A MEN1 pancreatic neuroendocrine tumour mouse model under temporal control

Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant disorder characterised by occurrence of parathyroid tumours and neuroendocrine tumours (NETs) of the pancreatic islets and anterior pituitary. The MEN1 gene, encoding menin, is a tumour suppressor, but its precise role in initiating in vivo tumourigenesis remains to be elucidated. The availability of a temporally controlled conditional MEN1 mouse model would greatly facilitate the study of such early tumourigenic events, and overcome the limitations of other MEN1 knockout models, in which menin is lost from conception or tumour development occurs asynchronously. To generate a temporally controlled conditional mouse model, we crossbred mice with the MEN1 gene floxed by LoxP sites (Men1L/L ), and mice expressing tamoxifen-inducible Cre recombinase under the control of the rat insulin promoter (RIP2-CreER), to establish a pancreatic β-cell-specific NET model under temporal control (Men1L/L /RIP2-CreER). Men1L/L /RIP2-CreER mice aged ~3 months were given tamoxifen in the diet for 5 days, and pancreata harvested 2-2.5, 2.9-3.5 and 4.5-5.5 months later. Control mice did not express Cre and did not receive tamoxifen. Immunostaining of pancreata from tamoxifen-treated Men1L/L /RIP2-CreER mice, compared to control mice, showed at all ages: loss of menin in all islets; increased islet area (>4.2-fold); increased proliferation of insulin immunostaining β-cells (>2.3-fold) and decreased proliferation of glucagon immunostaining α-cells (>1.7-fold). There were no gender and apoptotic or proliferation differences, and extra-pancreatic tumours were not detected. Thus, we have established a mouse model (Men1L/L /RIP2-CreER) to study early events in the development of pancreatic β-cell NETs.

Understanding How Bereaved Parents Cope With Their Grief to Inform the Services Provided to Them

Our objective was to develop a rich description of how parents experience their grief in the first year after the death of their child, and how various bereavement follow-up and support services helped them during this time, with the aim of informing follow-up and support services offered to bereaved parents. Our findings situated parents' individual experiences of coping within the social and institutional contexts in which they grieved. In the first year after the death of their child, parents regulated their intense feelings of grief through loss-oriented, restoration-oriented, and/or meaning reconstruction strategies. Often, parents' relationships with others and many of the bereavement follow-up and support services helped them in this regard. This article also explores how the results may aid service providers in accompanying parents in a way that optimizes outcomes for these parents.

Mice deleted for cell division cycle 73 gene develop parathyroid and uterine tumours: model for the hyperparathyroidism-jaw tumour syndrome

The hyperparathyroidism-jaw tumour (HPT-JT) syndrome is an autosomal dominant disorder characterized by occurrence of parathyroid tumours, often atypical adenomas and carcinomas, ossifying jaw fibromas, renal tumours and uterine benign and malignant neoplasms. HPT-JT is caused by mutations of the cell division cycle 73 (CDC73) gene, located on chromosome 1q31.2 and encodes a 531 amino acid protein, parafibromin. To facilitate in vivo studies of Cdc73 in tumourigenesis we generated conventional (Cdc73^+/-) and conditional parathyroid-specific (Cdc73^+/L/PTH-Cre and Cdc73^L/L/PTH-Cre) mouse models. Mice were aged to 18-21 months and studied for survival, tumour development and proliferation, and serum biochemistry, and compared to age-matched wild-type (Cdc73^+/+ and Cdc73^+/+/PTH-Cre) littermates. Survival of Cdc73^+/- mice, when compared to Cdc73^+/+ mice was reduced (Cdc73^+/-=80%; Cdc73^+/+=90% at 18 months of age, P<0.05). Cdc73^+/-, Cdc73^+/L/PTH-Cre and Cdc73^L/L/PTH-Cre mice developed parathyroid tumours, which had nuclear pleomorphism, fibrous septation and increased galectin-3 expression, consistent with atypical parathyroid adenomas, from 9 months of age. Parathyroid tumours in Cdc73^+/-, Cdc73^+/L/PTH-Cre and Cdc73^L/L/PTH-Cre mice had significantly increased proliferation, with rates >fourfold higher than that in parathyroid glands of wild-type littermates (P<0.0001). Cdc73^+/-, Cdc73^+/L/PTH-Cre and Cdc73^L/L/PTH-Cre mice had higher mean serum calcium concentrations than wild-type littermates, and Cdc73^+/- mice also had increased mean serum parathyroid hormone (PTH) concentrations. Parathyroid tumour development, and elevations in serum calcium and PTH, were similar in males and females. Cdc73^+/- mice did not develop bone or renal tumours but female Cdc73^+/- mice, at 18 months of age, had uterine neoplasms comprising squamous metaplasia, adenofibroma and adenomyoma. Uterine neoplasms, myometria and jaw bones of Cdc73^+/- mice had increased proliferation rates that were 2-fold higher than in Cdc73^+/+ mice (P<0.05). Thus, our studies, which have established mouse models for parathyroid tumours and uterine neoplasms that develop in the HPT-JT syndrome, provide in vivo models for future studies of these tumours.

