Mcl-1 downregulation by pro-inflammatory cytokines and palmitate is an early event contributing to β-cell apoptosis

Pancreatic β-cell apoptosis is a key feature of diabetes mellitus and the mitochondrial pathway of apoptosis is a major mediator of β-cell death. We presently evaluated the role of the myeloid cell leukemia sequence 1 (Mcl-1), an antiapoptotic protein of the Bcl-2 family, in β-cells following exposure to well-defined β-cell death effectors, for example, pro-inflammatory cytokines, palmitate and chemical endoplasmic reticulum (ER) stressors. All cytotoxic stresses rapidly and preferentially decreased Mcl-1 protein expression as compared with the late effect observed on the other antiapoptotic proteins, Bcl-2 and Bcl-xL. This was due to ER stress-mediated inhibition of translation through eIF2α phosphorylation for palmitate and ER stressors and through the combined action of translation inhibition and JNK activation for cytokines. Knocking down Mcl-1 using small interference RNAs increased apoptosis and caspase-3 cleavage induced by cytokines, palmitate or thapsigargin, whereas Mcl-1 overexpression partly prevented Bax translocation to the mitochondria, cytochrome c release, caspase-3 cleavage and apoptosis induced by the β-cell death effectors. Altogether, our data suggest that Mcl-1 downregulation is a crucial event leading to β-cell apoptosis and provide new insights into the mechanisms linking ER stress and the mitochondrial intrinsic pathway of apoptosis. Mcl-1 is therefore an attractive target for the design of new strategies in the treatment of diabetes.

Human Hendra virus encephalitis associated with equine outbreak, Australia, 2008

Emergence of this virus is a serious medical, veterinary, and public health challenge.

A recent Hendra virus outbreak at a veterinary clinic in Brisbane, Queensland, Australia, involved 5 equine and 2 human infections. In contrast to previous outbreaks, infected horses had predominantly encephalitic, rather than respiratory, signs. After an incubation period of 9–16 days, influenza-like illnesses developed in the 2 persons before progressing to encephalitis; 1 died. Both patients were given ribavirin. Basal serum and cerebrospinal fluid levels were 10–13 mg/L after intravenous administration and 6 mg/L after oral administration (isolate 90% inhibitory concentration 64 mg/L). Both patients were exposed to infected horses, 1 during the late incubation period in a horse. The attack rate for veterinary clinic staff exposed to infected horses was 10%. An isolate from this outbreak showed genetic heterogeneity with isolates from a concurrent, but geographically remote, outbreak and from previous outbreaks. Emergence of Hendra virus is a serious medical, veterinary, and public health challenge.

Hendra virus outbreak with novel clinical features, Australia

To determine the epidemiologic and clinical features of a 2008 outbreak of Hendra virus infection in a veterinary clinic in Australia, we investigated the equine case-series. Four of 5 infected horses died, as did 1 of 2 infected staff members. Clinical manifestation in horses was predominantly neurologic. Preclinical transmission appears likely.

Assessment of heavy metal concentration in the Khoshk River water and sediment, Shiraz, Southwest Iran

Heavy metal contents and contamination characteristics of the water and sediment of the Khoshk River, Shiraz, Southwest Iran were investigated. The abundance of heavy metals decreases as Zn > Mn > Cr > Ni >Pb > Cu > Cd in water samples and Mn > Cr > Pb > Ni > Zn > Cu > Cd in sediments, respectively. Based on the enrichment factor and geoaccumulation index values, sediments were loaded with Cr, Zn, Pb, Cu, and Cd. Pearson correlation matrix as well as cluster and principal components analyses and analysis of variance were implemented on data from sampling sites. Based on the locations of sampling sites in clusters and variable concentrations at these stations, it was concluded that municipal, industrial, and domestic discharges in the Shiraz urban area strongly affected heavy metals concentrations in the Khoshk River water and sediment. Results obtained from principal components analysis of sediment samples showed that the high concentration of Ni was mainly from natural origin, related to the composition of parent rocks, while the elevated values of Cr, Zn, Pb, Cd, and Cu were due to anthropogenic activities.

Monitoring deterioration of vegetation cover in the vicinity of smelting industry, using statistical methods and TM and ETM(+) imageries, Sarcheshmeh copper complex, Central Iran

Simple statistical methods on Normalized Difference Vegetation Index (NDVI) and bands 3 and 4 data of relatively coarse resolution Thematic Mapper (TM) and Enhanced Thematic Mapper plus (ETM(+)) imageries were used to investigate the impacts of air pollution on the deterioration of the vegetation cover in the Sarcheshmeh copper complex of central Iran. Descriptive statistics and k-means cluster analysis indicated that vegetation deterioration had already started in the prevailing wind directions. The results show that combination of simple statistical methods and satellite imageries can be used as effective monitoring tools to indicate vegetation stress even in regions of sparse vegetation. Despite various possible perturbing factors upon NDVI, this index remains to be a valuable quantitative vegetation monitoring tool.

The Immediate Management of the Patient with Rupture: Open Versus Endovascular repair (IMPROVE) aneurysm trial--ISRCTN 48334791 IMPROVE trialists

BACKGROUND

Systematic reviews have suggested a survival advantage for patients with ruptured abdominal aortic aneurysm (AAA), who are managed by endovascular repair. These reviews are based on single centre experiences of selected patients.

OBJECTIVE

To determine whether a policy of endovascular repair improves the survival of all patients with ruptured AAA.

