Phenazepam: A review of medico-legal deaths in South Scotland between 2010 and 2014

Phenazepam is a long acting benzodiazepine that is not prescribed in the United Kingdom. In Scotland it has been detected in a large number of post mortem cases, but very little data has been published looking at post mortem concentrations of this drug and indeed concentrations that may be associated with causing death. We looked at all post mortem cases between 2010 and 2014 where phenazepam was found in blood and correlated these with the given cause of death. The data collected shows the variability in reporting of phenazepam deaths and will provide a useful tool for those deciding when phenazepam should or should not be included as a cause of death. Cases discussed include drug related deaths with phenazepam as the sole cause of death (as is), drug related death when the cause of death was noted as being from a combination of phenazepam plus one or more other drugs (range <0.005-0.9mg/L, median 0.10mg/L) and causes of death in non-drug related deaths where phenazepam was detected (hangings range <0.05-0.39mg/L, median 0.09mg/L and deaths due to ischaemic heart disease range 0.05-0.1mg/L, median 0.04mg/L).

Mutations in EXPH5 result in autosomal recessive inherited skin fragility

Several different genes have been implicated in the pathophysiology of inherited blistering skin diseases. Recently, autosomal recessive loss-of-function mutations in EXPH5 (encoding exophilin-5, also known as Slac2-b, a protein involved in intracellular vesicle transport) were identified in a new mechanobullous disease resembling a form of epidermolysis bullosa simplex (EBS). Here, we searched for mutations in EXPH5 in a 4-year-old white boy with EBS in whom initial Sanger sequencing of known genes implicated in intraepidermal skin fragility failed to identify pathogenic mutations. Transmission electron microscopy of rubbed nonlesional patient skin revealed disruption of keratinocytes in the lower epidermis with cytolysis and acantholysis, keratin filament clumping and prominent perinuclear cytoplasmic vesicles, and provided the clue to the candidate gene pathology. Sanger sequencing of genomic DNA showed compound heterozygosity for two new mutations in EXPH5, c.1947dupC (p.Pro649fsPro*11) and c.2249C>A (p.Ser750*). Immunofluorescence microscopy of patient skin showed a complete absence of exophilin-5 labelling. This case represents the third pedigree with EXPH5 mutations resulting in inherited skin fragility. The clinical and molecular data expand genotype-phenotype correlation in this new form of EBS and demonstrate the important role of exophilin-5 in keratinocyte cell biology.

Podoplanin mediates ECM degradation by squamous carcinoma cells through control of invadopodia stability

Invadopodia are actin-rich cell membrane projections used by invasive cells to penetrate the basement membrane. Control of invadopodia stability is critical for efficient degradation of the extracellular matrix (ECM); however, the underlying molecular mechanisms remain poorly understood. Here, we uncover a new role for podoplanin, a transmembrane glycoprotein closely associated with malignant progression of squamous cell carcinomas (SCCs), in the regulation of invadopodia-mediated matrix degradation. Podoplanin downregulation in SCC cells impairs invadopodia stability, thereby reducing the efficiency of ECM degradation. We report podoplanin as a novel component of invadopodia-associated adhesion rings, where it clusters prior to matrix degradation. Early podoplanin recruitment to invadopodia is dependent on lipid rafts, whereas ezrin/moesin proteins mediate podoplanin ring assembly. Finally, we demonstrate that podoplanin regulates invadopodia maturation by acting upstream of the ROCK-LIMK-Cofilin pathway through the control of RhoC GTPase activity. Thus, podoplanin has a key role in the regulation of invadopodia function in SCC cells, controlling the initial steps of cancer cell invasion.

Effect of anticholinergics on the overactive bladder and bowel domain of the electronic personal assessment questionnaire (ePAQ)

INTRODUCTION AND HYPOTHESIS

Evidence suggests that OAB (overactive bladder) can occur alongside disorders of the colon, such as irritable bowel syndrome (IBS). Moreover, patients with constipation are more likely to develop OAB symptoms than those without. Anticholinergic medications (AcH) are commonly used for treating OAB, and can result in the unwanted side effects of constipation. We aimed to study the relationship of AcH, and their effects on quality of life using the electronic Personal Assessment Questionnaire (ePAQ) by assessing changes in the bowel and bladder domains, pre- and post-AcH treatment.