Social network analysis of the movement of poultry to and from live bird markets in Bali and Lombok, Indonesia

Highly pathogenic avian influenza H5N1 has resulted in large losses to the Indonesian poultry sector. Evidence suggests that live bird markets (LBMs) play an important role in the epidemiology of the disease. Knowledge of the frequency and type of contact between the various poultry market players should allow animal health authorities to develop a better understanding of factors influencing virus transmission between Indonesian villages. A questionnaire-based cross-sectional survey was conducted in 17 LBMs on the neighbouring Indonesian islands of Bali and Lombok to investigate the movement patterns of poultry to and from markets. Using social network analyses, a network of contacts was created for each island from a total of 413 live poultry traders and 134 customers. Individual nodes with high degree and/or betweenness were identified in each network. The Lombok network was more dense and connected than the Bali network indicating that disease transmission would be more efficient in the Lombok network. Our findings indicate that whilst live poultry are typically transported over relatively short distances of approximately 10 km, it is not uncommon for traders and customers to travel in excess of 100 km to buy or sell poultry, which may facilitate the spread of disease over a large geographical area. This study highlights the different roles markets play in poultry movement networks and their potential for disease dissemination. The identification of highly influential market nodes allows authorities to target HPAI surveillance activities to locations where disease is more likely to be present, which is crucial in low-resource settings.

Merging DNA typing and network analysis to assess the transmission of paratuberculosis between farms

Paratuberculosis, a chronic enteric infection caused by Mycobacterium subsp. paratuberculosis (MAP), is endemic in all farmed ruminant species in New Zealand. The use of genotyping in combination with network analysis of livestock movement events from one farm location to another has the potential to contribute to our understanding of between-farm transmission events. We studied a population of 122 farms from a corporate commercial livestock enterprise in New Zealand, trading with each other in near isolation from other commercial farms. The data consisted of longitudinal movements to and from these farms between 2006 and 2010, as well as the results of cross-sectional MAP screening and genotyping performed in 2010. We explored associations between past livestock movements and current strain type distribution in this population of farms using quadratic assignment procedure. Our results show that measures of farm clustering within the movement network were significantly associated with sharing of MAP strains. For example, farms closely related by trade were twice as likely to share the same strains of MAP (p=0.033). Other covariates were also associated with the probability of sharing the same strains of MAP, such as being located on the same island (OR=5.8 to 8.7, p<0.01), farming the same livestock species and Euclidian distance between farms. The novel approach we used supports the hypothesis that livestock movement is indeed a significant contributor to farm-to-farm transmission of MAP.

Aspirin for thromboprophylaxis after primary lower limb arthroplasty: early thromboembolic events and 90 day mortality in 11,459 patients

AIMS

The aim of this study was to present data on 11 459 patients who underwent total hip (THA), total knee (TKA) or unicompartmental knee arthroplasty (UKA) between November 2002 and April 2014 with aspirin as the primary agent for pharmacological thromboprophylaxis.

PATIENTS AND METHODS

We analysed the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) then compared the 90-day all-cause mortality with the corresponding data in the National Joint Registry for England and Wales (NJR).

RESULTS

The incidence of PE was 0.6% after THA, 1.47% after TKA and 1.2% after UKA. The 90-day mortality was 0.39% after THA and 0.44% after TKA. No deaths occurred after UKA. The main causes of death were ischaemic heart disease and respiratory failure. PE was responsible for only 18% of deaths. There was a decline in 90-day mortality, from 0.64% between 2002 and 2007, to 0.21% between 2008 and 2013 after THA, and from 0.47% to 0.39% after TKA for the corresponding period. The standardised mortality ratio (SMR) declined from 86.5 (confidence interval (CI) 63.0 to 137.7) to 39.7 (CI 31.2 to 54.3) p = 0.024. The incidence of proximal DVT was 0.3%.