METHODS

A randomized controlled trial, IMPROVE (ISRCTN 48334791) will randomize patients with a clinical diagnosis of rAAA, made in hospital, either to immediate CT scan and endovascular repair whenever anatomically suitable (endovascular first), or to open repair, with CT scan being optional (normal care), The trial is set on a background of guidelines for emergency care, CT scanning and anaesthesia, which incorporate the protocol of permissive hypotension. Recruitment started in October 2009 and 600 patients are required to show a 14% survival benefit at 30 days (primary outcome) for the endovascular first policy. Recruitment will be from the UK and Europe. Secondary outcomes include 24h, in-hospital and 1 year survival, complications, major morbidities, costs and quality of life.

DISCUSSION

This is a "real life" trial that will answer the fundamental relevant clinical dilemma, namely, do patients who present with ruptured AAA derive benefit from treatment in a system, which offers a preferential strategy of endovascular repair? The trial addresses whether the anticipated reduced mortality and morbidity associated with endovascular repair is offset by the relatively greater ease of access and speed to conventional surgery. This issue is pivotal to future patient care and provision of services.

Management of the open abdomen: from initial operation to definitive closure

The open abdomen is a relatively new and increasingly common strategy for the management of abdominal emergencies in both trauma and general surgery. The use of an abbreviated laparotomy can reduce mortality associated with conditions such as abdominal compartment syndrome; however, the resulting open abdomen is a complex clinical problem. Modern techniques and technologies are now available that allow for improved management of the open abdomen and the progressive reduction of the fascial defect. Indeed, recent evidence indicates that a large proportion of patients treated with open abdomen can now be closed within the initial hospitalization. These techniques and technologies include the appropriate use of negative pressure therapy and synthetic or biologic repair materials. It is essential that general and trauma surgeons understand the core principles underlying the need for and management of the open abdomen. Toward this goal, an Open Abdomen Advisory Panel was established to identify core principles in the management of the open abdomen and to develop a set of recommendations based on the best available evidence. This review presents the principles and recommendations identified by the Open Abdomen Advisory Panel and provides brief case studies for the illustration of these concepts.

Interferon regulatory factor-1 is a key transcription factor in murine beta cells under immune attack

AIMS/HYPOTHESIS

IFN-gamma, together with other inflammatory cytokines such as IL-1beta and TNF-alpha, contributes to beta cell death in type 1 diabetes. We analysed the role of the transcription factor interferon regulatory factor (IRF)-1, a downstream target of IFN-gamma/signal transducer and activator of transcription (STAT)-1, in immune-mediated beta cell destruction.

METHODS

Islets from mice lacking Irf-1 (Irf-1 (-/-)) and control C57BL/6 mice were transplanted in overtly diabetic NOD mice. Viability and functionality of islets were evaluated in vitro. Chemokine expression by Irf-1 (-/-) islets and INS-1E cells transfected with Irf-1 short interfering RNA (siRNA) was measured by real-time PCR as well as in functional assays in vitro.

RESULTS

IRF-1 deletion in islets was associated with higher prevalence of primary non-function (63% vs 25%, p <or= 0.05) and shorter functioning graft survival (6.0 +/- 2.6 vs 10.4 +/- 4.8 days, p <or= 0.05) in contrast to similar skin graft survival. Although Irf-1 (-/-) islets were resistant to cytokine-induced cell death, insulin secretion by them was lower than that of control C57BL/6 islets under medium and cytokine conditions. IL-1 receptor antagonist partly restored the cytokine-induced secretory defect in vitro and completely prevented primary non-function in vivo. Cytokine-exposed Irf-1 (-/-) islets and INS-1E cells transfected with Irf-1 siRNA showed increased expression of Mcp-1 (also known as Ccl2), Ip-10 (also known as Cxcl10), Mip-3alpha (also known as Ccl20) and Inos (also known as Nos2) mRNA and elevated production of monocyte chemoattractant protein-1 (MCP-1) and nitrite compared with controls. In vivo, Irf-1 (-/-) islets displayed a higher potential to attract immune cells, reflected by more aggressive immune infiltration in the grafted islets.

CONCLUSIONS/INTERPRETATION

These data indicate a key regulatory role for IRF-1 in insulin and chemokine secretion by pancreatic islets under inflammatory attack.

Lessons learned engaging Hispanic communities in cancer research

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Background: Community involvement is critical to advance cancer education and prevention in minority communities. Researchers must be knowledgeable of the target community's basic cultural beliefs and linguistic needs. This study sought to identify the best approach for conducting community based cancer research in South Texas Hispanic communities. We report our experiences and lessons learned with participants and site recruitment and retention. Methods: We introduced a community based, culturally relevant breast and cervical cancer screening and early detection program, Esperanza y Vida, to address barriers and disparities in four border communities (urban, rural, colonia, and small border town). These areas represent the diverse South Texas Mexican American population in terms of language use, immigration status, and length of time in the US. Within these communities we recruited a grassroots community organization, faith-based health center, rural hospital district, and federally qualified health center. Results: Focus groups were conducted with women and men to assess knowledge, attitudes, and beliefs about women's cancers. To successfully recruit participants, we implemented various techniques to engage the community and establish sustainable relationships. These included community health worker recruitment of community members, traditional recruitment (flyers, posters, word of mouth), key community and cultural leader support, and discussions with local groups and health organizations. We and our community partners identified and overcame investigator/community barriers (lack of community knowledge, community integration into the research process, community understanding of research methods, reluctance to develop innovative approaches). Consequently, participants are eager to remain with the program and are individually and collectively mobilizing others to create a sustainable and durable program. Conclusions: 1. Cultural leader engagement worked best for participant recruitment in the small border town and colonia settings, while key community leader engagement was most effective in the small city urban and rural settings. 2. Research/community partners must identify and discuss project barriers regardless of the fear of creating discordance to reach solutions.