METHODS

Ninety patients completed the ePAQ pre- and post-AcH treatment from January 2011 to April 2014. Data were collected retrospectively and prospectively, and analysed using a paired t test. Effect size (ES) was calculated for OAB and bowel domains to quantify the effect on QoL.

RESULTS

There was a significant improvement in the OAB (p = 0.0005) and bowel domains (p = 0.0005). In the bowel domains, the largest effect size was seen for IBS (0.5) followed by continence (0.4), evacuation (0.375) and a small ES was seen for constipation (0.2). There was a reduction in the "degree of bother" in OAB and bowel domains.

CONCLUSIONS

Patients may benefit from the possible effects of AcH on their bowels, and assessment of all aspects of pelvic floor function is important before commencing AcH. This may help to counsel patients, with possibly improved compliance with therapy.

Antigenic variation in African trypanosomes: DNA rearrangements program immune evasion

Individual B cells express only one of the many variable-region genes of the VH gene repertoire. Likewise, individual African trypanosomes express only one surface-antigen gene of the large surface-antigen gene repertoire. In both kinds of cells, expression is controlled at the level of transcriptional activation and has been shown to involve rearrangement of genomic DNA. Here, Nina Agabian and her colleagues review recent studies on the molecular mechanisms controlling trypanosome surface-antigen gene expression.

Defining acute ischemic stroke tissue pathophysiology with whole brain CT perfusion

BACKGROUND

This study aimed to identify and validate whole brain perfusion computed tomography (CTP) thresholds for ischemic core and salvageable penumbra in acute stroke patients and develop a probability based model to increase the accuracy of tissue pathophysiology measurements.

METHODS

One hundred and eighty-three patients underwent multimodal stroke CT using a 320-slice scanner within 6hours of acute stroke onset, followed by 24hour MRI that included diffusion weighted imaging (DWI) and dynamic susceptibility weighted perfusion imaging (PWI). Coregistered acute CTP and 24hour DWI was used to identify the optimum single perfusion parameter thresholds to define penumbra (in patients without reperfusion), and ischemic core (in patients with reperfusion), using a pixel based receiver operator curve analysis. Then, these results were used to develop a sigma curve fitted probability based model incorporating multiple perfusion parameter thresholds.

RESULTS

For single perfusion thresholds, a time to peak (TTP) of +5seconds best defined the penumbra (area under the curve, AUC 0.79 CI 0.74-0.83) while a cerebral blood flow (CBF) of < 50% best defined the acute ischemic core (AUC 0.73, CI 0.69-0.77). The probability model was more accurate at detecting the ischemic core (AUC 0.80 SD 0.75-0.83) and penumbra (0.85 SD 0.83-0.87) and was significantly closer in volume to the corresponding reference DWI (P=0.031).

CONCLUSIONS

Whole brain CTP can accurately identify penumbra and ischemic core using similar thresholds to previously validated 16 or 64 slice CTP. Additionally, a novel probability based model was closer to defining the ischemic core and penumbra than single thresholds.

Bladder perforation during sling procedures: diagnosis and management of injury

INTRODUCTION AND HYPOTHESIS

Midurethral slings are an effective and minimally invasive treatment for stress urinary incontinence. One of the most common intraoperative complications is bladder perforation, complicating between 2 and 10% of all operations, and on average 4.7%. It is usually corrected during surgery, with repositioning of the trocars. The purpose of this video is to demonstrate a method of replacing the trocars under direct vision.

METHODS

This video exhibits a bladder perforation during insertion of a retropubic midurethral sling (Advantage Fit; Boston Scientific) and gives a step-by step guide to the removal and repositioning of the sling under direct visualisation.

