Ultra fast x-ray streak camera for ten inch manipulator based platforms

Ultra fast x-ray streak cameras are a staple for time resolved x-ray measurements. There is a need for a ten inch manipulator (TIM) based streak camera that can be fielded in a newer large scale laser facility. The Lawrence Livermore National Laboratory ultra fast streak camera's drive electronics have been upgraded and redesigned to fit inside a TIM tube. The camera also has a new user interface that allows for remote control and data acquisition. The system has been outfitted with a new sensor package that gives the user more operational awareness and control.

Patent ductus arteriosus repair in general practice

A 3-month-old female German Shepherd puppy was presented for routine vaccination. Clinical evaluation revealed a grade 5/6 continuous murmur with the point of maximal intensity over the left 4th intercostal space. Echocardiography revealed a patent ductus arteriosus (PDA). The PDA was closed by a team of general practitioners using the Jackson-Henderson technique, via a standard 4th intercostal thoracotomy. A multi-modal approach to analgesia and premedication was employed. A successful outcome was achieved with no murmur or evidence of cardiac disease present 6 months after surgical occlusion. The literature is reviewed with an emphasis placed on choosing techniques that are appropriate to the level of expertise of the surgical and anaesthetic teams, as well as the surgical facilities available.

Isolation of the first three cases of Clostridium difficile polymerase chain reaction ribotype 027 in Singapore

INTRODUCTION

The incidence of Clostridium (C.) difficile infection (CDI) was on the rise from 2001 to 2006 in Singapore. Recent unpublished data suggests that its incidence had remained stable or decreased in most local public hospitals between 2006 and 2010. It is, however, not known if the polymerase chain reaction (PCR) ribotype 027 strains have been circulating, although reports suggest that this strain is emerging in Asia, with the first cases reported from Japan in 2007, as well as in Hong Kong and Australia in 2009. We initiated a culture-based surveillance to detect this epidemic strain in Singapore.

METHODS

From September 2008 to December 2009, all non-duplicate toxin-positive stool samples from the three largest public hospitals in Singapore were collected for culture and further analysis.

RESULTS

Out of the 366 samples collected, 272 viable isolates were cultured. Of these, 240 tested toxin-positive and ten tested positive for the binary toxin gene; 35 different PCR ribotypes were found. Three isolates that tested positive for binary toxin contained the same PCR ribotyping pattern as the C. difficile 027 control strain. All three had the 18-bp deletion and single nucleotide tcdC deletion at position 117. Susceptibility testing was performed, demonstrating susceptibility to erythromycin and moxifloxacin.

CONCLUSION

We report the first three isolates of C. difficile 027 from Singapore. However, their susceptibility patterns are more consistent with the historical 027 strains. Rising CDI incidence may not be associated with the emergence of the epidemic 027 strain at this time.

β-Catenin is required for Ron receptor-induced mammary tumorigenesis

Our previous studies demonstrated that selective overexpression of the Ron receptor tyrosine kinase in the murine mammary epithelium leads to mammary tumor formation. Biochemical analysis of mammary tumor lysates showed that Ron overexpression was associated with increases in β-catenin expression and tyrosine phosphorylation. β-Catenin has also been shown to be regulated through tyrosine phosphorylation by the receptor tyrosine kinases Met, Fer and Fyn. However, the molecular and physiological roles of β-catenin and β-catenin tyrosine phosphorylation downstream of Ron are not known. To investigate this association, we show that Ron and β-catenin are coordinately elevated in human breast cancers. Our data also demonstrate that activation of Ron, through ligand binding by hepatocyte growth factor-like protein (HGFL), induces the tyrosine phosphorylation of β-catenin, primarily on tyrosine residues Tyr 654 and Tyr 670. In addition, HGFL-mediated Ron activation induces both β-catenin nuclear localization and transcriptional activity, with Tyr 654 and Tyr 670 residues of β-catenin being critical for these processes. We also demonstrate that a knockdown of Ron in breast cancer cell lines leads to a loss of HGFL-induced β-catenin-dependent transcriptional activation and cell growth, which can be rescued by activation of canonical Wnt/β-catenin signaling. Moreover, we show that HGFL-dependent Ron activation mediates upregulation of the β-catenin target genes cyclin D1 and c-myc, and that expression of these target genes in breast cancer cells is decreased following inhibition of Ron and/or β-catenin. Finally, we show that genetic ablation of β-catenin in Ron-expressing breast cancer cells decreases cellular proliferation in vitro, as well as mammary tumor growth and metastasis, following orthotopic transplantation into the mammary fat pad. Together, our data suggest that β-catenin is a crucial downstream regulator of Ron receptor activation and is an important mediator of mammary tumorigenesis.

The value of auditing negative lower GI investigations preceding a final diagnosis of colorectal cancer

OBJECTIVE

To review all preceding 'negative' large bowel investigations in patients with a final diagnosis of colorectal cancer, and to examine whether delayed diagnosis was associated with worse outcome.

METHOD

Details were gathered on all patients with a new diagnosis of colorectal adenocarcinoma presenting over 4.5 years. For each patient the hospital's clinical workstation and radiology and endoscopy databases were interrogated for all flexible sigmoidoscopies, colonoscopies and barium enemas during the 5 years prior to diagnosis.