No significant financial relationships to disclose.

Induction of nuclear factor-kappaB and its downstream genes by TNF-alpha and IL-1beta has a pro-apoptotic role in pancreatic beta cells

AIMS/HYPOTHESIS

IL-1beta and TNF-alpha contribute to pancreatic beta cell death in type 1 diabetes. Both cytokines activate the transcription factor nuclear factor-kappaB (NF-kappaB), but recent observations suggest that NF-kappaB blockade prevents IL-1beta + IFN-gamma- but not TNF-alpha + IFN-gamma-induced beta cell apoptosis. The aim of the present study was to compare the effects of IL-1beta and TNF-alpha on cell death and the pattern of NF-kappaB activation and global gene expression in beta cells.

METHODS

Cell viability was measured after exposure to IL-1beta or to TNF-alpha alone or in combination with IFN-gamma, and blockade of NF-kappaB activation or protein synthesis. INS-1E cells exposed to IL-1beta or TNF-alpha in time course experiments were used for IkappaB kinase (IKK) activation assay, detection of p65 NF-kappaB by immunocytochemistry, real-time RT-PCR and microarray analysis.

RESULTS

Blocking NF-kappaB activation protected beta cells against IL-1beta + IFNgamma- or TNFalpha + IFNgamma-induced apoptosis. Blocking de novo protein synthesis did not increase TNF-alpha- or IL-1beta-induced beta cell death, in line with the observations that cytokines induced the expression of the anti-apoptotic genes A20, Iap-2 and Xiap to a similar extent. Microarray analysis of INS-1E cells treated with IL-1beta or TNF-alpha showed similar patterns of gene expression. IL-1beta, however, induced a higher rate of expression of NF-kappaB target genes putatively involved in beta cell dysfunction and death and a stronger activation of the IKK complex, leading to an earlier translocation of NF-kappaB to the nucleus.

CONCLUSIONS/INTERPRETATION

NF-kappaB activation in beta cells has a pro-apoptotic role following exposure not only to IL-1beta but also to TNF-alpha. The more marked beta cell death induced by IL-1beta is explained at least in part by higher intensity NF-kappaB activation, leading to increased transcription of key target genes.

Enteral glutamine during active shock resuscitation is safe and enhances tolerance of enteral feeding

BACKGROUND

Feeding the hemodynamically unstable patient is increasingly practiced, yet few data exist on its safety. Because enteral glutamine is protective to the gut in experimental models of shock and improves clinical outcomes, it may benefit trauma patients undergoing shock resuscitation and improve tolerance if administered early. This pilot study aimed to evaluate gastrointestinal tolerance and safety of enteral feeding with glutamine, beginning during shock resuscitation in severely injured patients.

METHODS

In a prospective randomized trial, 20 patients were randomly assigned to either an enteral glutamine group (n = 10) or a control group (n = 10). Patients with severe trauma meeting standardized shock resuscitation criteria received enteral glutamine 0.5 g/kg/d during the first 24 hours of resuscitation and 10 days thereafter. Immune-enhancing diet began on postinjury day 1, with a target of 25 kcal/kg/d. Control patients received isonitrogenous whey powder plus immune-enhancing diet. Tolerance (vomiting, nasogastric output, diarrhea, and distention) was assessed throughout the study.

RESULTS

Glutamine was well tolerated and no adverse events occurred. Treated patients had significantly fewer instances of high nasogastric output (5 vs 23; p = .010), abdominal distention (3 vs 12; p = .021), and total instances of intolerance (8 vs 42; p = .011). Intensive care unit (ICU) and hospital length of stay were comparable. Control patients required supplemental parenteral nutrition (PN) to meet goals at day 7.

CONCLUSIONS

Enteral glutamine administered during active shock resuscitation and through the early postinjury period is safe and enhances gastrointestinal tolerance. A large clinical trial is warranted to determine if enteral glutamine administered to the hemodynamically unstable patient can reduce infectious morbidity and mortality.

The gut in systemic inflammatory response syndrome and sepsis. Enzyme systems fighting multiple organ failure

The prognosis and care of critically ill ICU patients has improved over recent years, but the development of multiple organ failure (MOF) continues to cause significant morbidity and mortality. Shock, with resultant organ ischemia, appears to play a critical role in the development of MOF. It is our global hypothesis that MOF is a gut-derived phenomenon and that novel interventions can improve outcome in shock-induced gut inflammation and dysfunction in critically ill patients. We have found that the anesthetic agent ketamine has a profound impact on the response to endotoxic shock. This review summarizes our findings on the mechanisms of action by which ketamine is able to modulate the nitric oxide, cyclo-oxygenase and heme-oxygenase enzyme systems to attenuate endotoxin-induced organ dysfunction.

Aldose reductase inhibitors for the treatment of diabetic polyneuropathy

BACKGROUND

Polyneuropathy, a common complication of diabetes mellitus, causes pain and sensory and motor deficits in the limbs, and is also an important independent predictor of foot ulceration. Inhibiting the metabolism of glucose by the polyol pathway using aldose reductase inhibitors is a potential mechanism to slow or reverse the neuropathy's progression.

