Proceedings for the 5th Asia-Pacific Conference on Disaster Medicine: Creating an Agenda for Action

Disaster medicine has come to the forefront and has become the focus of interest not only in the medical community, but also in the eyes of the public. The 5th APCDM was convened in Vancouver, Canada, 27–30 September 2000. It brought together over 300 delegates from 32 countries to share their experiences and thoughts regarding disaster events and how to effectively manage them.

The conference was devoted to the task of establishing priorities and creating an Agenda for Action. From the discussions, key actions required were defined:

Communications: (1) Identify existing regional telehealth groups and gather lessons to be learned from them; (2) Form a telehealth advisory group to work with regional groups to compile telehealth initiatives, identify international protocols in telehealth already in existence, and solicit feedback before setting international standards; and (3) Increase corporate partnerships in the fields of telehealth and telecommunications, and invite corporations to send delegates to future APCDM meetings. This should be an initiative of the APCDM, the World Association of Disaster and Emergency Medicine (WADEM), or the European Society of Emergency Medicine.

Education and research: (1) Formalize education in disaster medicine and management. The World Health Organization and WADEM should take a leadership role; (2) WADEM is requested to hold a conference with a focus on qualitative research; (3) WHO is requested to continue the provision of international research teams, but to advocate for the development of national disaster research infrastructure; (4) Make research findings and reports available on web sites of such organizations as WHO and PAHO; (5) Develop the translation of research for community utilization. The WHO and PAHO are organizations that are requested to consider this action; and (6) WADEM/APCDM are requested to focus future conferences on applied research.

Information and data: (1) Create an “Information and Data Clearinghouse on Disaster Management” to collect, collate, and disseminate information; (2) Collect data using standardized tools, such as CAR or Hazmat indices; (3) Analyze incentives and disincentives for disaster readiness and establish mechanisms for addressing the obstacles to preparedness; and (4) WADEM is requested to develop a web site providing a resource list of interdisciplinary institutions and response activities, organized by country, topic, and research interests. Links to other pertinent web sites should be provided.

Interdisciplinary development: (1) Focus on the interdisciplinary nature of disaster response through more conferences encompassing grassroots efforts and through WADEM publications; (2)Develop and apply a standardized template of Needs Assessment for use by multidisciplinary teams. Team Needs Assessment is essential to determine the following: (a) Local response and international assistance required; (b) Appropriate command system; and (c) Psychosocial impact and support necessary.

Psychosocial aspects: (1) Incorporate relief for caregivers into action plans. This should include prime family members who also are caregivers; and (2) Implement measures that give survivors control over the recovery process.

Response management. (1) Define relationships and roles between governments, military and security personnel, non-governmental organizations (NGOs), and civic groups. Use an international legal framework and liability to reinforce accountability of disaster responders; (2) Establish a more sophisticated use of the media during disasters; (3) Establish standards in key areas. WADEM is requested to write “White Papers” on standards for the following areas: (a) management, (b) health/public health, (c) education/training, (d) psychosocial, and (e) disaster plans; (4) Establish task forces to anticipate and resolve issues around evolving and emerging disasters (e.g., chemical and biological terrorism, landmines, emerging infectious diseases). WADEM was again identified as the vehicle for promoting this action.

The responsibility of the next meeting of the Asia-Pacific Conference on Disaster Medicine will be to measure progress made in these areas by assessing how well these collective decisions have been implemented.

The use and effectiveness of cadaveric workshops in higher surgical training: a systematic review

INTRODUCTION

The aim of this systematic review is to describe the use of cadavers in postgraduate surgical training, to determine the effect of cadaveric training sessions on surgical trainees' technical skills performance and to determine how trainees perceive the use of cadaveric workshops as a training tool.

METHODS

An electronic literature search was performed, restricted to the English language, of MEDLINE(®), Embase™, the Cumulative Index to Nursing and Allied Health Literature (CINAHL(®)), Centre for Agricultural Bioscience (CAB) Abstracts, the Educational Resources Information Center (ERIC™) database, the British Education Index, the Australian Education Index, the Cochrane Library and the Best Evidence in Medical Education website. Studies that were eligible for review included primary studies evaluating the use of human cadaveric surgical workshops for surgical skills training in postgraduate surgical trainees and those that included a formal assessment of skills performance or trainee satisfaction after the training session.

RESULTS

Eight studies were identified as satisfying the eligibility criteria. One study showed a benefit from cadaveric workshop training with regard to the ability of trainees to perform relatively simple emergency procedures and one showed weak evidence of a benefit in performing more complex surgical procedures. Three studies showed that trainees valued the experience of cadaveric training.