RESULTS

Among the 570 patients, 28 (5%) had undergone colonoscopy and/or flexible sigmoidoscopy that had not shown colorectal cancer during the 5 years preceding final diagnosis, and a further 28 (5%) had undergone 'negative' barium enemas. Polyp surveillance might have missed four lesions destined to become malignant. Correspondingly there were three patients undergoing IBD surveillance found to have CRC, having had a negative complete colonoscopy within the preceding 5 years. Among patients undergoing de novo colonoscopy for diagnosis the true miss rate was only one patient per year. At August 2007, 29 (58%) of those with delayed diagnosis were still alive, compared with 216 (42%) of those diagnosed during initial investigation (chi2 = 5.04, P < 0.05).

CONCLUSIONS

Colonoscopic miss rates are in line with previous studies. The application of simple clinical ground rules will avoid most pitfalls. The methodology described herein may assist in auditing the quality assurance of lower gastrointestinal diagnostic services. Despite the delay, late diagnosis was found to be associated with improved survival and a lower likelihood of metastatic disease.

Mortality among tuberculosis patients on treatment in Singapore

OBJECTIVE

To identify the risk factors associated with mortality among tuberculosis (TB) patients on treatment in Singapore.

DESIGN

A retrospective cohort study of 7433 TB patients notified and started on TB treatment from 2000 to 2006 was conducted. Cox regression analysis was used to determine independent risk factors for mortality.

RESULTS

Of 7433 patients who started TB treatment between 2000 and 2006, there were 884 deaths (11.9%) from any cause. Older age, male sex, being in a long-term care facility, having comorbidity, absence of cough, more than one site of TB, bacteriologically confirmed laboratory results, resistance to at least isoniazid (INH) and rifampicin (RMP) and absence of cavity were strongly associated with all-cause mortality among TB patients. A total of 203 patients (2.7%) died of TB. Risk factors for death due to TB were older age, male sex, Malay ethnicity, being in a long-term care facility, absence of cough, more than one site of TB, bacteriologically confirmed laboratory results and resistance to at least INH and RMP or to at least INH but not RMP.

CONCLUSION

It is important to identify TB patients with risk factors related to mortality so that appropriate and timely interventions can be instituted to prevent deaths among TB patients.

Proinsulin peptide immunotherapy in type 1 diabetes: report of a first-in-man Phase I safety study

Immunotherapeutic strategies under consideration for type 1 diabetes include modification of the autoimmune response through antigen-specific routes. Administration of short peptides representing T cell epitopes targeted by patients with the disease represents one approach. This study evaluated safety and mechanistic outcomes during first-in-man intradermal administration of a human leucocyte antigen-DR4 (HLA-DR4)-restricted peptide epitope of proinsulin (C19-A3). This randomized, open-label study assessed two major theoretical risks of peptide immunotherapy, namely induction of allergic hypersensitivity and exacerbation of the proinflammatory autoimmune response, using clinical assessment and mechanistic assays in vitro. Patients with long-standing type 1 diabetes and HLA-DRB1*0401 genotype received 30 microg (n = 18) or 300 microg (n = 18) of peptide in three equal doses at 0, 1 and 2 months or no intervention (n = 12). Proinsulin peptide immunotherapy in the dosing regimen used is well tolerated and free from risk of systemic hypersensitivity and induction/reactivation of proinsulin-specific, proinflammatory T cells. Peptide-specific T cells secreting the immune suppressive cytokine interleukin (IL)-10 were observed at month 3 in four of 18 patients in the low-dose group (versus one of 12 in the control group; P = not significant). Mean IL-10 response to peptide in the low-dose group increased between 0 and 3 months (P = 0.05 after stimulation with 5 microM peptide in vitro) and then declined to baseline levels between 3 and 6 months (P = 0.01 at 10 microM peptide in vitro). These studies pave the way for future investigations in new-onset patients designed to examine whether proinsulin peptide immunotherapy has beneficial effects on markers of T cell autoimmunity and preservation of beta cell mass.

Methicillin-resistant Staphylococcus aureus infections among healthy full-term newborns

OBJECTIVE

Methicillin-resistant Staphylococcus aureus (MRSA) strains have emerged in the community, causing disease among healthy people lacking traditional risk factors for MRSA infection. This article describes an outbreak of MRSA among healthy full-term newborns.

DESIGN

Cases were identified and corresponding medical information collected. Telephone interviews were conducted with mothers of cases and surveillance cultures from mothers and newborns were performed. MRSA isolates were genotyped.

SETTING

Hospital in Chicago, Illinois, USA.

PARTICIPANTS

Newborns, their mothers and hospital healthcare workers.

INTERVENTION

Nursery infection control practices were enhanced. The MRSA-colonised healthcare workers received intranasal mupirocin.

MAIN OUTCOME

Within 4-23 days of birth, 11 newborns were identified with pustules, vesicles or blisters located on the head, groin, perineum, ears, legs, chin and trunk. All received antimicrobials and recovered without incident.

RESULTS

None of 432 peripartum women, one of 399 newborns, and two of 135 healthcare workers were nasal MRSA carriers. Available isolates from six patients, two healthcare workers, and one from an MRSA-colonised newborn were similar by pulsed-field gel electrophoresis. Other than contact with the hospital, no common exposures of MRSA transmission were identified.

CONCLUSIONS

MRSA strains that initially emerged in the community are now causing disease in healthcare settings. Providers should be aware that MRSA can cause skin infections among healthy newborns. Adherence to standard infection control practices is important to prevent transmission of MRSA in nurseries.