TAKE HOME MESSAGE

With individualised risk assessment and as part of a multimodal approach, Aspirin is safe to use as the main thromboprophylactic agent in primary arthroplasty. It is not associated with an increased incidence of symptomatic DVT, PE or death.

The influence of lime and nitrogen fertilisers on spore counts of Pithomyces chartarum in pasture

AIMS

To determine whether the application of lime or nitrogen to pasture affected the spore counts of Pithomyces chartarum.

MATERIALS AND METHODS

The lime application studies were undertaken on a spring-calving, pasture-based, commercial dairy farm near Te Awamutu, New Zealand. On 6 November 2012, five randomly selected paddocks were split into three equal sections. In two of the sections, lime was applied at either 1.5 or 2.5 t/ha, and the central section was left as an untreated control. Each section was sampled for spore counting weekly from 16 January to 15 May 2013. Starting in January 2013, five other randomly selected paddocks were monitored for spore counts. On 20 March 2013 the average spore counts in three paddocks were >100,000 spores/g of pasture. These paddocks were then divided into three equal sections and lime was applied as described above. Spore counting in each section continued weekly until 15 May 2013. The nitrogen application study was carried out on three commercial dairy farms near Te Awamutu, New Zealand. Two randomly selected paddocks on each farm were divided into three equal sections and, on 20 December 2012, nitrogen in the form of urea was applied at either 50 or 80 kg urea/ha to two of the sections; the central section remained as an untreated control. Each section was sampled for spore counting weekly from 16 January to 15 May 2013.

RESULTS

Following pre-summer lime application, treatment at 1.5 or 2.5 t/ha did not affect spore counts over time compared with the control section (p>0.26). Similarly following autumn lime application, treatment at 1.5 or 2.5 t/ha did not affect spore counts over time compared with the control section (p>0.11). Following nitrogen application median spore counts remained <20,000 spores/g pasture throughout the trial period and there was no effect of treatment on spore counts over time (p>0.49).

CONCLUSION

This study found that application of lime before the risk period for facial eczema, in November, application of lime after a spore count rise, in March, or urea application in December did not affect changes in number of spores produced by P. chartarum.

CLINICAL RELEVANCE

This study does not support previous suggestions that fertilising pasture with lime or urea could alter the spore counts of P. chartarum. Fertiliser use does not provide an alternative to, or support, conventional methods of facial eczema control such as zinc prophylaxis or treatment of pasture with fungicides.

Animal models of pituitary neoplasia

Pituitary neoplasias can occur as part of a complex inherited disorder, or more commonly as sporadic (non-familial) disease. Studies of the molecular and genetic mechanisms causing such pituitary tumours have identified dysregulation of >35 genes, with many revealed by studies in mice, rats and zebrafish. Strategies used to generate these animal models have included gene knockout, gene knockin and transgenic over-expression, as well as chemical mutagenesis and drug induction. These animal models provide an important resource for investigation of tissue-specific tumourigenic mechanisms, and evaluations of novel therapies, illustrated by studies into multiple endocrine neoplasia type 1 (MEN1), a hereditary syndrome in which ∼ 30% of patients develop pituitary adenomas. This review describes animal models of pituitary neoplasia that have been generated, together with some recent advances in gene editing technologies, and an illustration of the use of the Men1 mouse as a pre clinical model for evaluating novel therapies.

Evaluation of the Control Strategy for the 2010 Foot-and-Mouth Disease Outbreak in Japan Using Disease Simulation

In 2010, Japan experienced a foot-and-mouth disease (FMD) epidemic where 292 premises were infected over a period of 75 days. The epidemic was controlled by stamping-out and vaccination, applied 5 weeks after the first confirmation of disease within a 10 km radius of identified infected places. This study aimed at identifying the role of emergency vaccination to epidemic control while adjusting for the dynamic pattern of local spread, and assessing alternative vaccination strategies, using a disease simulation model. Our results indicate that the overall hazard of local spread remained high throughout the silent spread phase and the first two weeks post-detection, with significant reduction occurring from week 3 onwards. The estimated effectiveness of emergency vaccination quantified as reduction in the hazard of infection was at most 81% and 44% for cattle and pig farms, respectively. The vaccination strategy reduced the simulated median number of IPs by 22%, epidemic duration by 64% and culling duration by 52%, but increased the total number of infected or vaccinated premises subject to culling by 144% compared with no vaccination. The simulation indicated that vaccination starting 2 weeks earlier (3 weeks post-first detection) with a smaller vaccination radius (3 km) was more effective for eradication of the epidemic compared with the actually implemented strategy.