CONCLUSIONS

Evidence for the effectiveness of cadaveric workshops in surgical training is currently limited. In particular, there is little research into how these workshops improve the performance of surgical trainees during subsequent live surgery. However, both trainees and assessors hold them in high regard and feel they help to improve operative skills. Further research into the role of cadaveric workshops is required.

Drosophila Ndfip is a novel regulator of Notch signaling

In the Drosophila wing, the Nedd4 ubiquitin ligases (E3s), dNedd4 and Su(dx), are important negative regulators of Notch signaling; they ubiquitinate Notch, promoting its endocytosis and turnover. Here, we show that Drosophila Nedd4 family interacting protein (dNdfip) interacts with the Drosophila Nedd4-like E3s. dNdfip expression dramatically enhances dNedd4 and Su(dx)-mediated wing phenotypes and further disrupts Notch signaling. dNdfip colocalizes with Notch in wing imaginal discs and with the late endosomal marker Rab7 in cultured cells. In addition, dNdfip expression in the wing leads to ectopic Notch signaling. Supporting this, expression of dNdfip suppressed Notch(+/-) wing phenotype and knockdown of dNdfip enhanced the Notch(+/-) wing phenotype. The increase in Notch activity by dNdfip is ligand independent as dNdfip expression also suppressed deltex RNAi and Serrate(+/-) wing phenotypes. The opposing effects of dNdfip expression on Notch signaling and its late endosomal localization support a model whereby dNdfip promotes localization of Notch to the limiting membrane of late endosomes allowing for activation, similar to the model previously shown with ectopic Deltex expression. When dNedd4 or Su(dx) are also present, dNdfip promotes their activity in Notch ubiquitination and internalization to the lysosomal lumen for degradation.

Spinal epidural lipomatosis due to a bronchial ACTH-secreting carcinoid tumour

Spinal epidural lipomatosis (SEL) is a rare condition characterized by abnormal deposits of fat in the epidural space. In a severe form this may cause compression of neural elements. This is the second report of SEL secondary to a carcinoid tumour. Our patient was a 34-year-old Caucasian male farm worker presenting with acute spinal cord compression. He had gained 11kg, and had developed Type II diabetes mellitus in the preceding 12months. On examination he displayed characteristic features of Cushing's syndrome. MRI demonstrated posterior epidural lipomatosis, with cord compression from T3 to T8. Urgent spinal cord decompression was performed. Further investigation confirmed a biochemical Cushing's syndrome secondary to an ACTH-producing pulmonary carcinoid tumour.

A consensus on criteria for cure of acromegaly

OBJECTIVE

The Acromegaly Consensus Group met in April 2009 to revisit the guidelines on criteria for cure as defined in 2000.

PARTICIPANTS

Participants included 74 neurosurgeons and endocrinologists with extensive experience of treating acromegaly. EVIDENCE/CONSENSUS PROCESS: Relevant assays, biochemical measures, clinical outcomes, and definition of disease control were discussed, based on the available published evidence, and the strength of consensus statements was rated.

CONCLUSIONS

Criteria to define active acromegaly and disease control were agreed, and several significant changes were made to the 2000 guidelines. Appropriate methods of measuring and achieving disease control were summarized.

Non-invasive detection of bladder cancer by identification of abnormal CD44 proteins in exfoliated cancer cells in urine

Aims-To investigate the expression of CD44 proteins in exfoliated urothelial cells and in tumour tissues from bladder cancer patients. A further objective was to evaluate the diagnostic potential of the changes observed in the expression of these proteins as a marker for non-invasive detection of bladder cancer.Methods-Naturally voided urine specimens were collected from 47 patients with bladder cancer or severe urothelial dysplasia (n=3) and from a control group of 43 people with no evidence of neoplastic disease. Exfoliated urothelial cells floating in the urine were pelleted by centrifugation and lysed, and their constituent proteins extracted. The pattern of expression of CD44 proteins in each sample was examined by western blot analysis using a monoclonal antibody, Hermes 3, which recognises an epitope on the polypeptide backbone of the CD44 protein. Immunohistochemical studies were performed on neoplastic (n=10) and normal (n=4) bladder tissue specimens which were snap frozen in liquid nitrogen before examination with antibodies to CD44 gene products (CD44s and CD44v6).Results-Western blot analysis revealed several high molecular weight CD44 isoforms > 160 kDa in urine cell lysates from 75% of patients with histologically confirmed bladder cancer and in two of the three patients with severe dysplasia. Such patterns were not detected in the urine cell pellets from any persons in the control group. Immunohistochemical studies of the tissue distribution of CD44s and CD44v6 showed that the differentiation and maturation of the epithelial cells in the normal bladder mucosa is accompanied by a decrease in CD44 protein expression. However, carcinoma cells overexpress standard and variant CD44 isoforms and continue to do so as they proceed through the thickened epithelial layer to the luminal surface and after they are shed into the urine.Conclusions-The abnormal expression of CD44 proteins in exfoliated cancer cells may be a useful marker for the noninvasive diagnosis of bladder cancer.