Robotic Heller myotomy: a safe operation with higher postoperative quality-of-life indices

INTRODUCTION

Achalasia is a primary motility disorder of the esophagus that is treated most effectively with operative myotomy. Excellent outcomes with laparoscopic myotomy and fundoplication are well known. Heller myotomy utilizing a computer-enhanced (robotic) laparoscopic platform allows for a more precise dissection by utilizing the superior optics of a 3-dimensional camera and greater degrees of freedom provided by robotic instrumentation. How this affects outcome and quality of life is unknown.

METHODS

We assessed patients' health perceptions using a standardized, validated, health-related, disease-specific quality-of-life metric. Sixty-one consecutive patients undergoing laparoscopic or robotic myotomy over a 6-year period were evaluated prospectively. All operations were performed using intraoperative manometric and endoscopic guidance and all except 5 patients had a fundoplication. The effects of the operation on health-related quality of life were evaluated with the Short Form (SF-36) Health Status Questionnaire and a disease-specific gastroesophageal reflux disease activity (GERD) activity index (GRACI) preoperatively and postoperatively. All patients completed the questionnaire at both time points. Patient scores were compared using 2-way repeated measures analyses of variance followed by the Tukey test. Operative time, estimated blood loss, duration of stay, intraoperative complication, and postoperative complications were analyzed.

RESULTS

Thirty-seven patients had laparoscopic and 24 patients had robotic Heller myotomy. There was an increase in SF-36 overall evaluation of health postoperatively compared with preoperatively in both groups (P < .05). The robotic myotomy patients had better SF-36 Role Functioning (emotional) and General Health Perceptions (P < .05) compared with the laparoscopic group. The GRACI showed an equivalent improvement in severity of symptoms in both groups (P < .05). Operative time was 287 +/- 9 minutes for laparoscopic cases and 355 +/- 23 minutes for robotic cases. Estimated blood loss and duration of stay were not different between groups. There were 3 operative esophageal perforations (8%) during laparoscopic myotomy and all were repaired immediately. There were no perforations or operative complications in the robotic group. Neither group had any additional complications.

CONCLUSIONS

Minimally invasive operative myotomy improves functional status and overall evaluation of health in patients with achalasia. Robotic myotomy had no intraoperative esophageal perforations compared with an 8% intraoperative rate during laparoscopic myotomy. Heller myotomy with partial fundoplication using a robotic platform appears to be a more precise and safer operation than laparoscopic myotomy with improved quality-of-life indices postoperatively compared with laparoscopic myotomy with fewer complications; this suggests that, in skilled hands, the robotic platform may be safer, with improved quality-of-life outcomes.

Slipped upper femoral epiphysis in a child with spondyloepiphyseal dysplasia tarda: a rare coincidence?

We present a report of a child with Spondyloepiphyseal dysplasia tarda (SED) presenting with non-traumatic, insidious onset hip pain with limited internal rotation. Radiographs revealed a left sided stable slipped upper femoral epiphysis (SUFE). To our knowledge an association between these two pathologies has not been reported previously in the literature and hence a tentative commom etiopathogenesis between SED and SUFE is discussed. Patients who have SED often develop hip pain as part of the natural history of the condition. This case highlights the need to be vigilant regarding the potential for SUFE as a cause of hip pain rather than attributing it to the dysplasia itself in these patients.

Public health measures implemented during the SARS outbreak in Singapore, 2003

The SARS outbreak hit Singapore between March and May 2003. Public health control measures were applied along three fronts; prevention and control within healthcare settings, community and at the borders. Nosocomial spread composed majority of SARS cases in Singapore. To prevent infection within healthcare facilities, cases were centralized in a SARS-designated hospital, a no-visitors rule was applied and movement of patients and healthcare staff were restricted. For triaging purposes, fever clinics were established. A dedicated ambulance service was used to transport possible cases to the SARS-designated hospital. Hospitals were surveyed for fever clusters. The challenge was to identify cases with atypical presentation. Effective and safe discharge criteria were established from the lessons learnt. To prevent community spread, contacts of cases were stringently traced, quarantined in their homes and monitored daily. For prompt identification of a case and to reduce the time between onset of symptoms and isolation, the Infectious Diseases Act was amended. A large wholesale market closure resulted in massive quarantine thereby limiting the spread of infection. A mass education campaign was implemented in order to educate and raise awareness of the public. At all air, sea and land points-of-entry, exit and entry screening took place that resulted in zero importation and exportation of SARS cases after implementation of screening. Coordinated effort of the cross sectional inter-ministerial collaboration and strong coordination by the Task Force and commitment from different professionals made it possible to conquer the disease.

Incorporating a social networking approach to enhance contact tracing in a heterosexual outbreak of syphilis

OBJECTIVE

This report describes the outcomes of a social networking approach (SNA) in a heterosexually transmitted syphilis epidemic by street nurses in British Columbia, Canada.

METHODS

Street nurses used SNA interviewing cues, environmental observation, peer outreach, serial interviewing, conducted blood tests, and offered treatment on the street. Rates of cases of syphilis identified by outreach nurses and cases linked to another case were compared before and after adoption of an SNA.

RESULTS

SNA resulted in a significantly increased proportion of cases identified by the street nurses (p = 0.01) and increased the percentage of cases linked to a previous case (p = 0.03).

CONCLUSION

This preliminary study confirms that SNA can increase the number of cases and contacts identified in an epidemic of a sexually transmitted disease in a vulnerable, hard to reach population.

