Diagnosing variant Creutzfeldt-Jakob disease: a retrospective analysis of the first 150 cases in the UK

INTRODUCTION

Establishing an early clinical diagnosis in variant Creutzfeldt-Jakob disease (vCJD) can be difficult, resulting in extended periods of uncertainty for many families and sometimes a view that patients have been subjected to unnecessary investigations. This issue is accentuated by the progressive nature of vCJD and by the difficulty in achieving a confident clinical diagnosis before an advanced stage of illness. Although diagnostic delay may be a result of the non-specific early clinical features, a systematic analysis of the process of diagnosis was undertaken, with the aim of trying to achieve earlier diagnosis of vCJD.

METHODS

Retrospective case file analysis was undertaken of the first 150 definite and clinically probable cases of vCJD identified by the UK surveillance system.

RESULTS

There is a significant interval between illness onset and presentation to a primary care physician, which is influenced by the nature of the initial clinical features. Neurological review is invariably sought following the development of clinical signs and a diagnosis is then established relatively quickly. Despite the progressive clinical course, a confident clinical diagnosis is not usually achieved until a relatively advanced stage of illness (mean time to diagnosis 10.5 months) with a more rapid clinical progression accounting for those cases diagnosed earlier after symptom onset.

CONCLUSIONS

Early clinical diagnosis in vCJD is not possible in the great majority of cases because of non-specific initial symptoms. Once neurological signs develop, a diagnosis is usually made promptly but this is often at a relatively advanced stage of illness. The inherent delays in the diagnosis of vCJD have implications for those involved in both public health and therapeutics.

Skeletal morbidity in children receiving chemotherapy for acute lymphoblastic leukaemia

BACKGROUND

Children receiving chemotherapy for acute lymphoblastic leukaemia (ALL) may be susceptible to skeletal morbidity.

AIM

To determine the incidence and risk factors for skeletal morbidity in ALL children.

PATIENTS AND METHODS

The medical records of all (n=186, boys=110) children presenting to a single centre with ALL between 1997 and 2007 and treated on UKALL97, UKALL97/01 or UKALL2003 were studied. Skeletal morbidity included musculoskeletal pain, fractures and osteonecrosis (ON). Musculoskeletal pain was classified as any event of limb pain, muscle pain, joint symptoms or back pain that required radiological examination. Fractures and ON were confirmed by x-rays and MRI, respectively.

RESULTS

Skeletal morbidity, presenting as musculoskeletal pain, fractures or ON were reported in 88 (47%) children of whom 56 (63%) were boys. Of 88 children, 49 (55%), 27 (30%) and 18 (20%) had musculoskeletal pain, fracture(s) or ON, respectively. 6 (7%) had fractures and ON. The median (10th, 90th centiles) age at diagnosis of ALL in those children without skeletal morbidity was 3.9 (1.4-12) years which was lower than in those with skeletal morbidity at 8.2 (2.2-14.3) years (p<0.00001, 95% CI 1.7 to 4.4). Children with ALL diagnosed over 8 years of age were at increased risk of developing fracture(s) (p=0.01, OR=2.9, 95% CI 1.3 to 6.5) whereas the risk of ON was higher in those who were diagnosed after 9 years of age (p<0.0001, OR=15, 95% CI 4.1 to 54.4). There was no sex difference in the incidence of skeletal complications. Children who received Dexamethasone had a higher incidence of skeletal morbidity than those who were treated with Prednisolone (p=0.027, OR=2.6, 95% CI 1.1 to 5.9).

CONCLUSION

The occurrence of skeletal morbidity in ALL children may be influenced by age and the type of glucocorticoids. These findings may facilitate the development of effective bone protective intervention.

Interactions between voice clinics and singing teachers: a report on the British Voice Association questionnaire to voice clinics in the UK

Singers with vocal problems are among patients who present at multidisciplinary voice clinics led by Ear Nose and Throat consultants and laryngologists or speech and language therapists. However, the development and care of the singing voice are also important responsibilities of singing teachers. We report here on the current extent and nature of interactions between voice clinics and singing teachers, based on data from a recent survey undertaken on behalf of the British Voice Association. A questionnaire was sent to all 103 voice clinics at National Health Service (NHS) hospitals in the UK. Responses were received and analysed from 42 currently active clinics. Eight (19%) clinics reported having a singing teacher as an active member of the team. They were all satisfied with the singing teacher's knowledge and expertise, which had been acquired by several different means. Of 32 clinics without a singing teacher regularly associated with the team, funding and difficulty of finding an appropriate singing voice expert (81% and 50%, respectively) were among the main reasons for their absence. There was an expressed requirement for more interaction between voice clinics and singing teachers, and 86% replied that they would find it useful to have a list of singing teachers in their area. On the matter of gaining expertise and training, 74% of the clinics replying would enable singing teachers to observe clinic sessions for experience and 21% were willing to assist in training them for clinic-associated work.

