetermined. This study evaluates the degree of familial aggregation of cancer in a large series of brain tumor patients. Our study included 5,088 relatives of 639 probands (3,810 first- and 1,278 second-degree), diagnosed with a glioma between June 1992 and June 1995 at The University of Texas M. D. Anderson Cancer Center, Houston, Texas, with diagnosis under age 65 years, and residents of the United States or Canada. We conducted an in-person or telephone interview with patients and/or their next-of-kin, and obtained family histories for the probands' first-degree (parents, siblings, offspring) and selected second-degree relatives (aunts, uncles, grandparents) using a sequential sampling strategy. Reported cancers were documented by medical records and/or death certificates (if the relative was deceased and medical records were unavailable). We conducted segregation analysis using the Pedigree Analysis Program (PAP). The analyses were divided into two categories: (1) all 639 families, and (2) a subset of families whose gliomas stained positive on p53 immunohistochemistry analysis. We demonstrated that a multifactorial Mendelian model was favored, while a model postulating a purely environmental cause of brain cancer was rejected. This study indicates that familial cancer in relatives of glioma patients are probably a result of multigenic action, and familial clustering of cancer among relatives of glioma patients may involve unknown environmental exposures.

Children and the city: a summary of recent environmental psychology research

The environmental psychology literature is reviewed as it focuses on children's needs and experiences of towns and cities. Children are, we argue, the unacknowledged outsiders in the planning and management of urban areas; yet their enjoyment of and contribution to these areas is ignored at our peril. We discuss the importance of place attachment in the child's developing personal identity; and the rich affordances of towns and cities for the child's well-being and development, alongside an assessment of the evidence about the social and physical dangers that are more frequently stressed in popular discussions: these range from strangers and street crime, to traffic and pollution. Other related topics reviewed include: children's favourite places and their role in the child's self-regulation; the role of exploration of the local area as part of the child's widening social and cognitive world; gender differences in patterns of exploration, and whether these might be changing; and examples of children's involvement at more than a token level in the planning of their communities. The role of children as consumers in the local economy, and their use of public places, malls and plazas, has often been discussed as if they were inevitably socially problematic, and that their presence inevitably led to conflicts with adult users: yet we argue for a view of cityscapes which bring the different strands of society together. We conclude by discussing those Continental European city designs which foster the participation of children in the city's social life.

Home or hospital for stroke rehabilitation? results of a randomized controlled trial : I: health outcomes at 6 months

BACKGROUND AND PURPOSE

We wished to examine the effectiveness of an early hospital discharge and home-based rehabilitation scheme for patients with acute stroke.

METHODS

This was a randomized, controlled trial comparing early hospital discharge and home-based rehabilitation with usual inpatient rehabilitation and follow-up care. The trial was carried out in 2 affiliated teaching hospitals in Adelaide, South Australia. Participants were 86 patients with acute stroke (mean age, 75 years) who were admitted to hospital and required rehabilitation. Forty-two patients received early hospital discharge and home-based rehabilitation (median duration, 5 weeks), and 44 patients continued with conventional rehabilitation care after randomization. The primary end point was self-reported general health status (SF-36) at 6 months after randomization. A variety of secondary outcome measures were also assessed.

RESULTS

Overall, clinical outcomes for patients did not differ significantly between the groups at 6 months after randomization, but the total duration of hospital stay in the experimental group was significantly reduced (15 versus 30 days; P<0.001). Caregivers among the home-based rehabilitation group had significantly lower mental health SF-36 scores (mean difference, 7 points).

CONCLUSIONS

A policy of early hospital discharge and home-based rehabilitation for patients with stroke can reduce the use of hospital rehabilitation beds without compromising clinical patient outcomes. However, there is a potential risk of poorer mental health on the part of caregivers. The choice of this management strategy may therefore depend on convenience and costs but also on further evaluations of the impact of stroke on caregivers.

Home or hospital for stroke Rehabilitation? Results of a randomized controlled trial : II: cost minimization analysis at 6 months

BACKGROUND AND PURPOSE

The goal of the present study was to examine the resource and economic implications of an early hospital discharge and home-based rehabilitation scheme for patients with acute stroke.