Effects of prior exercise on components of insulin signalling in equine skeletal muscle

REASONS FOR PERFORMING STUDY

Exercise is an important stimulus for the regulation of numerous metabolic functions in muscle, but there has been little investigation of the mechanism of exercise-enhanced glucose utilisation.

OBJECTIVE

To examine the effects of exercise on the signalling components Akt and glycogen synthase kinase-3 (GSK3) involved in insulin regulation of glycogen synthase (GS) activity. It was hypothesised that hyperinsulinaemia and prior exercise would alter the extent of Akt phosphorylation and GSK3beta deactivation and increase insulin stimulation of GS activity in skeletal muscle.

METHODS

Eight Standardbred horses completed a euglycaemic-hyperinsulinaemic clamp (EHC) either without prior exercise (NonEX) or at 0.5, 4 or 24 h post exercise (0.5 PostEX, 4 PostEX, and 24 PostEX, respectively). Muscle samples for determination of Akt and GSK3 serine phosphorylation, and GS fractional velocity (GS(FV)) were collected 5 min before (Pre-INS) and at the end (Post-INS) of each EHC (pre- and post insulin stimulation). Protein was separated by SDS-PAGE on polyacrylamide gels, transferred to nitrocellulose membranes and incubated with antibodies against phospho-Akt Ser473 and GSK3alpha/beta Ser21/9.

RESULTS

GS(FV) was increased (P<0.05) 2-fold at 0.5 PostEX, 4 PostEX and 24 PostEX when compared to NonEX in Pre-INS and in Post-INS was increased 33 and 28% in NonEX and at 24PostEX (P<0.05), respectively, when compared to Pre-INS in these trials. Phospho-Akt Ser473 was increased at 0.5 PostEX only (P<0.05) in Pre-INS but increased in all trials in Post-INS. Phospho-GSK3alpha (Ser21) was also greater (P<0.05) at 0.5 PostEX in Pre-INS than in NonEX and 24 PostEX and in Post-INS increased (P<0.05) in NonEX and at 24 PostEX but not at 0.5 PostEX or 4 PostEX post exercise. There was no effect of time or treatment on GSK3, (Ser9) phosphorylation or on total GSK3.

CONCLUSIONS

Elevated plasma insulin and prior exercise were associated with Akt activation and GSK3alpha deactivation (0.5 PostEX) indicating that an effect of exercise is evident in the early post exercise period and supporting a physiological role for GSK3alpha in the regulation of GS activity. The changes are consistent with insulin signalling downstream from these molecules.

Diagnosis of motor fascicle compression in carpal tunnel syndrome

INTRODUCTION

Median nerve motor fascicle compression in patients with carpal tunnel syndrome is usually characterised by reduced finger grip and pinch strength, loss of thumb abduction and opposition strength and thenar atrophy. The functional outcome in patients with advanced changes may be poor due to irreversible intraneural changes.

HYPOTHESIS

The aim of this study was to investigate patient-reported symptoms, which may enable a clinical diagnosis of median nerve motor fascicle compression to be made irrespective of the presence of advanced signs.

PATIENTS AND METHODS

One hundred and twelve patients (166 hands) with a clinical diagnosis of carpal tunnel syndrome were referred to the neurophysiology department and completed symptom severity questionnaires with subsequent neurophysiological testing.

RESULTS

An increasing frequency of pain experienced by patients was significantly associated with an increased severity of median nerve motor fascicle compression with prolonged motor latencies measured in patients that described pain as a predominant symptom. An increasing frequency of paraesthesia and numbness and weakness associated with dropping objects was significantly associated with both motor and sensory involvement but not able to distinguish between them.

CONCLUSION

This study suggests that patients presenting with a clinical diagnosis of carpal tunnel syndrome with pain as a frequently experienced and predominant symptom require consideration for urgent investigation and surgical treatment to prevent chronic motor fascicle compression with permanent functional deficits.

Cross-sectional analysis of testosterone therapies in hypopituitary men on stable pituitary hormone replacement

OBJECTIVE

The last decade has seen a proliferation in options for testosterone replacement. However, little is known as to the benefits of different treatment modalities. Our objective was to determine the testosterone prescription pattern and to examine the impact on various outcome measures.

SUBJECTS AND METHODS

A total of 816 adult-onset hypopituitary males on stable pituitary replacement for at least 1 year were identified from the KIMS database. Patients were classified as either eugonadal (n = 106), or hypogonadal (n = 710) on intramuscular (IM, n = 558), oral (n = 74), transdermal (n = 61), and depot (n = 17) testosterone.