OBJECTIVES

To assess the effects of aldose reductase inhibitors on the progression of symptoms, signs or functional disability in diabetic polyneuropathy.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials Register, MEDLINE (from January 1966 to May 2007), EMBASE (from January 1980 to May 2007) and LILACS (from 1982 to May 2007). We reviewed bibliographies of randomized trials identified, and contacted authors and experts in the field.

SELECTION CRITERIA

We included randomized controlled trials comparing an aldose reductase inhibitor with control, and lasting at least six months. The primary outcome measure was change in neurological function, measured in various ways, including strength testing, sensory examination, and composite scores of neurological examination. Secondary outcome measures were nerve conduction studies, neuropathic symptoms, quality of life, occurrence of foot ulcers and adverse effects.

DATA COLLECTION AND ANALYSIS

Trials included in the review were selected and assessed independently by at least two of us. Methodological criteria and study results were recorded on data extraction forms.

MAIN RESULTS

Thirty-two randomized controlled trials meeting the inclusion criteria were identified. Many had significant methodological flaws. Change in neurological function, our primary outcome measure, was assessed in 29 trials, but sufficient data for meta-analysis were only available in 13 studies, involving 879 treated participants and 909 controls. There was no overall significant difference between the treated and control groups (SMD -0.25, 95% CI -0.56 to 0.05), although one subgroup analysis (four trials using tolrestat) favored treatment. A benefit for neuropathic symptoms was suggested by a group of trials using a dichotomized endpoint (improvement or not), but this was contradicted by another group of trials which measured symptoms on a continuous scale. There was no overall benefit on nerve conduction parameters (27 studies) or foot ulceration (one study). Quality of life was not assessed in any of the studies. While most adverse events were infrequent and minor, three compounds had dose limiting adverse events that lead to their withdrawal from human use: severe hypersensitivity reactions with sorbinil, elevation of creatinine with zenarestat, and alteration of liver function with tolrestat.

AUTHORS' CONCLUSIONS

We found no statistically significant difference between aldose reductase inhibitors and placebo in the treatment of diabetic polyneuropathy. Any future clinical trials of aldose reductase inhibitors should be restricted to compounds proven to have substantial biological or preclinical advantages over previously tested agents.

Physician Response Unit—A feasibility study of an initiative to enhance the delivery of pre-hospital emergency medical care

OBJECTIVES

To describe the rationale, development and initial results of a collaborative pre-hospital pilot project designed to enhance the emergency care needs of an inner city population.

METHODS

Retrospective descriptive analysis of emergency calls attended by a rapid response car staffed by a pre-hospital care physician and ambulance service technician or paramedic.

RESULTS

Seven hundred and forty-eight consecutive patients over a 13-month period are described. Six hundred and thirty-eight (82%) patients underwent clinical consultation with a physician within 8 min of emergency call. The Physician Response Unit (PRU) also provided an additional vehicle responding to emergency calls, reaching the national 8 min target response time in 638 (82%) of all cases. Two hundred and eighty-nine (39%) of the patients attended had medical therapy initiated by the PRU physician. Nearly two-thirds of this group, 189 (65%), received medical therapy outside current ambulance service protocols. A physician medical escort was provided for 142 (25%) of patients attending hospital. Of all patients seen 577 (77%) attended the emergency department via ambulance, and 136 (18%) patients were assessed, treated and prevented from attending the emergency department.

CONCLUSIONS

The PRU provided clinical care beyond that delivered by the ambulance service. It also contributed positively to local ambulance service response times. The service was able to prevent unnecessary ambulance journeys and attendance at hospital. It demonstrates that traditional working practices can be altered to improve the delivery of emergency medical care.

Hearing half the message? A re-audit of the care of patients with acute asthma by emergency ambulance crews in London

PROBLEM

An initial audit of the care provided to emergency asthma patients by the ambulance service was carried out in 1996. Some under-recognition and under-treatment of severe asthma was found as well as a lack of documentation of patient condition on scene. A re-audit was undertaken in 1999.

DESIGN

A multidisciplinary advisory group was reconvened. The same method was adopted as for the first audit. Patients included were those administered nebulised salbutamol by crews in the catchment areas of four hospitals and those diagnosed with asthma at the Accident & Emergency (A&E) departments of those hospitals between January and March 1999.

SETTING

London Ambulance Service.

KEY MEASURES FOR IMPROVEMENT

(1) Accuracy of diagnosis and appropriateness of treatment, and (2) adherence to protocol.

STRATEGIES FOR CHANGE

Following the first audit, treatment protocols were widened and brought into line with the British Thoracic Society guidelines for care of acute asthma patients. The results were widely disseminated within the service and training was initiated for all operational staff.

EFFECTS OF CHANGE

The number of patients included in the re-audit more than doubled (audit 1: n = 252, audit 2: n = 532). The increase occurred exclusively in those administered nebulised salbutamol by ambulance crews but diagnosed with conditions other than asthma in A&E (audit 1: n = 15, audit 2: n = 161). The proportion of patients diagnosed with asthma in A&E who were administered nebulised salbutamol by their attending crew rose from 58% to 75%. However, 43 asthma patients were not treated; several of these were not recognised as suffering from asthma and others fell within the changed protocols for treatment. Adherence to protocol for administration of salbutamol remained high. Pre-hospital documentation of key observations did not improve.

LESSONS LEARNT

Messages from the first audit seem to have been acted upon selectively. Implementing change is complex, and re-audit is necessary to understand the effects of the changes made.