IL-6?174G/C genotype is associated with the bone mineral density response to oestrogen replacement therapy in post-menopausal women

A reduction in interleukin-6 (IL-6) activity may contribute to the beneficial effects of hormone replacement therapy (HRT) on the menopausal decline in bone mineral density (BMD). We have examined this hypothesis using a genetic strategy. The -174C (rather than G) IL-6 gene variant is associated with lower IL-6 expression. As such, we might anticipate the C allele to be associated with a greater response to HRT. We have tested this hypothesis. Mean three-site [spine (L1-L4), neck of femur, and Ward's triangle] BMD was measured in 65 women in a 1-year randomised controlled trial of HRT with 0.625 mg oestrogen/day and 0.15 mg norgestrel (n=30). Baseline BMD was genotype-independent for both the control and HRT group. In the control group, the percentage change in BMD after 1 year was similar between genotypes (P=0.45). In contrast, in the HRT group, the rise was genotype-dependent. Those homozygous for the G allele showed a 3.62 (2.14)% increase in BMD compared with 10.44 (4.68)% for the C-homozygous group. Heterozygotes had an intermediate BMD increase of 5.6 (2.82)% [ P=0.006 ( P value for interaction between HRT and genotype was 0.04)] Although the study was limited by its small sample size, these are the first data to demonstrate the importance of IL-6 genotype in determining response to oestrogen therapy, rather than its physiological withdrawal.

The maternal endocrine environment in the low-protein model of intra-uterine growth restriction

Many adult diseases, including type 2 diabetes, hypertension and cardiovascular disease, are related to low birth weight. The mechanistic basis of this relationship is not known. To investigate the role of fetal undernutrition, we used a rat model of maternal protein restriction in which dams were fed a diet containing 80 g protein/kg (v. 200 g/kg in the control group) throughout gestation and lactation. Offspring were born smaller than controls and in adulthood developed diabetes, hyperinsulinaemia and tissue insulin resistance. To determine possible mechanisms of fetal programming, circulating levels of several hormones were measured in maternal plasma at gestational days 14, 17 and 21 and fetal plasma at gestational day 21. Several differences were noted at day 14, when glucose concentrations in maternal and feto-placental blood were raised significantly (P=0.04 and P=0.0001 respectively); insulin levels in the low-protein (LP) dams were raised (P=0.04), prolactin levels were raised (P=0.047) and progesterone levels were reduced (P=0.02). Circulating 17beta-oestradiol in the LP dams was raised by 35 % over those of the controls from day 17 to day 21 (P=0.008). A significant decrease in maternal leptin levels (P=0.004) was observed at gestation on day 21. Neither oestradiol nor leptin levels were altered in the fetal circulation at day 21. Maternal and fetal corticosterone levels were comparable with control levels, suggesting that they do not initiate the programming effects in this model. Our present results suggest that maternal protein restriction imposes changes in maternal levels of glucose, insulin, prolactin, progesterone, oestradiol and leptin; these changes could influence the programming of eventual adult disease in the developing fetus.

Hepatitis B Seroprevalence Study 1999

Hepatitis B is a disease of public health importance in Singapore. A study was conducted in 1999 to estimate the overall and gender-, age- and ethnic-specific prevalence of hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg) and antibody to hepatitis B surface antigen in the Singapore population. A cross-sectional sample of the Singapore population constituting 4,698 Singapore residents aged 18-69 years was surveyed. This was the first time a large-scale study has been conducted to assess the hepatitis B seroprevalence rates in the Singapore population. The overall prevalence of the HBsAg in the general population was estimated to be about 4%. About 13% of the HBsAg carriers were also HBeAg positive. Only about 40% of the population had immunity to hepatitis B virus either through immunisation or from previous exposure to the virus. There was still a large proportion (60%) of the population who had no immunity, especially the younger age group of 18-29 years where only 28% had immunity. There is a need to strengthen the hepatitis B immunisation programme to reach out to those who have no immunity, especially the young adults.

Autologous, cadaveric, and synthetic materials used in sling surgery: comparative biomechanical analysis

OBJECTIVES

To compare the biomechanical properties of allografts, autografts, and synthetic materials used in sling surgery using the Instron tensinometer.

METHODS

The sling grafts we studied consisted of autologous tissues (dermis, rectus fascia, and vaginal mucosa), cadaver tissues (decellularized dermis and freeze-dried, gamma-irradiated fascia lata), and synthetics (Gore-Tex and polypropylene mesh). The sling grafts were constructed into two types of slings: full strip sling (FSS) versus patch suture sling (PSS). The slings were loaded onto the Instron tensinometer and uniaxially loaded in tension until failure. From the load deformation curve, the mechanical properties of the sling grafts were compared.

RESULTS

A total of 140 sling grafts were analyzed. In rank order for the FSSs, cadaver allografts had the strongest tensile strength followed by the synthetics and autologous tissues (P <0.05). The tensile strength of the FSSs was greater than for the PSSs for all groups (P </=0.001). In rank order for the PSSs, the synthetics and dermal tissues (autograft and allograft) had the highest tensile strength followed by cadaver fascia lata, rectus fascia, and vaginal mucosa (P <0.05).

CONCLUSIONS

The tensile strength of the FSS was greater than that of the PSS for the autograft, allograft, and synthetic tissues. The autograft and allograft tissues were significantly weaker as a PSS. The synthetics were more durable as a PSS compared with the organic tissues. When a PSS is constructed from autograft and allograft tissues, the risk of suture pull-through and recurrent stress incontinence must be considered.