Familial effects on the clinical course of multiple sclerosis

BACKGROUND

Familial factors influence susceptibility to multiple sclerosis (MS) but it is unknown whether there are additional effects on the natural history of the disease.

METHOD

We evaluated 1,083 families with > or =2 first-degree relatives with MS for concordance of age at onset, clinical course, and disease severity and investigated transmission patterns of these clinical features in affected parent-child pairs.

RESULTS

There is concordance for age at onset for all families (correlation coefficient 0.14; p < 0.001), as well as for affected siblings (correlation coefficient 0.15; p < 0.001), and affected parent-child pairs (correlation coefficient 0.12; p = 0.03) when each is evaluated separately. Concordance for year of onset is present among affected siblings (correlation coefficient 0.18; p < 0.001) but not the parent-child group (correlation coefficient 0.08; p = 0.15). The clinical course is similar between siblings (kappa 0.12; p < 0.001) but not affected parents and their children (kappa -0.04; p = 0.09). This influence on the natural history is present in all clinical subgroups of relapsing-remitting, and primary and secondary progressive MS, reflecting a familial effect on episodic and progressive phases of the disease. There is no concordance for disease severity within any of the considered family groups (correlation coefficients: all families analyzed together, 0.02, p = 0.53; affected sibling group, 0.02, p = 0.61; affected parent-child group, 0.02, p = 0.69). Furthermore, there are no apparent transmission patterns of any of the investigated clinical features in affected parent-child pairs and no evidence for anticipation or effects of genetic loading.

CONCLUSION

Familial factors do not significantly affect eventual disease severity. However, they increase the probability of a progressive clinical course, either from onset or after a phase of relapsing remitting disease. The familial effect is more likely to reflect genetic than environmental conditions. The results are relevant for counseling patients and have implications for the design of studies seeking to identify factors that influence the natural history of the disease.

Polymorphisms within the CTLA4 gene are associated with infant atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is one of the most common childhood disorders. It can have a significant impact on the physical and psychological well-being of affected individuals. Although environmental triggers are important, AD also has a strong genetic component. Identifying genes associated with AD may help to understand better the basis of this disorder and its relationship with other allergic disorders such as asthma.

OBJECTIVES

Polymorphisms in the gene encoding the inhibitory CTLA4 receptor, an important regulator of T cells, are associated with asthma as well as autoimmune disorders. We have now tested whether polymorphisms in the CTLA4 gene are also associated with early childhood AD.

METHODS

A family-based cohort of 112 children and their parents was recruited from Western Sydney, Australia. All children were seen by a paediatric dermatologist and presented with AD within the first 3 years of life. Using the transmission disequilibrium test, individual and haplotypic associations with the +49 and CT60 polymorphisms in exon 1 and the 3' nontranslated DNA of the CTLA4 gene were tested.

RESULTS

Single tests of association revealed significant association of the +49(A) [P = 0.037, odds ratio (OR) 1.59, 95% confidence interval (CI) 1-2.55] and borderline significance of the CT60(A) alleles (P = 0.055, OR 1.51, 95% CI 1-2.38). Significant association of the +49(A)/CT60(A) haplotype was detected (P = 0.002, OR 1.78, 95% CI 1.2-2.65).

CONCLUSIONS

Polymorphisms within the gene encoding CTLA4 were associated with early onset infant AD. This is in agreement with findings from asthmatic cohorts, suggesting that the +49(A)/CT60(A) haplotype is a genetic risk factor common to asthma and AD.

Physiological and anthropometric characteristics of starters and non-starters and playing positions in elite Australian Rules Football: a case study

A purpose of this study was to determine if pre-season anthropometric and physiological measures were significantly different for the players from one Australian Football League (AFL) club selected to play in the first game of the season compared to the players not selected. Another purpose was to compare fitness test results for defenders, forwards and mid-fielders in the same AFL club. Thirty-four players were tested for isolated quadriceps and hamstrings strength, leg extensor muscle strength and power, upper body strength, sprinting speed, vertical jump (VJ), endurance, skinfolds and hamstring flexibility. The starters who were selected to play the first game were a significantly older and more experienced playing group, and were significantly better (p < 0.05) in measures of leg power, sprinting speed and the distance covered in the Yo Yo intermittent recovery test compared to the non-starters. Although there were trends for the superiority of the starters, the differences in lower and upper body strength, VJ and predicted VO2max were non-significant. The forwards generally produced the worst fitness scores of the playing positions with the midfielders having significantly lower skinfolds and the defenders possessing better hamstring strength and VJ compared to the forwards. It was concluded that some fitness qualities can differentiate between starters and non-starters, at least in one AFL club. Comparisons of playing positions and the development of fitness norms for AFL players require further research.