Unexpected effects of viral interleukin-10-secreting dendritic cells in vivo: preferential inhibition of TH2 responses

Viral interleukin (IL)-10 (vIL-10) has been widely described as an immunoregulatory cytokine that does not possess the T-cell costimulatory activities of cellular IL-10; it was therefore believed to be a more potent tolerogenic mediator. The immunosuppressive properties of this cytokine are partly attributed to its capacity to render dendritic cells (DCs) unable to undergo full maturation and to activate T cells. We reported here that myeloid DCs retrovirally transduced with vIL-10 had an impaired production of IL-12 and a decreased expression of MHC class II molecules but had minor defects in costimulatory molecule expression and no alteration on CCR5 and CCR7 expression. In mixed leukocyte reaction, vIL-10-transduced C57BL/6 bm12 (MHC class II mismatch) DCs had a reduced capacity to stimulate C57BL/6 wild-type CD4+ T-cell proliferation. We show that bm12 vIL-10-transduced DC administration in CD8-/- C57BL/6 mice promoted IFN-gamma production, down-regulated TH2-type cytokine production, and did not induce skin graft tolerance. These findings suggest that vIL-10-transduced DC may surprisingly facilitate Th1-type inflammatory responses in vivo.

Application of genome-wide expression analysis to human health and disease

The application of genome-wide expression analysis to a large-scale, multicentered program in critically ill patients poses a number of theoretical and technical challenges. We describe here an analytical and organizational approach to a systematic evaluation of the variance associated with genome-wide expression analysis specifically tailored to study human disease. We analyzed sources of variance in genome-wide expression analyses performed with commercial oligonucleotide arrays. In addition, variance in gene expression in human blood leukocytes caused by repeated sampling in the same subject, among different healthy subjects, among different leukocyte subpopulations, and the effect of traumatic injury, were also explored. We report that analytical variance caused by sample processing was acceptably small. Blood leukocyte gene expression in the same individual over a 24-h period was remarkably constant. In contrast, genome-wide expression varied significantly among different subjects and leukocyte subpopulations. Expectedly, traumatic injury induced dramatic changes in apparent gene expression that were greater in magnitude than the analytical noise and interindividual variance. We demonstrate that the development of a nation-wide program for gene expression analysis with careful attention to analytical details can reduce the variance in the clinical setting to a level where patterns of gene expression are informative among different healthy human subjects, and can be studied with confidence in human disease.

Primary Dural Mucosa-Associated Lymphoid Tissue-Type Lymphoma: Case Report and Review of the Literature

A 47-year-old Hispanic male presented with visual field disturbances, memory impairment, and a seizure. CT and MRI were consistent with meningioma. Both neurologic exam and routine laboratory tests were within normal limits. The patient underwent craniotomy and subtotal resection of the tumor. On H&E, the lesion was composed of a lymphoid mass with well-defined irregularly shaped follicles surrounded by a monomorphic population of small lymphocytes. Marginal zones stained for B-cell markers, CD20 and CD79a, one T-cell marker, CD43, and kappa light chains. While other markers did not stain the majority of tumor cells, they did identify other lymphoid and plasma cell elements. A diagnosis of marginal zone B-cell lymphoma of dura, mucosa-associated lymphoid tissue (MALT)-type (extranodal) was made. MALT-type lymphomas are unusual in the nervous system; this is the first such case reported in a male and serves to emphasize the wide diversity of presentation of a neoplasm originally described in the GI tract and thus far described in the CNS only in females.

True Winter Range of the Veery (Catharus Fuscescens): Lessons for Determining Winter Ranges of Species That Winter in The Tropics

Most recent references describe the winter range of the Veery (Catharus fuscescens) as including an extensive area from northern Colombia, Venezuela, and Guyana south to south-central Brazil. Analysis of seasonal distribution of specimen records in South America, however, shows that 91 of 105 specimens were taken during spring and fall, not winter; the remaining 14, taken from 2 December to 20 February, are all from three small areas at the periphery or south of the Amazon basin. Thus, the true winter range is almost completely south and east of the area generally described. The seasonal distribution of specimen records is consistent with observational data from South America and banding data from the Neotropics. Although those data must be treated cautiously, it appears that the true winter range of the Veery is in south-central and southeastern Brazil, an area where habitat destruction threatens many natural habitats, rather than in the relatively undisturbed areas of western Amazonia. Widespread erroneous portrayal of the winter range of the Veery seems to have been caused largely by the assumption that the species winters in South America wherever it has been recorded and by overlooking a previously published analysis of its winter distribution.

Developing an integrated nursing team approach

Nursing Standard recently published a literature search that explored different models of integrated nursing and more traditional models of community nursing in primary care (Baileff 2000). Models of change for implementing integrated nursing were also examined. This article aims to explore the development of an integrated nursing team in a healthcare centre in Northampton.

Myosin light chain kinase and the onset of labour in humans

Myosin light chain kinase (MLCK) is essential for myometrial contractions induced by calcium-mobilizing agonists. From the gene of vertebrate smooth muscle/non-muscle MLCK there are at least four proteins expressed. We have found that both a > 200 and a 137 kDa MLCK are equally expressed in human non-pregnant (NP) and term pregnant (P) uterine smooth muscle and confirmed that 19 kDa telokin (TK) is only expressed in P myometrium. In addition, we have observed that a MLCK immunogen at approximately 60 kDa is only expressed in NP myometrium, suggesting that its expression is inhibited during normal pregnancy in a hormonally dependent manner. However, when we compared pregnant myometrium from patients delivered preterm (PT) (< 34 weeks gestation), but not in labour (NIL), with PT patients in labour (IL) we found that PT(IL) samples expressed the approximately 60 kDa MLCK immunogen and thus displayed a NP phenotype whereas PT(NIL) samples did not express the protein and retained a pregnant phenotype. We hypothesize that the novel approximately 60 kDa MLCK immunogen contributes to the aberrent contractility associated with preterm labour. Experimental Physiology (2001) 86.2, 313-318.