The farnesyl transferase inhibitor SCH 66336 induces a G(2) --> M or G(1) pause in sensitive human tumor cell lines

SCH 66336 is a potent farnesyl transferase inhibitor (FTI) in clinical development. It efficiently prevents the membrane association of H-ras, but not K- or N-ras. Yet, in soft agar, it reverts the anchorage-independent growth of human tumor cell lines (hTCLs) harboring H-ras, K-ras, and N-ras mutations, implying that blocking farnesylation of proteins besides ras may be responsible for this effect. Experiments show that SCH 66336 altered the cell cycle distribution of sensitive human tumor cells in two distinct ways. Most sensitive hTCLs accumulated in the G(2)-->M phase after the FTI treatment, but those with an activated H-ras accumulated in G(1) phase, suggesting that the biological effects induced by FTIs in cells with an activated H-ras are distinct from other sensitive cells. A careful genotypic comparison of the hTCLs revealed that those cells with wild-type p53 are especially sensitive to the FTIs. In these cells p53 and its downstream target gene p21(Cip1) are induced after treatment with SCH 66336 for 24 h. These data suggest that cell cycle effects, either G(1) or G(2)-->M accumulation, and p53 status are important for mediating the effects of FTIs on tumor cells.

NO inhibits stretch-induced MAPK activity by cytoskeletal disruption

Mesangial cells (MC) grown on extracellular matrix protein-coated plates and exposed to cyclic strain/relaxation proliferate and produce extracellular matrix protein, providing an in vitro model of signaling in stretched MC. Intracellular transduction of mechanical strain involves mitogen-activated protein kinases, and we have shown that p42/44 mitogen-activated protein kinase (extracellular signal-regulated kinase (ERK)) is activated by cyclic strain in MC. In vivo studies show that increased production of nitric oxide (NO) in the remnant kidney limits glomerular injury without reducing glomerular capillary pressure, and we have observed that NO attenuates stretch-induced ERK activity in MC via generation of cyclic guanosine monophosphate (cGMP). Accordingly, we sought to determine whether NO affects strain-induced ERK activity after strain and how this is mediated. Strain-induced ERK activity was dependent on time and magnitude of stretch and was maximal after 10 min at -27 kilopascals. Actin cytoskeleton disruption with cytochalasin D abrogated this. The non-metabolizable cGMP analogue 8-bromo cyclic GMP (8-Br-cGMP) dose-dependently attenuated strain-induced ERK activity. Cytoskeletal stabilization with jasplakinolide prevented this inhibitory effect of 8-Br-cGMP. Cyclic strain increased nuclear translocation of phospho-ERK by immunofluorescent microscopy, again attenuated by 8-Br-cGMP. Jasplakinolide prevented the inhibitory effect of 8-Br-cGMP on activated ERK nuclear translocation after strain. Strain increased ERK-dependent AP-1 nuclear protein binding, which was attenuated by cytochalasin D and 8-Br-cGMP. These data indicate that cGMP can inhibit cyclic strain-induced ERK activity, nuclear translocation, and AP-1 nuclear protein binding. Cytoskeletal disruption leads to the same effect, whereas cytoskeleton stabilization reverses the effect of 8-Br-cGMP. Thus, NO inhibits strain-induced ERK activity by cytoskeletal destabilization.

The risk assessment profile score identifies trauma patients at risk for deep vein thrombosis

BACKGROUND

The identification of trauma patients at risk for the development of deep venous thrombosis (DVT) at the time of admission remains difficult. The purpose of this study is to validate the risk assessment profile (RAP) score to stratify patients for DVT prophylaxis.

METHODS

All patients admitted from November 1998 thru May 1999 were evaluated for enrollment. We prospectively assigned patients as low risk or high risk for DVT using the RAP score. High-risk patients received both pharmacologic and mechanical prophylaxis. Low-risk patients received none. Surveillance duplex Doppler scans were performed each week of hospitalization or if symptoms developed. Hospital charges for prophylaxis were used to determine the savings in the low-risk group. Statistical differences between the risk groups for each factor of the RAP and development of DVT were determined by the chi-squared test, with significance at a probability value of less than .05.

RESULTS

There were 102 high-risk (64%) and 58 low-risk (36%) individuals studied. Eleven of the high-risk group (10.8%) experienced the development of DVT (asymptomatic, 64%). None of the low-risk group was diagnosed with DVT. Five of the 16 RAP factors were statistically significant for DVT. Eliminating prophylaxis and Doppler scans in low-risk patients resulted in a total savings of $18,908 in hospital charges.

CONCLUSIONS

The RAP score correctly identified trauma patients at increased risk for the development of DVT. Despite prophylaxis, the high-risk group warrants surveillance scans. Withholding prophylaxis in low-risk patients can reduce hospital charges without risk.

Stretch activation of jun N-terminal kinase/stress-activated protein kinase in mesangial cells

BACKGROUND

Mesangial cells (MCs) grown on extracellular matrix (ECM)-coated plates and exposed to cyclic stretch/relaxation proliferate and produce ECM protein, suggesting that this may be a useful in vitro model for MC behavior in response to increased physical forces. The induction of c-fos in response to MC stretch has been shown. Stimuli that lead to c-fos induction pass through mitogen-activated protein (MAP) kinase pathways. We have seen early activation of jun N-terminal kinase/stress-activated protein kinase (SAPK/JNK) in MCs exposed to cyclic stretch. Accordingly, we studied SAPK/JNK activation in stretched MCs and the downstream consequences of this signaling.