CONCLUSION

Repositioning of the trocars under direct vision in cases of bladder perforation may have numerous advantages. It may prevent damage to the urethra, possibly reduce the risk of postoperative infection and may be beneficial for trainees.

Integrin α3β1-CD151 complex regulates dimerization of ErbB2 via RhoA

Integrin α3β1 regulates adhesive interactions of cells with laminins and have a critical role in adhesion-dependent cellular responses. Here, we examined the role of α3β1-integrin in ErbB2-dependent proliferation of breast cancer cells in three-dimensional laminin-rich extracellular matrix (3D lr-ECM). Depletion of α3β1 in ErbB2-overexpressing breast cancer cells suppressed growth and restore cell polarity in 3D lr-ECM. The phenotype of α3β1-depleted cells was reproduced upon depletion of tetraspanin CD151 and mirrored that of the cells treated with Herceptin, an established ErbB2 antagonist. Breast cancer cells expressing the α3β1-CD151 complex have higher steady-state phosphorylation of ErbB2 and show enhanced dimerization of the protein when compared with α3β1-/CD151-depleted cells. Furthermore, Herceptin-dependent dephosphorylation of ErbB2 was only observed in α3β1-CD151-expressing cells. Importantly, the inhibitory activity of Herceptin was more pronounced when cells expressed both α3β1 and CD151. We also found that the level of active RhoA was increased in α3β1- and CD151-depleted cells and that Rho controls dimerization of ErbB2. Expression of α3β1 alone did not have significant prognostic value in patients with invasive ductal carcinoma of the breast. However, expression of α3β1 in combination with CD151 represented a more stringent indicator of poor survival than CD151 alone. Taken together, these results demonstrate that the α3β1-CD151 complex has a critical regulatory role in ErbB2-dependent signalling and thereby may be involved in breast cancer progression.

Hyperintense optic nerve heads on diffusion-weighted imaging: a potential imaging sign of papilledema

BACKGROUND AND PURPOSE

Changes at the optic nerve head on DWI in the presence of papilledema have not been systematically studied. The purpose of this study was to evaluate if hyperintensity of ON heads on DWI is associated with papilledema.

MATERIALS AND METHODS

In this retrospective study, 19 patients (4 men, 15 women; median age, 32 years) with papilledema and 20 control participants (7 men, 13 women; median age, 48 years) who had undergone prior MR imaging of the brain were identified. Two neuroradiologists blinded to the diagnosis independently reviewed the DWI for the presence of hyperintense signal at the ON head of each eye. If present, they graded the signal as mild or prominent. Groups with and without papilledema were compared for the prevalence of ON head hyperintensity by using the Fisher exact test, with analyses performed both for groups of patients and for individual eyes. Presence of ON head hyperintensity was also studied as a function of Frisen papilledema grade on fundoscopy, when available.

RESULTS

Hyperintensity of the ON heads on DWI was significantly associated with papilledema (P = .001). For the 2 readers, hyperintensity at both ON heads was 26.3% and 42.1% sensitive and 100% specific in the detection of papilledema. The presence of unilateral ON head hyperintensity was not specific for papilledema and was invariably graded as mild when seen in the control group. Patients with higher papilledema grades had a higher prevalence of hyperintensity at the ON heads.

CONCLUSIONS

Hyperintensity of the ON heads on DWI can serve as a useful imaging marker for papilledema, especially if bilateral. Its absence, however, does not exclude papilledema.

Aspectasaurus (A Dinosaur)?

There is mounting evidence that shows how poorly noncontrast computed tomography (NCCT) Alberta Stroke Program Early CT Score (ASPECTS) performs in the first three-hours after stroke onset compared to Diffusion weighted (DWI) magnetic resonance imaging (MRI). It is time to move into the 21st century and use more advanced imaging routinely in hyper-acute stroke assessment. While a useful tool if one is limited to NCCT alone, ASPECTS becomes somewhat superfluous as we now have rapid, validated, automated infarct core and penumbra volumes with either MRI or perfusion CT.