Polymorphisms within the PHF11 gene at chromosome 13q14 are associated with childhood atopic dermatitis

Atopic dermatitis is an increasingly common and debilitating childhood disorder that is often accompanied by asthma and allergic rhinitis. Although the pathology of these disorders is distinct, the majority of cases are atopic, typified by elevated serum IgE. A new locus at chromosome 13q14 centred on the genes SETDB2 and PHF11 and associated with increased total serum IgE has recently been identified. Although the precise functions of SETDB2 and PHF11 are not known, both proteins are expressed in cells of the immune system and include conserved domains that suggest a role in chromatin remodelling or transcriptional regulation, respectively. In a family-based association study across the SETDB2 and PHF11 genes, we have identified two single-nucleotide polymorphisms in the PHF11 gene significantly associated with childhood atopic dermatitis in an Australian cohort. These results provide further evidence that this locus is a novel and important regulator of human atopic disease.

Effects of immediate post-game recovery procedures on muscle soreness, power and flexiblity levels over the next 48 hours

This study investigated whether or not immediate post-game recovery procedures could enhance the rate of recovery in Australian football players in the first 48 hr after a game. Control, stretch, pool walking and hot/cold recoveries were trialled. Typical next day recovery training (25 min of pool exercise) was also performed after each game. Muscle soreness ratings and measures of flexibility (sit and reach) and power (6-s cycling sprint and vertical jump) were obtained 45 hr pre-game (Thursdays) (baseline), 15 hr post-game (Sundays, prior to "next day" recovery) and 48 hr post-game (Mondays). Performance ratios (Sunday and Monday scores divided respectively by the Thursday score) were used as the primary index of recovery. Muscle soreness was significantly greater (p<0.01) than baseline on both Sunday and Monday in all conditions, but no differences between the three recoveries and control were evident. On Sunday, vertical jump and 6-s work and power scores were only significantly lower than baseline values in control and performance ratios recorded two significant differences (vertical jump: pool walking > control, p<0.01; 6-s power: stretch > control, p<0.01) and moderate to large effect sizes (>0.3). No differences were found between the three experimental recoveries. On Monday no significant differences were recorded in performance between the recoveries and the effect sizes were of lower magnitude. In conclusion, recovery of muscle soreness, flexibility and power at 48 hr post-game was not significantly enhanced by performing an immediate post-game recovery beyond that achieved by performing only next day recovery training.

Increased Risk of Hemorrhagic Complications in Renal Allograft Recipients Receiving Systemic Heparin Early Posttransplantation

The aim of this paper is to document the risk of hemorrhagic complications in renal allograft recipients requiring systemic heparinisation within the first 2 weeks posttransplantation.

METHODS

A retrospective chart review of 326 RA recipients from January 1998 to July 2003 was subjected to statistics by SPIDA with P values <.05 considered significant.

RESULTS

16/326 (4.9%) recipients were initiated on intravenous (IV) heparin within the study period. Enoxaparin was subsequently used in 10/16 (62.5%) of these recipients. Intravenous heparin was instituted at a median 8 (1-14) days posttransplantation. Hemorrhagic complications occurred in 10/16 (62.5%) recipients on IV heparin versus 11/310 (3.5%) nonanticoagulated RA recipients (P = .0001). Hemorrhage occurred at a mean 9.75 (2-43) days into the course of IV heparin. The median peak APTT 24 hours prior to hemorrhage in RA recipients on heparin was 68.5 (58-180) versus a median peak APTT of 70 (50-140) among recipients on heparin who did not sustain a hemorrhagic complication (P = .30). A major intervention (predominantly surgery) was required in 6/16 (37%) recipients on IV heparin versus 7/310 (2.2%) nonheparinised RA recipients (P < .0001). Enoxaparin was instituted at a mean 22.5 (4-55) days posttransplantation. Delayed hemorrhage subsequently occurred in 4/10 (40%) recipients on enoxaparin. In conclusion, major and minor hemorrhagic complications occur more commonly among recipients requiring early post transplant IV heparin. Hemorrhage occurred despite APTT monitoring with APTT levels tending to be similar in RA recipients with versus without complications. Delayed hemorrhage was also seen with the subsequent use of enoxaparin.