RESULTS

After 1 year of stable pituitary replacement therapy, body composition, cardiovascular parameters, GH replacement and quality of life were not significantly different in androgen-replaced hypogonadal patients compared to eugonadal patients. There were no differences in outcome variables within the hypogonadal group according to the testosterone replacement regimen used and no difference in response to GH therapy.

CONCLUSIONS

The majority of hypopituitary patients in the last decade have received IM testosterone. Body composition, cardiovascular parameters, GH replacement and quality of life were not different between eugonadal and hypogonadal patients and were not differentially affected by the mode of testosterone replacement. These findings are reassuring that there is no major difference in response to different testosterone replacement regimens.

Guidelines for acromegaly management: an update

OBJECTIVE

The Acromegaly Consensus Group reconvened in November 2007 to update guidelines for acromegaly management.

PARTICIPANTS

The meeting participants comprised 68 pituitary specialists, including neurosurgeons and endocrinologists with extensive experience treating patients with acromegaly. EVIDENCE/CONSENSUS PROCESS: Goals of treatment and the appropriate imaging and biochemical and clinical monitoring of patients with acromegaly were enunciated, based on the available published evidence.

CONCLUSIONS

The group developed a consensus on the approach to managing acromegaly including appropriate roles for neurosurgery, medical therapy, and radiation therapy in the management of these patients.

Neoadjuvant chemotherapy enables R0 resection of locally advanced rectal cancer in a patient with a previously irradiated pelvis

Pre-operative chemoradiation is frequently employed in an attempt to downstage locally advanced rectal cancer which threatens or involves the circumferential resection margin (CRM) on MRI scanning. We present a case where radiotherapy was contraindicated as the patient had previously been irradiated to a radical dose for prostatic adenocarcinoma. Neoadjuvant capecitabine and oxaliplatin were used to downsize the tumour to permit resection with a clear CRM.

A CD40 Kozak sequence polymorphism and susceptibility to antibody-mediated autoimmune conditions: the role of CD40 tissue-specific expression

Previously, we and others have demonstrated the association of a C/T single nucleotide polymorphism (SNP), in the Kozak sequence of CD40, with Graves' disease (GD). Here, using an expanded data set of patients, we confirm the association of the CD40 SNP with GD (n=210, P=0.002, odds ratio (OR)=1.8). Subset analysis of patients with persistently elevated thyroid peroxidase (TPO) and/or thyroglobulin (Tg) antibodies (Abs), (TPO/Tg Abs), after treatment (n=126), revealed a significantly stronger association of the SNP with disease (P=5.2 x 10(-5), OR=2.5) than in GD patients who were thyroid antibody-negative. However, the CD40 SNP was not associated with TPO/Tg Abs in healthy individuals. Next, we tested the CD40 SNP for association with Myasthenia Gravis (MG), which, like GD is an antibody-mediated autoimmune condition. Analysis of 81 MG patients found no association of the SNP with disease. Functional studies revealed significant expression of CD40 mRNA and protein in the thyroid (target tissue in GD) but not in skeletal muscle (target tissue in MG). Combined, our genetic and tissue expression data suggest that the CD40 Kozak SNP is specific for thyroid antibody production involved in the etiology of GD. Increased thyroidal expression of CD40 driven by the SNP may contribute to this disease specificity.

A prepelvic tunnel for the rectus abdominis myocutaneous flap in perineal reconstruction

BACKGROUND

The use of the transpelvic vertical rectus abdominis myocutaneous (VRAM) flap in pelvic reconstruction is well documented. It can be used to fill large defects after pelvic exenteration, reconstruct the vagina and provide skin coverage in perineal reconstruction. This study examines an alternate prepelvic pathway for the flap to enhance its versatility and reliability.

PATIENTS AND METHOD

A female patient with recurrent squamous cell carcinoma in the pelvis, who underwent radical pelvic exenteration and a successful VRAM flap reconstruction with a prepelvic tunnel.

RESULTS

The patient experienced a small area of epithelial tip necrosis over the sacral promontory from shear forces. This healed with dressings within two weeks. There were no major flap complications and the patient had good flap integrity at one-year follow-up. The prepelvic pathway for the VRAM flap is advantageous to the conventional transpelvic course in perineal reconstruction. The more direct, shorter path to the defect allows for a more reliable skin paddle design without the need for de-epithelialisation. A greater area of skin paddle is available and creates a more versatile flap with no tension on the pedicle. This is especially in cases where a skin paddle is needed for vaginal reconstruction or when pelvic organs such as bladder and uterus are left in situ. These advantages may result in less flap complications.

Pathogenesis of osteoarthritis-like changes in the joints of mice deficient in type IX collagen

OBJECTIVE

To examine the pathogenetic mechanisms of osteoarthritis (OA)-like changes in Col9a1-/- mice, which are deficient in type IX collagen.