NK-1 antagonist reduces colonic inflammation and oxidative stress in dextran sulfate-induced colitis in rats

Although substance P (SP) has been implicated as a mediator of neurogenic inflammation in the small intestine, little information is available regarding the role of SP in the pathogenesis of chronic ulcerative colitis. In this study, our aim was to investigate whether the intraperitoneal administration of a nonpeptide neurokinin-1 (NK-1) antagonist, CP-96345, which antagonizes the binding of SP to its NK-1 receptor, results in the attenuation of colonic inflammation induced in rats by 5% dextran sodium sulfate (DSS) in drinking water for 10 days compared with an inactive enantiomer, CP-96344. Disease activity was assessed daily for 10 days, after which colonic tissue damage was scored and myeloperoxidase activity and colon and urinary 8-isoprostanes were measured. Animals receiving DSS exhibited marked physical signs of colitis by day 5 compared with controls. Chronic administration of the NK-1 antagonist significantly reduced the disease activity index, mucosal myeloperoxidase activity, colonic tissue damage score, and mucosal and urinary levels of 8-isoprostanes compared with inactive enantiomer- or vehicle-injected (saline) animals receiving DSS alone. These data indicate that the administration of an NK-1 antagonist can attenuate colonic inflammation and oxidative stress and suggest a novel therapeutic approach in the treatment of chronic ulcerative colitis.

Somatosensory evoked potential monitoring in anterior thoracic vertebrectomy

OBJECT

Spine surgeons have used intraoperative cortical and subcortical somatosensory evoked potential (SSEP) monitoring to detect changes in spinal cord function when intraoperative procedures can be performed to prevent neurological deterioration. However, the reliability of SSEP monitoring as applied to anterior thoracic vertebral body resections has not been rigorously assessed.

METHODS

The authors retrospectively reviewed hospital charts and operating room records obtained between August 1993 and December 1998 and found that SSEP monitoring was used in 44 surgical procedures involving an anterior approach for thoracic vertebral body resections. There were no patients in whom SSEP changes did not return to baseline during the surgical procedure. Patients in four cases, despite their stable SSEP recordings throughout the procedure, were noted immediately postoperatively to have experienced significant neurological deterioration. The false-negative rate in SSEP monitoring was 9%. Sensitivity was determined to be 0%.

CONCLUSIONS

It is important to recognize high false-negative rates and low sensitivity of SSEP monitoring when it is used to record spinal cord function during anterior approaches for thoracic vertebrectomies. The insensitivity of SSEPs for motor deterioration during anterior thoracic vertebrectomies is likely due to the limitation of SSEPs, which monitor only posterior column function whereas motor paths are conveyed in the anterior and anterolateral spinal cord. The authors believe that SSEPs can not be relied on to detect reversible spinal damage during anterior thoracic vertebrectomies.

Up-regulation of p21- and RhoA-activated protein kinases in human pregnant myometrium

The role of small ras homologous GTP-binding proteins in the regulation of smooth muscle contractility has become increasingly apparent but there is still little information about the presence of these proteins in human uterine smooth muscle. Messenger RNAs for p21-activated protein kinase isoforms (PAK1, PAK2, and PAK3) were detectable in both nonpregnant and pregnant human myometrial tissue. However, PAK3 protein was not detectable and the proteins for PAK1 and PAK2 were only detectable in pregnant tissue. Moreover there was a large increase in the constitutively active p34 protein fragment of PAK2 in pregnant tissue. Protein expression of RhoA-activated protein kinases isoforms (ROK1 and ROK2) also increased during pregnancy. Stimulation of RhoA signaling in pregnant myometrial tissue with lysophosphatic acid (LPA) increased the level of myosin light chain (MLC20) phosphorylation. Preincubation of the tissue with C3 toxin inhibited LPA-stimulated MLC20 phosphorylation and lowered the basal phosphorylation level of MLC20. Thus ROKS and PAKS have the potential to regulate uterine contractility and/or load-bearing during human pregnancy.

Longitudinal changes in bone density in hyperparathyroidism

Primary hyperparathyroidism (HPTH) is a known risk factor for cortical bone loss. The primary objective of this study was to examine the time course and location of changes in bone mass within the first year after parathyroidectomy (PAX). The secondary goal was to evaluate the efficacy of combined estrogen therapy and parathyroidectomy in postmenopausal women. Thirty-two subjects with primary HPTH participated in a prospective, longitudinal study for at least 1 yr. Twenty-seven subjects underwent PTX, while five received no therapy (control). Among the PTX patients, 21 were postmenopausal women, and 8 of these women also received estrogen. Subjects had serial measurements of parathyroid hormone levels, serum chemistries, and bone density at multiple sites. Among all PTX patients, lumbar spine, hip, and whole body bone mineral content increased significantly (3.8-6%; p < 0.005) at 12 mo, with most of the increments observed by 3 mo. In postmenopausal women, estrogen treatment resulted in higher increments in the femoral neck (8.6 +/- 2% vs 4.9 +/- 1.2%, respectively; p = 0.07) and the whole body (6 +/- 2% vs 2.4 +/- 1.6%, respectively; p = 0.07). In HPTH, early and generalized increments in bone mass follow PTX, and the combination of surgery with estrogen therapy may be superior to surgery without estrogen treatment. A randomized, controlled trial including PTX, estrogen, and a combination of the two is needed to determine the optimal therapy in postmenopausal women.