METHODS

MCs (passages 5 to 10) cultured on type 1 collagen-coated, flexible-bottom plates were exposed to 2 to 60 minutes of cyclic strain (60 cycles per minute) by generation of vacuums of -10 to -27 kPa, inducing approximately 16 to 28% maximum elongation in the diameter of the surfaces. Control MCs were grown on coated rigid bottom plates. Protein levels (by Western blot) and activity assays for SAPK/JNK were performed under these conditions. We observed marked activation at -18 kPa and above and at two minutes, and then we studied activation mechanisms under these conditions. Nuclear protein binding to activator protein-1 (AP-1) consensus sequences was also examined. The role of calcium was studied with EGTA and BAPTA-AM to chelate extra- and intracellular calcium, respectively. Protein kinase C (PKC) was down-regulated by incubation with phorbol ester (PMA) for 24 hours prior to stretch. In unstretched MCs, A23187 was used as a calcium ionophore, and PKC was up-regulated with PMA application for 30 minutes to determine the effects on SAPK/JNK. Nuclear protein binding to AP-1 was also determined under these conditions. The effects of stretch, acute PMA, and A23187 on fibronectin mRNA levels were studied using reverse transcriptase-polymerase chain reaction (RT-PCR).

RESULTS

Cyclic strain/relaxation led to increased SAPK/JNK activity only at two minutes and -18 kPa and above. The activation of SAPK/JNK was dependent on intracellular calcium, with BAPTA-AM almost completely abrogating the response to stretch. EGTA was without effect. Down-regulation of PKC also led to a diminution of activity. In static cells, the calcium ionophore A23187 increased SAPK/JNK activity, and this was potentiated by acute PMA. Stretch, acute PMA, and A23187 all increased nuclear protein binding to AP-1 consensus sequences. mRNA levels for fibronectin were increased by stretch in MCs and by PMA and A23187 in static MCs. No change was observed in the amount of SAPK/JNK protein present in stretched MCs by Western blot.

CONCLUSIONS

Stretch leads to early activation of SAPK/JNK in MCs. This is dependent on intracellular calcium and PKC and can be replicated by activation of these stimuli in static MCs. A downstream induction of nuclear protein binding to AP-1 consensus sequences was seen in a pattern that was completely concordant with the SAPK/JNK induction.

Farnesyl transferase inhibitors block the farnesylation of CENP-E and CENP-F and alter the association of CENP-E with the microtubules

Human tumor cell lines that are sensitive to the effects of farnesyl transferase inhibitors accumulate in G(2) --> M (except for cells with an activated Ha-ras that accumulate in G(1)). A search for CAAX box proteins from Swiss-Prot revealed more than 300 peptides. Of these, the centromeric proteins CENP-E and CENP-F are preferentially expressed during mitosis and are implicated as mediators of the G(2) --> M checkpoint. Experiments performed here show that peptides from the COOH-terminal CAAX box of CENP-E and CENP-F are substrates for farnesyl transferase but not geranylgeranyl transferase-I. Although both proteins are prenylated in the human tumor cell line DLD-1, their prenylation is completely inhibited by the farnesyl transferase inhibitor, SCH 66336. Immunohistochemical data with the lung carcinoma cell line, A549, showed that preventing the farnesylation of CENP-E and CENP-F by treatment with the farnesyl transferase inhibitor SCH 66336 does not affect their localization to the kinetochores. However, the presence of farnesyl transferase inhibitors alters the association between CENP-E and the microtubules. Our results imply that the inhibition of CENP-E farnesylation results in the alteration of the microtubule-centromere interaction during mitosis and results in the accumulation of cells prior to metaphase.

Nitric oxide modulates stretch activation of mitogen-activated protein kinases in mesangial cells

BACKGROUND

In vivo, intraglomerular hypertension results in resident cell hypertrophy, proliferation and matrix protein production, leading to glomerulosclerosis. Mesangial cells (MCs) exposed to in vitro stretch also proliferate and produce matrix. We have shown activation of Jun N-terminal kinase/stress-activated protein kinase (SAPK) and p42/44 mitogen-activated protein kinase (MAPK) in stretched MCs and have also demonstrated that L-arginine decreases resident cell proliferation and protects against glomerulosclerosis in remnant kidney glomeruli, presumably by increasing nitric oxide (NO) production. Consequently, we studied whether NO could affect SAPK and p42/44 MAPK activation in stretched MCs.

METHODS

MCs (passages 5 to 10) cultured on type 1 collagen-coated, flexible-bottom plates were exposed to 0 to 30 minutes of cyclic strain (60 cycles per minute) by computer-driven generation of vacuum of -27 kPa, inducing 28% elongation in the diameter of the surface. Control MCs were grown on coated, flexible-bottom plates. Protein levels (by Western blot) and activity assays for SAPK/JNK and p42/44 MAPK were performed under these conditions. As maximal activation was at 10 minutes, with decay by 30 minutes, the effect of NO on kinase activation was studied at 0, 2, 5, and 10 minutes by preincubation with 70 micromol/L s-nitroso-n-acetylpenicillamine (SNAP; an NO donor) or 1 mmol/L 8-bromo cyclic guanosine monophosphate (8-bromo-cGMP). Downstream events in response to stretch and NO were studied at the time of maximal response (10 minutes) by examining nuclear translocation of SAPK with immunofluorescence microscopy and transcription factor activator protein-1 nuclear protein binding by gel mobility shift assay. The effect of kinase inhibition by NO donors on MC proliferation was studied by Western blotting for proliferating cell nuclear antigen (PCNA).