Magnetoresistive properties of 1st AFM Co/Cu multilayers sputtered in an Ar+O2 atmosphere

Sputter-deposited Co/Cu multilayers at the 1st antiferromagnetic maximum (tCu= 9Å) exhibit large magnetoresistance and low relative hysteresis and are attractive for use in many position sensor applications. Unfortunately, their large magnetoresistance values can be hard to reproduce, perhaps a consequence of the difficulties in growing flat, pin-hole free layers. In this study we demonstrate that their magnetoresistive properties can be improved with the addition O2 to the Ar sputtering gas. A sequence of [Co(15Å)/Cu(9Å)]20 multilayers were made using magnetron sputtering in a 2mTorr Ar+O2 atmosphere, with the O2 concentration ranging from <1 ppm to 10,000 ppm. For films sputtered in our purest Ar, the magnetoresistance was typically less than 10%. Adding small amounts of O2 to the Ar improved the magnetoresistance, and at 1000 ppm O2 concentration it reached an optimal value of ∼45% and was found to be quite reproducible. The largest saturation fields were also achieved at 1000 ppm O2. Increasing the O2 concentration beyond 1000 ppm degraded the magnetoresistance and reduced the saturation fields. Magnetic measurements indicate that the improved magnetoresistance for films sputtered in Ar + O2 is primarily a consequence of more complete antiferromagnetic ordering at low fields. Auger depth profiling revealed no evidence for the O2 incorporation into the films, even for those fabricated in 10,000 ppm O2. Influence of the O2 on the microstructure of the multilayers is discussed.

Improving colon cancer screening rates in primary care: a pilot study emphasising the role of the medical assistant

BACKGROUND

Colorectal cancer (CRC) is the third-leading cause of cancer death for both men and women in the USA. Despite consensus recommendations for screening, just over half of eligible adults nationally have undergone screening. We therefore implemented a programme to improve the rate of CRC screening.

METHODS

This study was conducted in the Utah Health Research Network and the University of Utah Community Clinics, a 100 000 patient, seven-practice, university-owned system offering primary and secondary care and ancillary services including endoscopy. We focused on patients aged >or=50 who were seen between 1 January 2003 and 31 October 2006, and who were not current for CRC screening at the time of the visit. The study included a three-phase

INTERVENTION

electronic medical record (EMR) reminders, physician and medical assistant (MA) education about CRC screening guidelines, and redesign of patient visit workflow with an expanded role for MAs to review patients' CRC screening status and recommend testing when appropriate. With patient agreement, the MA entered a preliminary order in the EMR, and the physician confirmed or rejected the order. The primary outcome measure was the rate of screening colonoscopy ordered for eligible patients.

RESULTS

The baseline colonoscopy referral rate was 6.0%. Provider education and electronic reminders had minimal immediate impact on screening rates. Addition of the expanded MA role was associated with a sustained increase in colonoscopy referral order rate to 13.4%, a relative improvement of 123%.

CONCLUSIONS

The MA can play a key role in improving CRC screening rates as part of a redesigned system of primary care.

An analysis of a performance feedback system: the effects of timing and feedback, public posting, and praise upon academic performance and peer interaction

In the first experiment, after establishing baseline composition rates in each classroom, timing (announcing time limits) and feedback (student self-scoring) were introduced followed by the introduction, removal, and reintroduction of public posting of highest scores. Timing and feedback improved story writing performance and public posting of highest scores improved performance even further in both classrooms. Teacher praise produced further improvement in one classroom but had no effect on performance in the other. Changes in on-task behavior paralleled changes in writing rate. Comments made by children concerning their own work or work of their peers were recorded throughout the experiment. Although the baseline rate of performance comments was almost zero, the introduction of each variable markedly increased the rate of performance comments. In the second experiment, baseline rates on reading and language exercises were established in a fifth-grade classroom. The entire performance feedback system was introduced on a multiple baseline across the two behaviors and then removed during the final phase of the experiment. Introducing the system improved performance on both tasks. These results further increased the generality of some of the findings of the previous experiment and of previous research on the efficacy of the experimental package of timing, feedback, public posting, and praise.