[Digital radiography of the thorax with selenium detector. Clinical results and optimization potential of the technique]

INTRODUCTION

We compared the image quality of the chest radiograph obtained with a digital selenium detector and with a conventional system and investigated the possible improvements in the digital technique resulting from kilovoltage (kV) lowering, antiscattering grid addition and image format reduction.

MATERIAL AND METHODS

150 subjects in the first series were submitted to posteroanterior chest radiography with both the selenium and the conventional systems. Image quality was compared by giving a score to the depiction of anatominal and pathologic findings. Thirty-two and 31 subjects from two other series were submitted to two digital chest radiographs each: the former at high (150) and low (90) kV, and the latter at 150 kV with the antiscattering grid and at 90 kV without the grid. Comparisons were made by choosing the better of the two images of each subjects. A score was given to the depiction quality of several difficult-to-detect findings in full-size and small-size format digital images obtained in another series of 27 subjects.

RESULTS

As for anatomical detailing, digital selenium images were of much better quality than conventional images: the mean scores given by 3 observers to digital images (5.32; 5.55; 6.68) are higher than those given to the corresponding conventional images (4.49; 5.02; 5.81) and the difference is statistically significant (p < 0.001 in all cases). The advantage of digital over conventional images is also significant with reference to diagnostic confidence in the identification of pathologic findings (p < 0.001; p < 0.005; p < 0.01), but to a lessere extent (mean scores: 3.98; 4.22; 3.60 for the digital system, versus 3.43; 3.69; 3.38 for the conventional system). The digital images acquired at lower kV (90 kV) were much more frequently chosen by the two observes (87.5% and 96.8% of cases) than the images acquired at 150 kV; the entry dose at lower energies (91 muGy using an anthropomorphic phantom) is not significantly higher than the dose given at 150 kV (85 muGy). No significant difference was found in the two observers' choice between the digital images taken at 90 kV without antiscattering grid and those taken at 150 kV with the grid, the former being preferred in 38.7% and 58% of cases. The level of diagnostic confidence in the detailing of difficult-to-detect findings was slightly higher in full-size digital images (mean scores: 5.33 and 6.77) than in small-size ones (4.88 and 5.96).

DISCUSSION AND CONCLUSIONS

Digital selenium images always exibit better quality than conventional images: the difference is very marked relative to anatomical detailing and not so striking, though still significant, in showing pathologic findings. Digital selenium image quality can be improved relative to the manufacturer's guidelines (150 kV exposure with no grid), by lowering the kV and adding the antiscattering grid, without increasing patient exposure too much. Digital image format reduction allows cost containment without affecting diagnostic reliability.

Management of tumors of the thoracolumbar spine

Current improvements in radiologic imaging and surgical instrumentation have greatly expanded the role of surgery in management of tumors of the thoracolumbar junction. For primary malignant tumors, the aim of surgery should be curative, with eradiction of all gross disease. For metastatic tumors, indications for surgery include cancer therapy, stabilization, neurologic palliation, tissue diagnosis, and pain relief. Because the thoracolumbar region is a transitional zone, surgical stabilization may require anterior-posterior approaches and instrumentation.

Epstein-Barr virus-associated dural leiomyosarcoma in a man infected with human immunodeficiency virus. Case report

A 35-year-old man infected with human immunodeficiency virus presented with cervical myelopathy of 2 months duration. Clinical and radiographic evaluation revealed a discrete, subdural mass at C-6. At surgery, the mass proved to have a dural attachment and thus clinically, radiographically, and grossly, it resembled meningioma. Histopathological analysis revealed a leiomyosarcoma that stained diffusely for muscle-specific actin. Electron microscopy revealed basal lamina surrounding the tumor cells and intracytoplasmic bundles of myofilaments. Epstein-Barr virus (EBV) was demonstrated within tumor cell nuclei by in situ hybridization for EBER1 messenger RNA and immunohistochemical staining for EBNA2 protein. Epstein-Barr virus latent membrane protein (LMP1) was not detected. This is the first documentation of an EBV-associated smooth-muscle tumor of the dura, and the first demonstration that tumors in this location contain EBV in an unusual form of latency not seen in lymphoid cell lines. With increasing numbers of individuals being afflicted with long-term immunosuppression, EBV-associated dural leiomyoma and leiomyosarcoma may be encountered more frequently in the future.

Intracerebral hemorrhage occurring remote from the craniotomy site

OBJECTIVE

The purpose of this study was to analyze the available clinical data on postoperative intracerebral hemorrhages that occur in locations remote from the sites of craniotomy.

METHODS

The findings of 37 cases of postoperative intracerebral hemorrhages occurring remote from the craniotomy sites were reviewed (5 from our records and 32 from the literature).

RESULTS

Remote postoperative intracerebral hemorrhages presented within the first few hours postoperatively in 78% of the patients and were not related to the types of lesions for which the craniotomies were performed. Supratentorial procedures that produced infratentorial hemorrhages involved operations in the deep sylvian fissure and paraclinoid region in 81% of the patients and hemorrhages in the cerebellar vermis in 67% of the patients. Infratentorial procedures that produced supratentorial hemorrhages were performed with the patient in the sitting position for 87% of the patients. The remote supratentorial hemorrhages that occurred were superficial and lobar in 84% of the patients, as opposed to deep and basal ganglionic, which are classic locations for hypertensive hemorrhages. Remote intracerebral hemorrhages occurring after craniotomies were not associated with hypertension, coagulopathy, cerebrospinal fluid drainage, or underlying occult lesions. These hemorrhages commonly led to significant complications; 5 of 37 patients (14%) were left severely disabled, and 12 of 37 patients (32%) died.