METHODS

Knee joints and temporomandibular joints (TMJs) from Col9a1-/- mice and their wild-type (Col9a1+/+) littermates were examined by light microscopy. Immunohistochemical staining was performed to examine the expression of matrix metalloproteinase 3 (MMP-3) and MMP-13, degraded type II collagen, and the discoidin domain receptor 2 (DDR-2) in knee joints. Cartilage mechanics were also evaluated for compressive properties by microindentation testing of the tibial plateau and for tensile properties by osmotic loading of the femoral condyle.

RESULTS

Histologic analysis showed age-dependent OA-like changes in the knee and TMJs of Col9a1-/- mice starting at the age of 3 months. At the age of 6 months, enhanced proteoglycan degradation was observed in the articular cartilage of the knee and TMJs of the mutant mice. The expression of MMP-13 and DDR-2 protein and the amount of degraded type II collagen were higher in the knee joints of Col9a1-/- mice than in their wild-type littermates at the age of 6 months. Changes in cartilage mechanics were observed in the femoral and tibial plateaus of Col9a1-/- mice at 6 months, including a decrease in the compressive modulus and uniaxial modulus. At 3 and 6 months of age, tibial cartilage in Col9a1-/- mice was found to be more permeable to fluid flow, with an associated compromise in the fluid pressurization mechanism of load support. All of these changes occurred only at medial sites.

CONCLUSION

Lack of type IX collagen in Col9a1-/- mice results in age-dependent OA-like changes in the knee joints and TMJs.

The management of life-threatening haemorrhage following blunt facial trauma

Life-threatening bleeding is uncommon following blunt facial trauma. There have been few reports in the literature describing its optimal management and a clear approach to treatment is yet to be defined. Reported strategies for control of facial haemorrhage include oro-nasal packing, external carotid artery ligation, transantral ligation of the internal maxillary artery, maxillary reduction and angiographic embolisation. Advances in angiography and selective vessel embolisation have made this the treatment of choice in cases of bleeding following penetrating facial injury. Its use in the management of bleeding following blunt facial trauma is unclear. The combined experience of the facial trauma teams at Harborview Hospital, Seattle, USA and Liverpool Hospital, Sydney, Australia yielded four cases of severe life-threatening haemorrhage following blunt trauma that underwent angiography. The roles of various management strategies were evaluated to generate a preferred management pathway in treating severe bleeding following blunt facial trauma.

Innovative technique for correction of the congenital lop ear

Congenital lop ear is a deformity affecting the upper third of the ear. It is characterised by varying degrees of lidding of the helix, reduction in the fossa triangularis, scapha compression, reduction or absence of the superior crus of the antihelix and an associated reduction in vertical height of the external ear. Reported strategies for the surgical correction of this deformity include simple excision of the excess overhanging cartilage, radial cartilage incisions of the helix to reverse its memory, various cartilage grafts from the surrounding ear or rib to strut or fill the defect, and mastoid hitching stitches to reinforce the repair. We present a novel technique using a reversed conchal cartilage graft to strut the deformed antihelix. The memory of the reversed conchal cartilage is used to correct lidding of the superior helix and obviates the need for intrinsic cartilage modification or excision. We have found a good aesthetic and structural result in a patient with bilateral congenital lop ear with 12 months follow up.

Consensus statement: medical management of acromegaly

In November 2003, the Pituitary Society and the European Neuroendocrine Association sponsored a consensus workshop in Seville to address challenging issues in the medical management of acromegaly. Participants comprised 70 endocrinologists and neurosurgeons with international expertise in managing patients with acromegaly. All participants participated in the workshop proceedings, and the final document written by the scientific committee reflects the consensus opinion of the interactive deliberations. The meeting was supported by an unrestricted educational grant from Ipsen. No pharmaceutical representatives participated in the program planning or in the scientific deliberations.

The effect of severe acute respiratory syndrome on emergency airway management

Study objectives: From early March 2003 to late May 2003, severe acute respiratory syndrome (SARS) was detected in Singapore. Two hundred thirty-eight patients were infected; 33 died. Forty-two percent were health care workers. The whole medical system in the country was put under stress. One major public hospital became the designated SARS hospital. Emergency cases were diverted to the remaining public hospitals, of which Singapore General Hospital was the main recipient. The increase in workload, new infection control procedures including mandatory wearing of the positive airway pressure respirator and personal protective equipment (PPE), and limiting the number of person-contacts with each patient were thought to affect resuscitation and airway management. Our aim is to study the effects of wearing of PPE and the restriction in number of resuscitation personnel on airway management during the SARS crisis.