Comparison of training activities and game demands in the Australian Football League

his paper serves as a companion to our recent study of the movement patterns and game activities of players (from five different positions) during matches in the 2000 Australian Football League season. Using lapsed-time video analysis, the same individual players (n= 11) as filmed in matches were also monitored during 21 in-season, main training sessions conducted by their clubs in order to assess the degree to which training activities matched game demands. In general, the training sessions did not involve physical pressure; therefore there were very few contested marks and ground balls or tackles, shepherds and spoils, thereby not matching these game demands. Players typically had more possessions (kicks and handballs) at training than in games. They also spent a greater percentage of total time standing and less time walking at training than in games. Fast-running and sprinting efforts at training were almost all for durations of <6 secs, which matched game demands, as did changes of direction when sprinting, which were almost all in a 0-90 degrees arc. However, across all players filmed, high intensity (fast-running and sprinting) movements were not performed as frequently at training (one every 76 secs) as in games (one every 51 secs). Therefore, while some game demands were adequately replicated at training, others were not closely simulated, suggesting that, after careful interpretation of these results, some improvements in training practices could be made.

Evaluation of detection methods for genetically modified traits in genotypes resistant to European corn borer and herbicides

Detection of genetically modified (GM) traits in corn (Zea mays L.) is urgently needed for preservation of genetic identity and marketing GM products. A laboratory study was conducted to evaluate the efficiency, accuracy, and reliability of different analytical methods to detect GM traits in corn. Samples with known fractions of GM concentrations (Bacillus thuringiensis [Bt], Liberty Link [LL] and stacked [Bt/LL] genes) from commercial seed companies and those derived from yellow kernels in a white corn ear, outcrossed by pollen of neighboring Bt hybrid, were tested by lateral flow quick test kits and by enzyme-linked immunosorbent assay (ELISA)-based test strips purchased from different companies. Liberty Link hybrids are resistant to glufosinate (Liberty or Basta) herbicides, whereas Bt corn is developed for the control of European corn borer (Ostrinia nubilalis). Selected samples of GM concentrations were also tested in a commercial laboratory using DNA-based polymerase chain reaction (PCR) test. The results demonstrated that qualitative lateral flow quick tests could detect samples containing 1% or higher Bt and 2% or higher LL concentrations within the recommended time limit of the test. Faint test lines for samples containing 0.5 to 1% Bt or 1 to 2% LL concentrations appeared if samples remained in the test cup overnight. ELISA test strips detected the Bt content semiquantitatively in the range of 0.5 to 2.0%. Grain samples derived from non-Bt corn outcrossed by neighboring Bt pollen had usually lower GM concentrations than commercial GM seed samples. Both ELISA- and DNA-based PCR tests distinguished samples with GM concentrations between 0.1 to 0.5%, but the precision of quantification at this range was very low and results were highly inconsistent.

A case-control study of sporadic Creutzfeldt-Jakob disease in the United Kingdom: Analysis of clustering

BACKGROUND

The authors investigated whether cases of sporadic Creutzfeldt-Jakob disease (CJD) had lived closer to one another at some time in life than individuals without sporadic CJD. Such a phenomenon would be compatible with some cases resulting from transmission.

METHODS

UK sporadic CJD cases occurring from 1990 to 1998 were identified. Age-, sex- and hospital-matched controls were recruited. Lifetime residential histories were obtained by interview, usually with a proxy respondent. With use of Monte Carlo simulation, the residential proximity of cases during various time periods was compared with that expected in the absence of any clustering, using the information collected on the controls.

RESULTS

Two hundred twenty sporadic CJD disease cases and 220 controls were included. Cases lived closer together than might be expected in the absence of any disease-clustering mechanism. This evidence became stronger as the critical period during which residential proximity was required to have occurred extended further into the past.

CONCLUSIONS

These findings are consistent with some sporadic Creutzfeldt-Jakob disease (CJD) cases resulting from exposure to a common external factor. The rarity of sporadic CJD suggests that repeated point-source outbreaks of infection are more likely to explain our observations than direct case-to-case transmission. Identifying sources of such outbreaks many years after the event will be extremely difficult.