METHODS

A cost minimization analysis in conjunction with a randomized controlled trial was carried out at 2 affiliated teaching hospitals in the southern metropolitan region of Adelaide, South Australia, between 1997 and 1998. Eighty-six hospitalized patients with acute stroke who required rehabilitation were randomized to receive both early hospital discharge and home-based rehabilitation, or conventional in-hospital rehabilitation and community care. Direct and indirect costs related to stroke rehabilitation were calculated, including hospital bed days, home-based intervention program, community services, and personal expenses during the 6 months after randomization.

RESULTS

The mean cost per patient was lower for patients randomized to the early hospital discharge and home-based rehabilitation ($8040) compared with those who received conventional care ($10 054). This cost saving was not statistically significant (P=0.14). However, sensitivity analyses indicated that the cost of home-based rehabilitation was consistently lower than that of conventional care except when hospital costs were assumed to be 50% less than those used in the main analysis. Multiple regression analysis demonstrated that the cost of the home-based program was significantly related to a patient's level of disability after adjustment for age, comorbidity, and the presence or absence of a caregiver.

CONCLUSIONS

The early hospital discharge and home-based rehabilitation scheme was less costly than conventional hospital care for patients with stroke. Limitation of the provision of such services to patients with mild disability is likely to be most cost effective.

CI-1017, a functionally M1-selective muscarinic agonist: design, synthesis, and preclinical pharmacology

The five muscarinic receptor subtypes (M1-M5) are characterized by seven helices that define a transmembrane cavity which serves as the binding pocket for agonists and antagonists. The five cavities appear to be topographically different enough to permit subtype selectivity among antagonists but not among classical agonists which tend to be smaller in size than antagonists. It was reasoned that synthesis of muscarinic agonists longer/larger than their classical counterparts might result in subtype selectivity. M1 subtype selectivity was found in a class of 1-azabicyclo[2.2.1]heptan-3-one, O-(3-aryl-2-propynyl) oximes. One of these, CI-1017, improved spatial memory of hippocampally deficient mice and nbM-lesioned rats at doses of 1.0-3.2 and 0.1-0.3 mg/kg, respectively, while producing parasympathetic side effects only at very high doses (100-178 mg/kg). Additionally, CI-1017 inhibited production of amyloidogenic A beta and increased secretion of soluble APP. Thus, CI-1017, besides treating AD symptomatically, may also retard its progression. CI-1017 has recently completed phase I clinical trials.

Epirubicin: a review of its efficacy as adjuvant therapy and in the treatment of metastatic disease in breast cancer

Epirubicin is a semisynthetic derivative of doxorubicin which has been extensively evaluated in patients with breast cancer. It is effective in the management of metastatic disease and as adjuvant therapy in patients with early breast cancer. In the adjuvant setting, epirubicin-based therapy appears to have efficacy at least equivalent to that of the standard therapy cyclophosphamide, methotrexate and fluorouracil (CMF), with the most recent trials, predominantly in premenopausal patients, reporting significant gains in relapse-free survival and overall survival for epirubicin-based vs CMF therapy. In a single trial, the 5-year relapse-free survival of postmenopausal patients receiving long term hormonal therapy (tamoxifen) was significantly increased when epirubicin was added as single-agent chemotherapy and compared with tamoxifen alone. In patients with metastatic disease, epirubicin- and doxorubicin-containing regimens (with cyclophosphamide and fluorouracil; FEC and FAC) are therapeutically equivalent. Increasing the dose of epirubicin appears to improve response rates in patients with either metastatic or early disease but, with the exception of 1 adjuvant study, improved overall survival has not been demonstrated. Quality of life (QOL) has yet to be adequately evaluated with epirubicin. The major adverse effects of epirubicin are acute dose-limiting haematotoxicity and cumulative dose-related cardiotoxicity. Other important adverse effects include mucositis, nausea and vomiting, reversible alopecia and local cutaneous reactions. However, the tolerability of epirubicin is better than that of doxorubicin at equimolar doses.