Methods: The emergency department has an ongoing airway registry that prospectively captures patient demographics, diagnosis, indications for intubation, persons and discipline of intubating physician, number of attempts, method of intubation, success rates, and complications. The data were divided into 3 periods: (1) before PPE was instituted from November 1, 2002, to March 31, 2003; (2) during SARS (when PPE use was mandatory) from April 1 to July 31, 2003; and (3) after SARs (when PPE use was nonmandatory but encouraged) from August 1 to December 31, 2003.

Results: There was no change in patient demographics during the 3 periods, but there was a change in the patient diagnoses in period 2, with decreases in the proportion of respiratory and cardiac cases and increases in neurology and trauma cases. These changes reverted to the previous distribution in period 3. The alarming discovery was that whereas in period 1 (pre-SARS), resident medical officers attempted intubations 45% of the time, this figure went down to 35% in period 2 (SARS) and 23% in period 3 (post-SARS). Anesthetists performed 1.2%, 8%, and 0% of emergency intubations in periods 1, 2, and 3, respectively. Attending emergency physicians performed 54%, 56%, and 77% of intubations in periods 1, 2, and 3, respectively. The complication/peri-intubation event rates were 10.5%, 9.9%, and 9.4% in periods 1, 2, and 3, respectively. The success rate for residents was 80.8%, 89%, and 86.2% in periods 1, 2, and 3, respectively.

Conclusion: The wearing of PPE and positive airway pressure respirator is thought to make intubation more difficult, as seen by the increase in proportion of intubations performed by anesthetists in period 2 and by attending emergency physicians in periods 2 and 3. The infection control policy that restricts the number of health care staff attending to each patient may have influenced the department's decision to allow only the most confident or experienced personnel to manage the airway. The exposure of junior residents in emergency airway management during SARS and the immediate post-SARS period was decreased. This trend should be further monitored, and intervention may be necessary should it continue to decline.

Pharmacological characterization of glutamatergic agonists and antagonists at recombinant human homomeric and heteromeric kainate receptors in vitro

An increasing body of evidence suggests that native kainate receptors form ion channels from homomeric and heteromeric combinations of five receptor subunits: GluR5, GluR6, GluR7, KA1 and KA2. We have examined the activity of agonists and antagonists at recombinant human kainate receptors expressed in HEK293 cells, using both whole-cell electrophysiological recording and 96-well plate fluo-3 based calcium microfluorimetry (FLIPR). Both homomeric (GluR5 and GluR6) and heteromeric (GluR5/6, GluR5/KA2 and GluR6/KA2) receptors were examined. Heteromeric receptor assemblies showed electrophysiological and pharmacological profiles which were distinct from homomeric channels. Several agonists, including AMPA, ATPA and (S)-5-iodowillardiine, and antagonists, including gamma-D-glutamylaminomethylsulphonic acid (GAMS) and the decahydroisoquinoline compounds LY293558, LY377770 and LY382884, were found to act at GluR5-containing channels while having no effect at GluR6 homomers. AMPA, ATPA and (S)-5-iodowillardiine did activate GluR6/KA2 heteromers, but only as partial agonists. Additionally, ATPA was shown to act as an antagonist at homomeric GluR6 receptors at high concentrations (IC50 approximately 2 mM). Kynurenic acid was also found to differentiate between GluR6 and GluR6/KA2 receptors, antagonizing glutamate at GluR6 (IC50 = 0.4 mM), while having no effect at GluR6/KA2 channels. The results of the current study provide a broad pharmacological characterization of both homomeric and heteromeric recombinant human kainate receptors, and identify which compounds are likely to be useful tools for studying these various receptor subtypes.

Intravenous administration of an AAV-2 vector for the expression of factor IX in mice and a dog model of hemophilia B

Previous experiments have demonstrated the stable expression of factor IX (FIX) protein in mice and canine models of hemophilia B following portal vein gene transfer with a recombinant adeno-associated virus (rAAV) vector encoding FIX. Here, we present the results of studies that further optimized the rAAV vector transgene cassette used to express FIX and explored the use of the less-invasive intravenous (i.v.) route of vector administration for the treatment of hemophilia B. First, a liver-specific promoter was evaluated in conjunction with cis-acting regulatory elements in mice. Constructs that included both the beta-globin intron and the woodchuck hepatitis virus post-transcriptional regulatory element resulted in the highest level of FIX expression in vivo. Using this optimized vector, we demonstrate that i.v. injection was feasible for hepatic gene transfer in mice, achieving 70-80% of portal vein expression levels of FIX. In further studies using the Chapel Hill strain of hemophilia B dogs, we demonstrate for the first time FIX expression and partial correction of the bleeding disorder following i.v. administration of an AAV vector.