Early surveillance of ceramic-on-metal total hip arthroplasty

Ceramic-on-metal (CoM) is a relatively new bearing combination for total hip arthroplasty (THA) with few reported outcomes. A total of 287 CoM THAs were carried out in 271 patients (mean age 55.6 years (20 to 77), 150 THAs in female patients, 137 in male) under the care of a single surgeon between October 2007 and October 2009. With the issues surrounding metal-on-metal bearings the decision was taken to review these patients between March and November 2011, at a mean follow-up of 34 months (23 to 45) and to record pain, outcome scores, radiological analysis and blood ion levels. The mean Oxford Hip Score was 19.2 (12 to 53), 254 patients with 268 hips (95%) had mild/very mild/no pain, the mean angle of inclination of the acetabular component was 44.8o (28o to 63o), 82 stems (29%) had evidence of radiolucent lines of > 1 mm in at least one Gruen zone and the median levels of cobalt and chromium ions in the blood were 0.83 μg/L (0.24 μg/L to 27.56 μg/L) and 0.78 μg/L (0.21 μg/L to 8.84 μg/L), respectively. The five-year survival rate is 96.9% (95% confidence interval 94.7% to 99%).

Due to the presence of radiolucent lines and the higher than expected levels of metal ions in the blood, we would not recommend the use of CoM THA without further long-term follow-up. We plan to monitor all these patients regularly.

Cite this article: Bone Joint J 2015;97-B:300–5.

A novel approach to improve undergraduate surgical teaching

BACKGROUND

Undergraduate surgery is at an important crossroads. Many departments report significant difficulties delivering effective teaching. Our student feedback indicated a dated surgical curriculum lacking structure, quality and uniformity. We report on a new "blended" approach employing a combination of professional DVDs, case based discussions, online material and traditional bedside teaching designed to provide structure, standardization, and equality of learning .

METHODS

Year 4 students who had undertaken the new course and year 5 students who had participated in the traditional teaching programme were compared. Students completed a 20 item questionnaire about their experiences of the surgical teaching programme.

RESULTS

One hundred and seventy-one year 4 (70%) and 148 year 5 students (66%) responded. Domains relating to "Overall Satisfaction with the course", "Approval of innovative teaching methods and interactivity" and "Satisfaction with the clarity of course information" showed improvements when comparing the new and old programmes. However bedside teaching was not rated as highly in the new programme (p<0.05).

CONCLUSION

This blended approach has resulted in improved student understanding and engagement. The apparent compromise of bedside teaching may be a reflection of higher expectations. We believe that a similar blended approach has the potential to re-invigorate surgical teaching elsewhere.

Does rheumatoid arthritis disease activity correlate with weather conditions?

To determine whether rheumatoid arthritis disease activity correlates with changing weather conditions. A longitudinal analysis of 133 patients attending the Department of Rheumatology, Musgrave Park Hospital, Belfast was performed. Participants had a diagnosis of rheumatoid arthritis and were receiving subcutaneous anti-TNF therapy (Adalimumab or Etanercept) for a period of >6 months. Data were collected at five time points. This included tender joint count, swollen joint count, patient visual analogue score (VAS), erythrocyte sedimentation rate, C-reactive protein, VAS, and DAS-28 (Disease Activity Score). Each weather factor (maximum, minimum temperature, pressure, rainfall, sunshine, humidity, and wind-speed) was analysed against each patients' DAS-28 score at five time points, using an analysis of covariance. A significant correlation was noted between low DAS-28 and increased hours of sunshine (p < 0.001). Sunny conditions were associated with a DAS-28 reduction of 0.037 (95 % CI -0.059, -0.016) p < 0.001. A significant correlation between humidity and DAS-28 was also noted (p = 0.016). Increased humidity was associated with an increased DAS-28 of 0.007 (95 % CI 0.001, 0.013) p = 0.016. Higher temperatures were associated with a non-significant decrease in DAS-28 (p = 0.16). In this study, rheumatoid arthritis disease activity (as measured by DAS-28) was significantly lower in both more sunny and less humid conditions.