RESULTS

Cyclic MC stretch led to prompt SAPK and p42/44 MAPK activation, which was maximal at 10 minutes. Preincubation with either SNAP or 8-bromo-cGMP decreased this by 50 and 70%, respectively (N = 4), suggesting that the effect of NO was through cGMP generation. Nuclear translocation of both phosphorylated kinases was seen after 10 minutes of stretch and was largely prevented by 8-bromo-cGMP. Increased DNA binding of activator protein-1 proteins was observed in the nuclei of stretched MCs at 10 minutes by mobility shift assay (N = 4), which was also largely prevented by 8-bromo-cGMP. Stretch increased PCNA expression by MCs, and this was inhibited by 8-bromo-cGMP.

CONCLUSIONS

Stretch-induced activation of SAPK and p42/44 MAPK in MCs can be inhibited by NO. The effect of NO is mediated by the generation of cGMP. These mechanisms may be responsible, at least in part, for the protective effect of NO in animal models of glomerular injury characterized by glomerular capillary hypertension.

Nitric oxide modulates mechanical strain-induced activation of p38 MAPK in mesangial cells

Mesangial cells (MC), grown on extracellular matrix (ECM) protein-coated plates and stretched, proliferate and produce ECM, recapitulating in vivo responses to increased glomerular capillary pressure (Pgc). Transduction of strain involves mitogen-activated protein kinases (MAPK), and we have shown that p38 MAPK is activated by strain in MC. Because in vivo studies show that nitric oxide (NO) in the remnant kidney limits glomerular injury without reducing Pgc, we studied whether NO attenuated stretch-induced p38 activation in MC. Increasing p38 activation occurred with increasing stretch, maximally at 10 min at -27-kPa vacuum. Cyclic strain increased nuclear translocation of phosphorylated p38 by immunofluorescent microscopy and nuclear protein binding to nuclear factor-kappaB (NF-kappaB) consensus sequences by mobility shift assay. Both events were largely abrogated by the p38 inhibitor SB-203580. The NO donors 3-morpholinosydnonimine, S-nitroso-N-acetylpenicillamine, and 8-bromoguanosine 3',5'-cyclic monophosphate, a stable cGMP analog, prevented p38 activation and nuclear translocation. Thus strain induces p38 activity and translocation to the nucleus and p38-dependent increases in nuclear protein binding to NF-kappaB. This pathway is attenuated by the NO donors or a cGMP analog.

Characterization of the inspiratory manoeuvre when asthmatics inhale through a Turbohaler pre- and post-counselling in a community pharmacy

Dose emission from a Turbohaler has been shown to be dependent on the rate of inhalation, with an optimal flow of 60 l min(-1) recommended. Some patients may need counselling to achieve this fast inhalation. Inhalation rate profiles of 24 asthmatics were measured when they inhaled through a placebo Turbohaler. The setting was a community pharmacy when the asthmatics came to collect their next supply of medication. Profiles were measured before and after counselling on how to use the Turbohaler. The mean (SD) peak inhalation rate through the Turbohaler pre- and post-counselling was 48.0 (16.8) and 54.7 (17.6) l min(-1), and their inspiratory volume was 1.75 (0.68) and 1.94 (0.62) l, respectively. Their mean (SD) percent predicted FEV1 was 57.0 (18.9)%. After counselling, 12 patients achieved an inhalation rate of > 60 l min(-1) and a further four obtained > 55 l min(-1). Emphasis should be placed on counselling patients prescribed all types of inhaled devices rather than concentrating on metered dose inhalers.

Effects of body temperature on accuracy of continuous cardiac output measurements

Intermittent measurement of cardiac output is routine in the critically ill surgical patient. A new catheter allows real-time continuous measurement of cardiac output. This study evaluated the impact of body temperature variation on the accuracy of these measurements compared to standard intermittent bolus thermodilution technique. This prospective study in a university hospital surgical intensive care unit included 20 consecutive trauma patients. Data were collected with pulmonary artery catheters, which allowed both continuous (COC) and bolus (COB) thermodilution measurements. The catheter was placed through either the subclavian or internal jugular vein. Measurements for COB were performed using a bolus (10 cm3) of ice-cold saline with a closed-injectate delivery system at end-expiration. Computer-generated curves were created on a bedside monitor, and the average of three measurements within 10% of one another was used as COB. COC was determined as the average of the displayed CO before and after thermodilution CO measurements. Body temperature was measured from the pulmonary artery catheter and was grouped as < or =36.5 degrees C, 36.6-38.4 degrees C, and > or =38.5 degrees C. COB and COC were compared for agreement by plotting the mean of the differences (COB - COC) between the methods. The differences were plotted against the average of each pair and analyzed with linear regression. One hundred seventy-eight paired measurements were made over a period of 1 to 3 days. CO ranged from 3.7 to 15.5 L/min. Eighty-one percent of measurements were at a temperature of 36.5-38.4 degrees C. Approximately 7% of measurements were at a temperature below 36.5 degrees C and 11.2% were in patients with a core temperature above 38.5 degrees C. Correlation between the two techniques was 0.96, 0.91, and 0.82 for temperatures of < or =36.5 degrees C, 36.6-38.4 degrees C, and > or = 38.5 degrees C, respectively. In conclusion, the COC measurements correlate well with COB in trauma patients with a core temperature < or =38.5 degrees C. The accuracy degraded at higher temperatures, which may be related to the smaller signal-to-noise ratio at elevated body temperatures.