CONCLUSION

Epirubicin has been extensively investigated in patients with breast cancer and has been found to be a highly effective agent, both for the treatment of patients with metastatic disease and as an adjuvant therapy. Recent trials have confirmed that, in selected patients requiring adjuvant therapy, FEC therapy is at least as effective as CMF, a standard treatment. FEC is also therapeutically equivalent to FAC in patients with metastatic breast cancer, and because the therapeutic index appears to be better the opportunity exists to increase dose intensity in an effort to improve efficacy. Such trials, and those of combinations of epirubicin with newer or alternative agents, should result in the introduction of more effective and better tolerated epirubicin-based protocols for adjuvant therapy and the management of patients with advanced breast cancer. In the meantime there is sufficient evidence to justify consideration of epirubicin for inclusion in first-line therapies for patients with early or metastatic breast cancer.

A randomised comparison of the effects of oral versus transdermal 17beta-oestradiol, each combined with sequential oral norethisterone acetate, on serum lipoprotein levels

OBJECTIVE

To investigate the effects of oral versus transdermal 17beta-oestradiol, given in both cases with sequential addition of oral norethisterone acetate, on serum lipid and lipoprotein levels in postmenopausal women.

DESIGN

Open, randomised, parallel groups study.

SETTING

University Clinical Research Group.

POPULATION

Sixty-four postmenopausal women with climacteric complaints who were otherwise healthy were screened. Of these, 58 fulfilled the entry criteria.

METHODS

Fifty-eight postmenopausal women were randomised to receive either oral 17beta-oestradiol/oestriol (Trisequens) or transdermal 17beta-oestradiol (Estrapak) together with cyclical addition of norethisterone acetate for 48 weeks.

MAIN OUTCOME MEASURES

Serum levels of total cholesterol, triglycerides, high density lipoproteins (HDL), low density lipoproteins (LDL), very low density lipoproteins (VLDL), apolipoproteins, and lipoprotein(a) at baseline, and after 46 weeks (oestrogen-alone phase), and 48 weeks (oestrogen-progestogen phase) of treatment.

RESULTS

Oral oestradiol therapy did not affect serum total cholesterol levels during the oestrogen-alone phase, but during the combined phase there was a 5% fall (P < 0.05) due to a 7% decrease in LDL cholesterol levels (P < 0.01). Oral therapy also increased serum triglyceride levels by 9.4% during the oestrogen-alone phase (P < 0.05). During the combined phase of transdermal therapy, there was a 19% fall in serum triglyceride levels (P < 0.05) and a 6% fall in HDL levels (P < 0.05). Oral oestradiol reduced lipoprotein(a) levels by 31% during the oestrogen-alone phase and by 37% with norethisterone acetate addition (P < 0.05). Transdermal therapy had no significant effect on lipoprotein(a).

CONCLUSIONS

Other than a minor fall in HDL3 in women receiving transdermal 17beta-oestradiol, coadministration of oral progestogen in general improved, rather than worsened, this serum lipoprotein profile.

Forearm and calf blood flow in response to cortical arousal in normal male and female subjects

The aim of this study was to investigate cardiovascular changes, particularly in forearm and calf blood flows, in response to acute emotional stress in men and women. The study was approved by the Ethics Committee of the Queen's Medical Centre, Nottingham University. Fifty-six healthy non-smokers (29 men and 27 women) aged 19 to 22 years participated. Blood flow was measured by venous occlusion plethysmography using mercury-in-silastic strain gauges. Acute emotional stress (2 min) was elicited by a visual orientation task. During acute emotional stress, there were increases in heart rate (males = 40 +/- 3%, females = 49 +/- 5%) and mean arterial pressure (males = 24 +/- 2%, females = 22 +/- 2%), and hyperaemia and vasodilatation were observed in the forearm (males = 162 +/- 15%, females = 239 +/- 31%) and calf (males = 78 +/- 16%, females = 131 +/- 24%). Vasoconstriction also occurred in some subjects. Forearm vasodilatation was significantly greater than calf vasodilatation. Gender variation was apparent in the calf, where vasodilatation was significantly greater in females, and vasoconstriction was significantly greater in males. In some subgroups of men and women, mean values indicated that acute emotional stress elicited increases in forearm, but not in calf, blood flows and vascular conductances. This pattern is similar to that reported by Rusch et al. (see text), but the present findings indicate that vasodilatation in the forearm and calf in response to acute emotional stress is more common.