Diagnosis and treatment of acromegaly complications

The Pituitary Society in conjunction with the European Neuroendocrine Association held a consensus workshop to develop guidelines for diagnosis and treatment of the co-morbid complications of acromegaly. Fifty nine pituitary specialists (endocrinologists, neurosurgeons and cardiologists) assessed the current published literature on acromegaly complications in light of recent advances in maintaining tight therapeutic control of GH hypersecretion. The impact of elevated GH levels on cardiovascular disease, hypertension, diabetes, sleep apnea, colon polyps, bone disease, reproductive disorders, and neuropsychologic complications were considered. Guidelines are proposed for effective management of these complications in the context of overall acromegaly control. When appropriate, requirements for prospective evidence-based studies and surveillance database development are enunciated. Effective management of co-morbid acromegaly complications will lead to improved morbidity and mortality in acromegaly.

Vitamin D receptor start codon polymorphism (Fok I) and bone mineral density in Chinese men and women

The relationship between Fok I polymorphism of the vitamin D receptor start codon, bone mineral density (BMD) and vertebral fractures was studied in 684 Chinese men and women. A significant trend was observed only in Chinese women aged 70-79 years. The mean BMD at the total body was 0.85 +/- 0.01 g/cm2, 0.82 +/- 0.01 g/cm2 and 0.84 +/- 0.01 g/cm2 for elderly women of the FF, Ff and ff genotypes respectively (p = 0.06 by ANOVA). Similar but statistically non-significant trends were observed at the hip and spine. However, no association between BMD and the Fok I genotype was observed in younger women (aged 50-59 years) and elderly men (aged 70-79 years). In all study groups, there was no effect of an interaction between Fok I polymorphism and calcium intake on BMD (p > 0.05 for the interaction effects by two-way ANOVA). No significant association was observed between Fok I polymorphism and vertebral fracture in elderly men or women (p > 0.05 by the chi-square test). We conclude that the Fok I polymorphism may have a weak effect on the BMD of elderly Chinese women.

A microsatellite sequence from the rice blast fungus (Magnaporthe grisea) distinguishes between the centromeres of Hordeum vulgare and H. bulbosum in hybrid plants

A TC/AG-repeat microsatellite sequence derived from the rice blast fungus (Magnaporthe grisea) hybridized to all of the centromeres of Hordeum vulgare chromosomes, but hybridized faintly or not at all to the chromosomes of Hordeum bulbosum. Using this H. vulgare centromere-specific probe, the chromosomes of four F1 hybrids between H. vulgare and H. bulbosum were analyzed. The chromosome constitution in the root tips of the hybrids was mosaic, i.e., 7 (7v, H. vulgare) and 14 (7v + 7b H. bulbosum), or 14 (7v + 7b) and 27 (14v + 13b), or 7 (7v), 14 (7v + 7b), and 27 (14v + 13b). The 27-chromosome tetraploid hybrid cells were revealed to have the NOR (nucleolus organizer region) bearing chromosome of H. bulbosum in a hemizygous state, which might indicate some role for this chromosome in the chromosome instability of the hybrid condition. The chromosomal distribution showed that the chromosomes of H. vulgare were concentric and chromosomes of H. bulbosum were peripheral in the mitotic squash. This non-random chromosome distribution and the centromere-specific repeated DNA differences in the two species were discussed in relation to H. bulbosum chromosome elimination. Meiotic chromosome analyses revealed a high frequency of homoeologous chromosome pairing in early prophase. However, this chromosome pairing did not persist until later meiotic stages and many univalents and chromosome fragments resulted. These were revealed to be H. bulbosum by fluorescence in situ hybridization (FISH) analysis with the H. vulgare centromere-specific probe. Because the chromosome segregation of H. vulgare and H. bulbosum chromosomes at anaphase I of meiosis was random, the possibility for obtaining chromosome substitution lines in diploid barley from the diploid hybrid was discussed.

Lower hypertension prevalence in first-generation African immigrants compared to US-born African Americans

Both genetic and environmental factors have been hypothesized to explain the higher prevalence of hypertension in US African Americans compared to populations still residing in western Africa. Studies of first-generation immigrants can help to identify risk factors for increased chronic disease expression in the developed world. Since we could identify no prior studies of hypertension in African immigrants to the United States, we conducted a cross-sectional survey of African-born and US-born African-American health professionals to compare the two groups for the prevalence of hypertension (blood pressure > or = 140/90 mm Hg or use of antihypertensive medication) and risk factors for hypertension (body mass index, lifestyle factors, and psychosocial variables hypothesized to relate to hypertension). Subjects were registered pharmacists and nurses recruited by mail. For the 182 individuals who completed study measurements (95 US-born and 87 African-born), the unadjusted odds ratio for hypertension associated with birthplace was 2.16 (95% CI = 1.12, 3.98). After adjustment for body mass index and age, the OR for birthplace was 1.92 (95% CI = 0.92, 4.00). No lifestyle or psychosocial variables were associated with hypertension prevalence. We conclude that there is a lower prevalence of hypertension in first-generation African immigrants that cannot be readily explained by the environmental effects measured in this study. Larger scale studies with African immigrants could advance understanding of the causes of the increased hypertension prevalence in US-born African Americans.