Picosecond 554 nm yellow-green fiber laser source with average power over 1 W

We demonstrate a source of 554 nm pulses with 2.7 ps pulse duration and 1.41 W average power, at a repetition rate of 300 MHz. The yellow-green pulse train is generated from the second harmonic of a 1.11 μm fiber laser source in periodically-poled stoichiometric LiTaO3. A total fundamental power of 2.52 W was used, giving a conversion efficiency of 56%.

Clinical effectiveness and cost-effectiveness of minimally invasive techniques to manage varicose veins: a systematic review and economic evaluation

BACKGROUND

Varicose veins are enlarged, visibly lumpy knotted veins, usually in the legs. Uncomplicated varicose veins can cause major discomfort and some complications. They are part of chronic venous disease (CVD), which is reported to have a substantial negative impact on health-related quality of life (HRQoL). Traditional treatments for varicose veins involve surgical stripping and ligation and liquid sclerotherapy (LS), but can be invasive and painful. New minimally invasive treatments offer an alternative. These treatments typically involve use of laser, radiofrequency or foam sclerosant. They are increasingly widely used and offer potential benefits such as reduced complications, faster recovery, fewer physical limitations and improved quality of life.

OBJECTIVE

The aim of this report is to evaluate the clinical effectiveness, safety and cost-effectiveness of the minimally invasive techniques of foam sclerotherapy (FS), endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) in comparison with other techniques, including traditional surgical techniques, LS and conservative management, in the management of varicose veins.

DATA SOURCES

A systematic search was made of 11 bibliographic databases of published and unpublished literature from their inception to July 2011: MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature; The Cochrane Library; Biological Abstracts; Science Citation Index (SCI); Social Sciences Citation Index; Conference Proceedings Citation Index-Science; UK Clinical Research Network; Current Controlled Trials; and ClinicalTrials.gov.

REVIEW METHODS

A systematic review of randomised controlled trials (RCTs) to assess the clinical effectiveness of minimally invasive techniques compared with other treatments, principally surgical stripping, in terms of recurrence of varicose veins, retreatment and clinical symptoms, as measured by the Venous Clinical Severity Score (VCSS), pain and quality of life. Network meta-analysis and exploratory cost-effectiveness modelling were performed.

RESULTS

The literature search identified 1453 unique citations, of which 34 RCTs (54 papers) satisfied the criteria for the clinical effectiveness review. The minimally invasive techniques reported clinical outcomes similar to surgery. Rates of recurrence were slightly lower for EVLA, RFA and FS, especially for longer follow-up periods; VCSS score was lower for EVLA and FS than for stripping, but slightly higher for RFA; short-term pain was less for FS and RFA but higher for EVLA; higher quality-of-life scores were reported for all evaluated interventions than for stripping. Differences between treatments were therefore negligible in terms of clinical outcomes, so the treatment with the lowest cost appears to be most cost-effective. Our central estimate is that total FS costs were lowest and FS is marginally more effective than stripping. However, this result was sensitive to the model time horizon. Threshold analysis indicated that EVLA and RFA might be considered cost-effective if their costs are equivalent to stripping. These findings are subject to uncertainty on account of the risk of bias present in the evidence base and the variation in costs.

LIMITATIONS

The relative clinical effectiveness and cost-effectiveness of the techniques are principally based on rates of post-operative technical recurrence rather than symptomatic recurrence, as this was the reported outcome in all trials. The true proportion of treated individuals who are likely to present with symptoms of recurrence requiring retreatment is therefore not certain. A figure reflecting the likely proportion of treated individuals who would experience symptomatic recurrence requiring retreatment (with its associated costs), therefore, had to be calculated by the authors based on a small number of studies. The findings of this report also need to be verified by data from future trials with longer follow-up and using more standardised outcome measures.

CONCLUSIONS

This assessment of the currently available evidence suggests there is little to choose between the minimally invasive techniques in terms of efficacy or cost, and each offers a viable, clinically effective alternative to stripping. FS might offer the most cost-effective alternative to stripping, within certain time parameters. High-quality RCT evidence is needed. Future trials should aim to measure and report outcomes in a standardised manner, which would permit more efficient pooling of their results.

STUDY REGISTRATION

PROSPERO number CRD42011001355.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.