Elderly patients with fluoropyrimidine and thymidylate synthase inhibitor-resistant advanced colorectal cancer derive similar benefit without excessive toxicity when treated with irinotecan monotherapy

Elderly patients are recommended to have a reduced starting dose (300 mg m⁻² once every 3 weeks) of irinotecan monotherapy. The aims of this analysis are to compare toxicity and survival according to age, performance status (PS), gender and prior radical pelvic radiotherapy (RT). The primary end points were overall survival and an irinotecan-specific toxicity composite end point (TCE) defined as the occurrence of grade 3 or 4 diarrhoea, neutropenia, febrile neutropenia, fever, infection or nausea and vomiting. Between 1997 and 2003, 339 eligible patients with advanced colorectal cancer (CRC) progressing on or within 24 weeks of completing fluoropyrimidine-based chemotherapy were prospectively registered in a multicentre randomised trial. All patients commenced irinotecan at 350 mg m⁻² once every 3 weeks. There were no differences in proportions of patients developing TCE by age (<70 vs ⩾70 : 37.8 vs 45.8%; P=0.218), PS (0–1 vs 2 : 39.3 vs 41.5%; P=0.793) or prior RT (RT vs no RT : 45.1 vs 38.5%; P=0.377). Males experienced more toxicity than females (44.3 vs 32.6%; P=0.031), but this was not significant after controlling for other co-variates (P=0.06). Patients aged ⩾70 had similar objective responses (11.1 vs 9%; P=0.585) and survival (median 9.4 vs 9 months; log rank P=0.74) compared to younger patients. Elderly patients derive the same benefit without experiencing more toxicity with second-line irinotecan treatment for advanced CRC. Our data do not support the recommendation to reduce the starting dose for the elderly patients.

Player movement patterns and game activities in the Australian Football League

In the Australian Football League (AFL), specific game movements and activities have not been studied since the 1970s and 1980s and the game is now much faster than it was 20-30 years ago. Using lapsed-time video analysis, AFL players from five different positions (full forward/full back, centre half forward/centre half back, small forward/small back, mid fielders and ruckmen) had their movement patterns (stand, walk, jog, fast-run, sprint, change of direction) and game activities (possessions, ruck duels, ground ball contests, shepherds, spoils, bumps and tackles) recorded in two games each in the 2000 season. A descriptive analysis of the results was undertaken. The main findings were: full forward/full back were most different from the other positions, as they were seen to stand more and jog and fast-run less: ruckmen and midfielders were involved in more game activities than the other positions; for all positions, there were more than 150 high intensity movements (fast-run plus sprint) in the game, but these accounted for only 4-6% of total movement time: virtually all of the high intensity movements lasted for <6 secs; more than half of all sprints involved at least one change of direction, mostly within the 0-90 degrees arc (left or right) and all ground ball contests took <6 secs, with midfielders having 2-3 times as many as the other positions. Improvements in specific pre-season and in-season training practices for different positions should be possible after careful interpretation of these findings.

Active management of term prelabour rupture of membranes with oral misoprostol

OBJECTIVE

To compare the active management of term prelabour rupture of membranes with oral misoprostol with conservative management for 24 hours followed by induction with oxytocin or prostaglandin E(2) (PGE(2)) gel.

DESIGN

A non-blinded randomised controlled trial.

SETTING

Induction and labour wards, Aberdeen Maternity Hospital.

POPULATION

Sixty-one women with confirmed prelabour rupture of the membranes at > or =36 weeks of gestation.

METHODS

The women were randomised to 50 microg of oral misoprostol repeated every 4 hours, if required, to a maximum of five doses (active group), or to induction of labour with PGE(2) gel or oxytocin only if not in spontaneous labour 24 hours after prelabour rupture of membranes (conservative group).

MAIN OUTCOME MEASURES

Number of women in active labour within 24 hours of the prelabour rupture of membranes, preference of women for any one particular method of management in any subsequent pregnancy with prelabour rupture of membranes.

RESULTS

93.3% of the active group and 54.8% of the conservative group were in spontaneous labour within 24 hours of the prelabour rupture of membranes (RR 1.7, 95% CI 1.2 to 2.4). Of those achieving a vaginal delivery, 72% of the active group did so within 24 hours of the prelabour rupture of membranes as compared with 26.9% of the conservative group (RR 2.7, 95% CI 1.4 to 5.3, P = 0.002). There were no significant differences in the neonatal or maternal outcomes. In the active group, 78% felt they would have the same method of induction as compared with 40% in the conservative group (RR 1.9, 95% CI 1.1 to 3.3, P = 0.03).

CONCLUSIONS

Active management with oral misoprostol resulted in more women going into labour and delivering within 24 hours of the prelabour rupture of membranes with no increase in maternal or neonatal complications. Women tended to view active management of prelabour rupture of membranes more positively. Oral misoprostol might be an option to consider in those wishing active management.