Liver transplantation for cholangiocarcinoma: results in 207 patients

BACKGROUND

Because of the high incidence of recurrent tumor, many surgeons have become disenchanted with transplantation as a treatment for cholangiocarcinoma.

METHODS

The Cincinnati Transplant Tumor Registry database was used to examine 207 patients who underwent liver transplantation for otherwise unresectable cholangiocarcinoma or cholangiohepatoma. Specific factors evaluated included tumor size, presence of multiple nodules, evidence of tumor spread at surgery, and treatment with adjuvant chemotherapy and/or radiation therapy. Incidentally found tumors were compared to tumors that were known or suspected to be present before transplantation.

RESULTS

The 1, 2, and 5-year survival estimates using life table analysis were 72, 48, and 23%. Fifty-one percent of patients had recurrence of their tumors after transplantation and 84% of recurrences occurred within 2 years of transplantation. Survival after recurrence was rarely more than 1 year. Forty-seven percent of recurrences occurred in the allograft and 30% in the lungs. Tumor recurrence, and evidence of tumor spread at the time of surgery, were negative prognostic variables. There were no positive prognostic variables. Patients with incidentally found cholangiocarcinomas did not have improved survival over patients with known or suspected tumors. A small number of patients survived for more than 5 years without recurrence. However, this group had no variable in common that would aid in the selection of similar patients in the future.

CONCLUSIONS

Because of the high rate of recurrent tumor and lack of positive prognostic variables, transplantation should seldom be used as a treatment for cholangiocarcinoma. For transplantation to be a viable treatment in the future, more effective adjuvant therapies are necessary.

Parent-daughter discussions to discourage tobacco use: feasibility and content

Parents engaged their 6th- and 8th-grade daughters in a conversation about tobacco. The parents were guided by a pamphlet designed to encourage effective family communication about tobacco. Conversations were audiotaped for later coding. Evidence is presented that such parent-daughter conversations about tobacco use can be successfully carried out in a nonaversive manner. Overall, the conversations were perceived to have gone well, with very little conflict reported. Further, the daughters reported that the parental advice was helpful and they did not resist receiving such advice. Among the topics suggested by the pamphlet, the following were most frequently discussed: consequences of smoking as experienced by friends and relatives, difficulty of quitting, promotional tactics of tobacco companies, making rules about tobacco use, and deciding on the consequences of rules adherence or violation. Other frequently discussed topics, which were not covered in the pamphlet, may also be appropriate for parent-daughter conversations: diminished physical attractiveness and body-image issues, how to resist peer pressure, and health risks.

Analogues of 1-(3,10-dibromo-8-chloro-6,11-dihydro-5H-benzo-[5,6]-cyclohepta [1,2-b]pyridin-11-yl)piperidine as inhibitors of farnesyl protein transferase

The synthesis of several 4-pyridylacetyl N-oxide derivatives of 4-(3-bromo-6,11-dihydro-5H-benzo[5,6]-cyclohepta[1,2-b]-pyridin-11-yl)pi perazine/piperidine 3 is described. This study was aimed at identifying fomesyl protein transferase (FPT) inhibitors in these two series of tricycles containing different phenyl ring substituents. The in vitro activity profile of the initial group of compounds 7a-7g led to the synthesis of the 8-methyl-10-methoxy and 8-methyl-10-bromo analogues 7i, 13i, and 13j. The 11R(-) enantiomers of these compounds were found to exhibit potent in vitro FPT inhibition activity.

Identification of pharmacokinetically stable 3, 10-dibromo-8-chlorobenzocycloheptapyridine farnesyl protein transferase inhibitors with potent enzyme and cellular activities

Farnesyl protein transferase (FPT) is a promising target for the development of cancer chemotherapeutics because it is responsible for the farnesylation of oncogenic p21 Ras proteins which are found in nearly 30% of all human cancers and necessary for cellular development and growth. The recent discovery and progression to phase II clinical trials of trihalobenzocycloheptapyridine Sch-66336 as a potent inhibitor of FPT with oral, in vivo efficacy in mice have spawned extensive structure-activity relationship studies (SAR) of this class of compounds. Of the many trihalobenzocycloheptapyridine analogues prepared, we have identified several which inhibit FPT and cellular proliferation at single-digit nanomolar concentrations and which have good pharmacokinetic properties in mice.

Analogs of 4-(3-bromo-8-methyl-10-methoxy-6,11-dihydro-5H-benzo[5,6]-cyclo hepta[1,2-b]pyridin-11-yl)-1-(4-pyridinylacetyl)piperidine N-oxide as inhibitors of farnesyl protein transferase

A series of 3-substituted analogs 3 of 4-(3-bromo-8-methyl-10-methoxy-6,11-dihydro-5H-benzo[5,6]-cyclohepta[1,2 b]pyridin-11-yl)-1-(4-pyridinylacetyl)piperidine N-oxide 2 was prepared and evaluated as FPT inhibitors. The objective of this study was to identify other substituents at C3 in this series of FPT inhibitors that would have the FPT potency enhancement similar to that found for a C3 bromo substituent. The 3-methyl analog 17b was found to be tenfold less active than 2, and other C3 substituents having more steric bulk were found to cause a further reduction in activity.