Effect of low molecular weight heparin on bone metabolism and hyperlipidemia in patients on maintenance hemodialysis

The effect of low molecular weight heparin (LMWH) on serum lipid profile in hemodialysis remains controversial and its effect on bone metabolism has not been studied. A crossover study was conducted in 40 patients on stable hemodialysis using unfractionated heparin (UFH) for more than 24 months. These patients were then treated with a LMWH (nadroparin-Ca) for 8 months during hemodialysis and subsequently switched back to UFH for 12 months. Serum lipid profile, biochemical markers for bone metabolism, and bone densitometry (BMD) were monitored at four-month intervals while all medications remained unchanged. Cholesterol (TC), triglyceride (TG), low-density lipoprotein-cholesterol (LDL-C), lipoprotein(a) (Lp(a)), apolipoprotein B (Apo B) were raised in 35%, 29%, 12%, 24% and 24% of patients respectively. High-density lipoprotein-cholesterol (HDL-C) and apolipoprotein A1 (Apo A-1) were reduced in 47% and 9% of patients. Bone-specific alkaline phosphatase (BALP) and intact osteocalcin (OSC), both reflecting osteoblastic activity, were raised in 65% and 94% of patients. Tartrate-resistant acid phosphatase (TRACP) reflecting osteoclastic activity and parathyroid hormone (PTH) were elevated in 35% and 88% of patients. Following LMWH treatment, TC, Tg, Lp(a) and Apo B were reduced by 7%, 30%, 21% and 10% respectively (p<0.05 or <0.01) while Apo A-1 were raised by 7% (p<0.01). Simultaneously, TRACP was reduced by 13% (p<0.05). These biochemical changes were detected soon after 4 months of LMWH administration. Although BMD values in our patients were lower than those of age-matched normal subjects, significant changes were not observed with LMWH treatment. After switching back to UFH for hemodialysis, these biochemical indices reverted to previous values during UFH treatment with a significant higher level in TC and Apo B while serum Apo A-1 remained elevated. Our study suggests LMWH may partially alleviate hyperlipidemia and, perhaps, osteoporosis associated with UFH administration in patients on maintenance hemodialysis.

Pharmacological aids for smoking cessation

To smokers, nicotine addiction is a powerful vice that is difficult to overcome even with pharmaceutical aids. Relapse rates are high and maintaining a successful quitting strategy is difficult regardless of the method used. Therefore, clinicians should routinely provide positive feedback to help maintain their patients' cessation. Encouraging smoking cessation, selecting appropriate products, and monitoring and supporting patients through their withdrawal symptoms makes for a more complete therapeutic care plan for cessation of tobacco use. In the long term, helping patients to succeed in their cessation treatment has the potential to reduce healthcare costs, save clinicians time and money, and improve morbidity and mortality rates.

Novel AMPA receptor potentiators LY392098 and LY404187: effects on recombinant human AMPA receptors in vitro

The present study describes the activity of two novel potent and selective AMPA receptor potentiator molecules LY392098 and LY404187. LY392098 and LY404187 enhance glutamate (100 microM) stimulated ion influx through recombinant homomeric human AMPA receptor ion channels, GluR1-4, with estimated EC(50) values of 1.77 microM (GluR1(i)), 0.22 microM (GluR2(i)), 0.56 microM (GluR2(o)), 1.89 microM (GluR3(i)) and 0.20 microM (GluR4(i)) for LY392098 and EC(50) values of 5.65 microM (GluR1(i)), 0.15 microM (GluR2(i)), 1.44 microM (GluR2(o)), 1.66 microM (GluR3(i)) and 0.21 microM (GluR4(i)) for LY404187. Neither compound affected ion influx in untransfected HEK293 cells or GluR transfected cells in the absence of glutamate. Both compounds were selective for activity at AMPA receptors, with no activity at human recombinant kainate receptors. Electrophysiological recordings demonstrated that glutamate (1 mM)-evoked inward currents in human GluR4 transfected HEK293 cells were potentiated by LY392098 and LY404187 at low concentrations (3-10 nM). In addition, both compounds removed glutamate-dependent desensitization of recombinant GluR4 AMPA receptors. These studies demonstrate that LY392098 and LY404187 allosterically potentiate responses mediated by human AMPA receptor ion channels expressed in HEK 293 cells in vitro.