Barmah-Millewa forest environmental water allocation

The formal allocation of water for the environment is a developing area of river management both scientifically and in terms of community participation. This case study, illustrating the recent use of the Barmah-Millewa Forest Environmental Water Allocation (EWA), provides a practical demonstration of community participation in environmental water management, the application of hydrological and biological "triggers" and a positive, demonstrable biological outcome from an environmental water allocation. The Barmah-Millewa Forest covers an area of 70,000 ha across the floodplain of the Murray River, upstream of the town of Echuca. About half the forest is in NSW (Millewa) and half is in Victoria (Barmah). The Barmah Forest is a Wetland of International Importance listed under the Convention on Wetlands - Ramsar Convention. The forest is the largest river redgum forest in the world. The natural flooding cycle associated with the forest has been significantly altered by regulation of the Murray River--impacting upon the overall health of the forest ecosystem. Recognising this, the Murray Darling Basin Commission developed a water management strategy for the forest to enhance forest, fish and wildlife values. To implement this strategy, between 1990 and 1993 reports were completed and community consultation took place. In 1993 the Murray Darling Basin Ministerial Council approved allocation of 100 Gigalitres of water per year, provided in equal shares by NSW and Victoria, to meet the needs of the forest ecosystem and in 1994 the Barmah-Millewa Forum was established under the Murray-Darling Basin Agreement. The vision for the Forum is to maintain and, where possible, improve the ecological and productive sustainability of the Barmah-Millewa Forest and to establish a planning and operational framework to better meet the flooding and drying requirements of the riparian forests and wetlands. Between October 2000 and January 2001 the Barmah-Millewa Forest Environmental Water Allocation was used for the second time. A total of 341 GL was released as an EWA. This amount represented only 8% of the total flows downstream of Yarrawonga Weir from September 2000 and January 2001. The strategic use of the relatively small amount of water enabled flooding to be maintained and ensured significant breeding success for water birds and other biota in the Forest.

p53 dysfunction in B-cell chronic lymphocytic leukemia: inactivation of ATM as an alternative to TP53 mutation

The well-established association between TP53 mutations and adverse clinical outcome in a range of human cancers reflects the importance of p53 protein in regulating tumor-cell growth and survival. Although it is theoretically possible for p53 dysfunction to arise through mechanisms that do not involve TP53 mutation, such a phenomenon has not previously been demonstrated in a sporadic tumor. Here, we show that p53 dysfunction in B-cell chronic lymphocytic leukemia (CLL) can occur in the absence of TP53 mutation and that such dysfunction is associated with mutation of the gene encoding ATM, a kinase implicated in p53 activation. Forty-three patients with CLL were examined for p53 dysfunction, as detected by impaired up-regulation of p53 and of the p53-dependent protein p21(CIP1/WAF1) after exposure to ionizing radiation (IR). Thirty (70%) patients had normal p53 responses and underwent progressive IR-induced apoptosis. In 13 (30%) patients, p21 up-regulation was markedly impaired, indicating p53 dysfunction. Six (14%) of these patients with p53 dysfunction had increased baseline levels of p53, were found to have TP53 mutations, and were completely resistant to IR-induced apoptosis. In the other 7 (16%) patients with p53 dysfunction, IR-induced p53 up-regulation and apoptosis were markedly impaired, but baseline levels of p53 were not increased, and no TP53 mutations were detected. Each of these patients was found to have at least one ATM mutation, and a variable reduction in ATM protein was detected in all 4 patients examined. This is the first study to provide a direct demonstration that p53 dysfunction can arise in a sporadic tumor by a mechanism that does not involve TP53 mutation. (Blood. 2001;98:814-822)

The -590C/T and -34C/T interleukin-4 promoter polymorphisms are not associated with atopic eczema in childhood

Susceptibility to the development of asthma and other atopic diseases is known to have a genetic component. To date, several studies have linked chromosome 5q31 to asthma and atopy in human beings. This region harbors a cluster of cytokine and growth factor genes, IL-4 presenting as a prime atopy candidate gene, inasmuch as it plays a pivotal role in the atopy pathway. Our approach was to identify polymorphisms within the promoter regions of IL-4 and test their association with atopic eczema. Polymorphisms were typed in a cohort of 76 small nuclear families and 25 triads with childhood atopic eczema. The genotypes were used to test for linkage in the presence of association with atopic eczema. A new polymorphism, -34C/T, was identified and studied with a known polymorphism, -590C/T. On its own, each polymorphism showed no association with atopic eczema. The 2 polymorphisms were used to generate haplotypes, and a significant result was found for the -590C/-34C haplotype. However, after Bonferroni correction for multiple testing, the association became nonsignificant. Neither polymorphism predisposes to early-onset atopic eczema by itself, but suggestive linkage was found for the -590C/-34C haplotype in this study.