CONCLUSIONS

Remote intracerebral hemorrhage is a rare complication of craniotomy with significant morbidity and mortality. Such hemorrhages likely develop at or soon after surgery, tend to occur preferentially in certain locations, and can be related to the craniotomy site, operative positioning, and nonspecific mechanical factors. They do not seem to be related to hypertension, coagulopathy, cerebrospinal fluid drainage, or underlying pathological abnormalities.

Multidisciplinary discharge planning: developing a process

In today's health care environment, Frankford Health Care System identified the need for a discharge planning process. A multidisciplinary task force developed and implemented a system that decreased length of stay and duplication of services, improved timeliness of intervention and fostered communication and respect among team members. The process included assessment of patient/family needs and coordination of care, services and referrals for all patients.

Indications and results of combined anterior-posterior approaches for spine tumor surgery

Spinal instrumentation currently allows gross-total resection and reconstruction in cases of malignancies at all levels of the spine. The authors analyzed the results in 110 patients who underwent surgery for primary and metastatic spinal tumors over a 5-year period (1989-1993) at a single institution. Major primary sites of tumor included breast (14 cases), chordoma (14 cases), lung (12 cases), kidney (11 cases), sarcoma (13 cases), plasmacytoma (10 cases), and others (36 cases). Prior to surgery, 55 patients (50%) had received prior treatment. Forty-eight patients (44%) were nonambulatory, and severe paraparesis was present in 20 patients. Fifty-three patients (48%) underwent combined anterior-posterior resection and instrumentation. 33 (30%) underwent anterior resection with instrumentation, 18 (16%) underwent anterior or posterior resection alone, and the remaining six patients (5%) underwent posterior resection and instrumentation. Major indications for anterior-posterior resection included three-column involvement, high-grade instability, involvement of contiguous vertebral bodies, and solitary metastases. Postoperatively, 90 patients improved neurologically. The overall median survival was 16 months, with 46% of patients surviving 2 years. Fifty-three patients (48%) suffered postoperative complications. Despite the high incidence of complications, the majority of patients reported improvement in their quality of life at follow-up review. Our findings suggest that half of all patients with spinal malignancies require combined anterior-posterior surgery for adequate tumor removal and stabilization.

Primary hyperaldosteronism in pregnancy. A case report

BACKGROUND

Primary hyperaldosteronism is an uncommon disorder, and there are few reports of its occurrence and management in pregnancy.

CASE

Primary hyperaldosteronism was suspected before pregnancy in a 31-year-old women with refractory hypertension and hypokalemia. Pregnancy evaluation revealed suppressed renin levels and high aldosterone levels; computed tomography revealed a 1-cm mass in the left adrenal gland. The patient became pregnant before completion of evaluation and treatment. On high doses of nifedipine and nadolol, the first-trimester blood pressure was 130/98 mm Hg and remained high in the early second trimester. In view of the risks of poorly controlled hypertension, adrenalectomy was performed at 15 weeks' gestation, with rapid improvement in blood pressure and elimination of the patient's requirement for large doses of potassium daily. Antihypertensive medication was withdrawn, with maintenance of normal blood pressure until 36 weeks' gestation. At that time the blood pressure rose slightly but responded to bed rest. A healthy female infant was delivered at term by cesarean section.

CONCLUSION

Previous reports of emergency preterm delivery and a case of neonatal mortality in the setting of hyperaldosteronism in pregnancy confirm the significant risks associated with this condition. In our patient, adrenalectomy in the early second trimester resulted in a rapid and sustained improvement in hypertension, reversal of hypokalemia and a good pregnancy outcome.

Surgical treatment of spinal cord compression from epidural metastasis

PURPOSE

A retrospective study of the results of neoplastic cord compression was undertaken to determine the effectiveness of surgical treatment and to assess quality of life in patients undergoing extensive procedures with potential morbidity.

PATIENTS AND METHODS

Over a 5-year period (1989 to 1993), a total of 110 patients underwent surgery. Fifty-five patients (50%) had undergone prior treatment, including 47 (43%) who had failed to respond to prior irradiation (RT). Before surgery, 48 patients (44%) were nonambulatory, with severe paresis being present in 20. Surgery included staged anterior-posterior resections in 53 patients (48%), anterior resections in 33 (30%), and posterior resection in six (5%), all of whom required spinal instrumentation for reconstruction; only 18 patients underwent resection without instrumentation.

RESULTS

Postoperatively, 90 patients (82%) were improved, both in terms of pain relief and ambulatory status. Fifty-three patients (48%) experienced postoperative complications, related statistically to the following three factors: age over 65 years, prior treatment, and presence of paraparesis. The overall median survival duration was 16 months, with 46% alive at 2 years. Apart from primary tumor, the presence of preoperative paraparesis had the most significant impact on survival.

CONCLUSION

Our data suggest that the effective surgical treatment of neoplastic compression requires anterior-posterior resection in most patients to achieve the goal of total tumor resection, with the majority requiring instrumentation. Long-term survival is feasible in a subset of patients with this aggressive surgical approach.