Caspase inhibition prevents staurosporine-induced apoptosis in CHO-K1 cells

Apoptosis is a distinct form of programmed cell death that plays an important role in many biological processes. Although the phenotypes of apoptotic cells are well documented, little is known of the central mechanism leading to programmed cell death. Over the past few years, a number of ICE/CED-3 family proteases (also termed caspases) have been discovered and implicated as the common effectors of apoptosis. In this report, we demonstrate that induction of apoptosis in CHO-K1 cells by staurosporine, a broad spectrum inhibitor of protein kinases, results in an increase in DEVD-dependent protease activity. These events were followed by nuclear DNA fragmentation and cell death. Inhibition of the DEVD-cleaving activity by a synthetic tetrapeptide inhibitor DEVD-CHO, blocked staurosporine-induced downstream apoptotic phenotypes, such as morphological characteristics and DNA fragmentation. These results suggest that staurosporine-induced apoptosis in CHO-K1 cells is mediated through the CPP32/caspase-3-like cysteine proteases.

Regulation of calreticulin gene expression by calcium

We have isolated and characterized a 12-kb mouse genomic DNA fragment containing the entire calreticulin gene and 2.14 kb of the promoter region. The mouse calreticulin gene consists of nine exons and eight introns, and it spans 4.2 kb of genomic DNA. A 1.8-kb fragment of the calreticulin promoter was subcloned into a reporter gene plasmid containing chloramphenicol acetyltransferase. This construct was then used in transient and stable transfection of NIH/ 3T3 cells. Treatment of transfected cells either with the Ca2+ ionophore A23187, or with the ER Ca2+-ATPase inhibitor thapsigargin, resulted in a five- to sevenfold increase of the expression of chloramphenicol acetyltransferase protein. Transactivation of the calreticulin promoter was also increased by fourfold in NIH/3T3 cells treated with bradykinin, a hormone that induces Ca2+ release from the intracellular Ca2+ stores. Analysis of the promoter deletion constructs revealed that A23187- and thapsigargin-responsive regions are confined to two regions (-115 to -260 and -685 to -1,763) in the calreticulin promoter that contain the CCAAT nucleotide sequences. Northern blot analysis of cells treated with A23187, or with thapsigargin, revealed a fivefold increase in calreticulin mRNA levels. Thapsigargin also induced a fourfold increase in calreticulun protein levels. Importantly, we show by nuclear run-on transcription analysis that calreticulin gene transcription is increased in NIH/3T3 cells treated with A23187 and thapsigargin in vivo. This increase in gene expression required over 4 h of continuous incubation with the drugs and was also sensitive to treatment with cycloheximide, suggesting that it is dependent on protein synthesis. Changes in the concentration of extracellular and cytoplasmic Ca2+ did not affect the increased expression of the calreticulin gene. These studies suggest that stress response to the depletion of intracellular Ca2+ stores induces expression of the calreticulin gene in vitro and in vivo.

Promoting healthy bladder habits for seniors

Urinary incontinence (UI) effects people of all ages, but is especially prevalent in the elderly population. Also significant is a lack of knowledge about UI. A health promotion project was developed and implemented in six ethnically diverse, predominantly minority, inner city senior centers, a program designed to address an elder population, as they are very likely to be experiencing UI and lacking knowledge concerning healthy bladder habits. The project consisted of three phases: orientation/training of key staff members/peer educators at the six senior centers; educating elder consumers through four one-hour weekly sessions involving visual aids and completion of bladder records and quizzes, and follow-up sessions with senior staff/peer educators to reinforce previous training. One result was that training of peer educators needed further refinement to allow for a more significant role throughout the program. The program was very well received by the participants and roughly 80 percent felt they had more control over their bladder by the end of the last session. This project will continue into 1997 and in addition to information on UI, the project will include prostate health for men and gynecological health for women, as this need became evident throughout the program.