Epidemiology and diagnosis of meningitis: results of a five-year prospective, population-based study

Implementation of the advice to give penicillin prior to admission, a fall in the lumbar puncture rate and the introduction into routine use of the meningococcal polymerase chain reaction (PCR) test are factors that have led us to reassess the way meningitis is diagnosed. We examined data for the period 1994-98 from a health district of 800,000 population. Of the 355 cases of meningitis reported, 258 (73%) had either confirmed, probable or possible meningococcal disease. Only 28% of meningococcal cases had received pre-admission benzylpenicillin. The proportion of suspected meningitis cases undergoing lumbar puncture fell over the period. It was 79% in 1994 and 61% in 1998 (p < 0.001). After meningococcal PCR was introduced in 1996, 73 (68%) meningococcal cases were microbiologically confirmed, compared to 72 (48%) before 1996 (p = 0.001). In all cases, age was an independent predictor of meningitis mortality, and for meningococcal cases, age and serogroup were independent predictors. Advice to general practitioners (GPs) to give preadmission benzylpenicillin to any suspected case of meningitis or meningococcal septicaemia should be reinforced regardless of age or whether a rash is present.

Geographical distribution of variant Creutzfeldt-Jakob disease in Great Britain, 1994-2000

BACKGROUND

Geographical variation in the distribution of variant Creutzfeldt-Jakob disease (vCJD) might indicate the transmission route of the infectious agent to man. We investigated whether regional incidences of vCJD were correlated with regional dietary data.

METHODS

The National CJD Surveillance Unit prospectively identified 84 people with vCJD up to Nov 10, 2000, in Great Britain. Their lifetime residential histories were obtained by interviews with a close relative. Cumulative incidences of vCJD by standard region were calculated. Grid references for places of residence in 1991 were identified and evidence of geographical clusters were sought. Data on diet in the 1980s were analysed for regional correlations with vCJD incidence. The socioeconomic status of the places of residence of people with vCJD was compared with that of the general population.

FINDINGS

vCJD incidence was higher in the north of Great Britain than the south. The rate ratio (north vs south) was 1.94 (95% CI 1.27-2.98). The mean Carstairs' deprivation score for areas of residence of people with vCJD was -0.09 (-0.73 to 0.55), which is close to the national average of zero. Regional rates of vCJD were correlated with consumption of other meat or meat products as classified and recorded by the Household Food Consumption and Expenditure Survey (r=0.72), but not with data from the Dietary and Nutritional Survey of British Adults. Five people with vCJD in Leicestershire formed a cluster (p=0.004).

INTERPRETATION

Regional differences in vCJD incidence are unlikely to be due to ascertainment bias. We had difficulty determining whether regional variations in diet might cause these differences, since the results of dietary analyses were inconsistent.

Renal venous thrombosis with calcification and preservation of renal function

Two neonates were found on US to have branching linear calcification in the renal parenchyma, right sided in one and bilateral in the other. CT confirmed the presence of branching calcification in the kidneys and demonstrated calcified thrombus in the inferior vena cava in both babies. Antenatal detection of adrenal haemorrhage in one baby and presence of calcification at the age of 3 days in the other indicate that thrombosis probably occurred before birth. The kidneys remained normal in size, and uptake of 99mTc-labelled dimercaptosuccinic acid (99mTc-DMSA) was normal on follow-up examination. The presence of branching calcification and normal renal size probably indicates good prognosis for renal function in neonates in whom renal venous thrombosis is found and may indicate prenatal thrombosis.

Multiplexing of optical fiber gas sensors with a frequency-modulated continuous-wave technique

We report on the use of a frequency-modulated continuous-wave technique for multiplexing optical fiber gas sensors. The sensor network is of a ladder topology and is interrogated by a tunable laser. The system performance in terms of detection sensitivity and cross talk between sensors was investigated and found to be limited by coherent mixing between signals from different channels. The system performance can be improved significantly by use of appropriate wavelength modulation-scanning coupled with low-pass filtering. Computer simulation shows that an array of 37 acetylene sensors with a detection accuracy of 2000 parts in 10(6) for each sensor may be realized. A two-sensor acetylene detection system was experimentally demonstrated that had a detection sensitivity of 165 parts in 10(6) for 2.5-cm gas cells (or a minimum detectable absorbance of 2.1 x 10(-4)) and a cross talk of -25 dB.

Acyl-homoserine lactone production is more common among plant-associated Pseudomonas spp. than among soilborne Pseudomonas spp

A total of 137 soilborne and plant-associated bacterial strains belonging to different Pseudomonas species were tested for their ability to synthesize N-acyl-homoserine lactones (NAHL). Fifty-four strains synthesized NAHL. Interestingly, NAHL production appears to be more common among plant-associated than among soilborne Pseudomonas spp. Indeed, 40% of the analyzed Pseudomonas syringae strains produced NAHL which were identified most often as the short-chain NAHL, N-hexanoyl-L-homoserine lactone, N-(3-oxo-hexanoyl)-homoserine lactone, and N-(3-oxo-octanoyl)-L-homoserine lactone (no absolute correlation between genomospecies of P. syringae and their ability to produce NAHL could be found). Six strains of fluorescent pseudomonads, belonging to the species P. chlororaphis, P. fluorescens, and P. putida, isolated from the plant rhizosphere produced different types of NAHL. In contrast, none of the strains isolated from soil samples were shown to produce NAHL. The gene encoding the NAHL synthase in P. syringae pv. maculicola was isolated by complementation of an NAHL-deficient Chromobacterium mutant. Sequence analysis revealed the existence of a luxI homologue that we named psmI. This gene is sufficient to confer NAHL synthesis upon its bacterial host and has strong homology to psyI and ahlI, two genes involved in NAHL production in P. syringae pv. tabaci and P. syringae pv. syringae, respectively. We identified another open reading frame that we termed psmR, transcribed convergently in relation to psmI and partly overlapping psmI; this gene encodes a putative LuxR regulatory protein. This gene organization, with luxI and luxR homologues facing each other and overlapping, has been found so far only in the enteric bacteria Erwinia and Pantoea and in the related species P. syringae pv. tabaci.

Characterization of the mouse metal-regulatory-element-binding proteins, metal element protein-1 and metal regulatory transcription factor-1

Metal activation of metallothionein gene transcription depends mainly on the presence of regulatory DNA sequences termed metal-regulatory elements (MREs) and involves MRE-binding transcription factor-1 (MTF-1) interacting with the MREs in a Zn(2+)-dependent manner. We previously identified and characterized a nuclear protein, termed metal element protein-1 (MEP-1), specifically binding with high affinity to MRE elements. The precise relationship between MTF-1 and MEP-1 was unclear, and to determine whether MEP-1 and MTF-1 were distinct protein species, we performed DNA binding analyses to characterize the binding properties of both proteins. Electrophoretic mobility-shift assays showed that MTF-1, produced in COS cells, produces a slower-migrating band compared with that obtained with purified MEP-1. Using an anti-MTF-1 antibody, we showed that both the MTF-1-MRE and the MEP-1-MRE complexes are supershifted by an anti-MTF-1 antibody, thus demonstrating that MEP-1 is antigenically related to MTF-1. RNase protection analyses carried out with RNA prepared from different tissues and cell lines failed to reveal the presence of MTF-1 splicing variants. This indicates that MEP-1 may be a proteolytic fragment of MTF-1. MTF-1 DNA-binding activity was rapidly activated in vivo by Zn(2+) ions but not by Cd(2+), UV irradiation or PMA, and occurred on ice as well as at 21 degrees C. In control and Zn(2+)-treated cell extracts, DNA-binding activity was not enhanced in vitro following the addition of exogenous Zn(2+) or a preincubation at 37 degrees C. However, recombinant MTF-1 produced in vitro required Zn(2+) activation for DNA binding. Interestingly, treatment of nuclear extracts with calf intestine phosphatase completely abrogated MTF-1 DNA-binding activity, thus suggesting that phosphorylation is involved in the regulation of MTF-1 activity.

Role of Mycobacterium tuberculosis copper-zinc superoxide dismutase

Superoxide dismutases (SODs) play an important role in protection against oxidative stress and have been shown to contribute to the pathogenicity of many bacterial species. To determine the function of the mycobacterial copper and zinc-cofactored SOD (CuZnSOD), we constructed and characterized Mycobacterium tuberculosis and Mycobacterium bovis BCG CuZnSOD null mutants. Both strains were more sensitive to superoxides and hydrogen peroxide than were their respective parental strains. The survival of M. bovis BCG in unstimulated as well as activated mouse bone marrow-derived macrophages was not affected by the loss of CuZnSOD. The survival of CuZnSOD deficient-M. tuberculosis in guinea pig tissues was comparable to that of its parental strain. These results indicate that the mycobacterial CuZnSOD is not essential for intracellular growth within macrophages and does not detectably contribute to the pathogenicity of M. tuberculosis.