Vitamin D/vitamin D receptor axis regulates DNA repair during oncogene-induced senescence

Oncogenic Ras expression is associated with activation of the DNA damage response (DDR) pathway, as evidenced by elevated DNA damage, primarily DNA double-strand breaks (DSBs), and activation of DNA damage checkpoints, which in primary human cells leads to entry into senescence. DDR activation is viewed as a physiological barrier against uncontrolled proliferation in oncogenic Ras-expressing cells, and arises in response to genotoxic stress due to the production of reactive oxygen species (ROS) that damage DNA, and to hyper-replication stress. Although oncogene-induced senescence (OIS) is considered a tumor suppressor mechanism, the accumulation of DNA damage in senescent cells is thought to cause genomic instability, eventually allowing secondary hits in the genome that promote tumorigenesis. To date, the molecular mechanisms behind DNA repair defects during OIS remain poorly understood. Here, we show that oncogenic Ras expression in human primary cells results in down-regulation of BRCA1 and 53BP1, two key factors in DNA DSBs repair by homologous recombination (HR) and non-homologous end joining (NHEJ), respectively. As a consequence, Ras-induced senescent cells are hindered in their ability to recruit BRCA1 and 53BP1 to DNA damage sites. While BRCA1 is down-regulated at transcripts levels, 53BP1 loss is caused by activation of cathepsin L (CTSL)-mediated degradation of 53BP1 protein. Moreover, we discovered a marked down-regulation of vitamin D receptor (VDR) during OIS, and a role for the vitamin D/VDR axis regulating the levels of these DNA repair factors during OIS. This study reveals a new functional relationship between the oncogene Ras, the vitamin D/VDR axis, and the expression of DNA repair factors, in the context of OIS. The observed deficiencies in DNA repair factors in senescent cells could contribute to the genomic instability that allows senescence bypass and tumorigenesis.

PERIPHERAL NERVE BING-NEEL SYNDROME

Background

Bing-Neel syndrome (BNS) is a rare manifestation of Waldenstrom's Macroglobulinaemia (WM) due to direct infiltration of the central nervous system. Isolated peripheral nerve infiltration has not been described but as the blood-nerve-barrier has similar characteristics to the blood-brain-barrier, CNS-penetrating chemotherapy would be required.

Case

A 43 year-old man was diagnosed with WM after presenting with constitutional symptoms; IgMk paraprotein (34.6 g/L) and lymphoplasmacytoid cells in the bone marrow. He received R-CVP (Rituximab, Cyclophosphamide, Vincristine, and Prednisolone) with good partial haematological response and minimal distal sensory vincristine-related neuropathy. Ten months later he developed a rapidly progressive, symmetric sensorimotor deficit in all four limbs with impairment of walking and hand clumsiness, MRC sum score=61/70. Electrophysiology showed a non-length dependant axonal neuropathy with patchy slowing. Sural nerve biopsy revealed a patchy infiltrate WM cells. He tolerated 4 cycles of blood-nerve-barrier penetrating multi-agent chemotherapy, IDARAM (idarubicin, dexamethasone, cytosine arabinoside, methotrexate, cytosine arabinoside plus intrathecal methotrexate). A marked improvement was seen during treatment and by 3 months later MRC score was 70/70. No electrophysiological difference was detectable at this stage.

Discussion

Peripheral BNS is not a recognised neurological manifestation of WM but with appropriate treatment a good outcome may be achieved.

Faecal calprotectin testing for differentiating amongst inflammatory and non-inflammatory bowel diseases: systematic review and economic evaluation

BACKGROUND

Irritable bowel syndrome (IBS) is common, and causes pain, bloating and diarrhoea and/or constipation. It is a troublesome condition that reduces the quality of life but causes no permanent damage. Inflammatory bowel disease (IBD) comprises mainly ulcerative colitis (UC) and Crohn's disease (CD). Both cause serious complications and may lead to sections of the bowel having to be removed, although this is more common with CD. The presenting symptoms of IBS and IBD can be similar. Distinguishing them on clinical signs and symptoms can be difficult. Until recently, colonoscopy was often required to rule out IBD. In younger people, > 60% of colonoscopies showed no abnormality. Faecal calprotectin (FC) is a protein released by the white blood cells, neutrophils, found in inflamed areas of the bowel in IBD. Determining the level of FC in stool samples may help distinguish IBS from IBD.

OBJECTIVE

To review the value of FC for distinguishing between IBD and non-IBD.

DATA SOURCES

Sources included MEDLINE, EMBASE, The Cochrane Library, Web of Science, websites of journals and the European Crohn's and Colitis Organisation (conference abstracts 2012 and 2013), and contact with experts.

REVIEW METHODS

Systematic review and economic modelling. Review Manager (RevMan) version 5.2 (The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark) was used for most analysis, with statistical analyses done in Stata version 12 (StataCorp LP, College Station, TX, USA). Forest plots and receiver operating characteristic curves were produced. Quality Assessment of Diagnostic Accuracy Studies was used for quality assessment. Economic modelling was done in Microsoft Excel 2010 (Microsoft Corporation, Redmond, WA, USA).

LIMITATIONS

Studies were often small, most used only one calprotectin cut-off level, and nearly all came from secondary care populations.

RESULTS

Twenty-eight studies provided data for 2 × 2 tables and were included in meta-analyses, with seven in the most important comparison in adults (IBS vs. IBD) and eight in the key comparison in paediatrics (IBD vs. non-IBD). Most studies used laboratory enzyme-linked immunosorbent assay (ELISA) tests. For distinguishing between IBD and IBS in adults, these gave pooled sensitivity of 93% and specificity of 94% at FC cut-off level of 50 µg/g. Sensitivities at that cut-off ranged from 83% to 100%, and specificities from 60% to 100%. For distinguishing between IBD and non-IBD in paediatric populations with ELISA tests, sensitivities ranged from 95% to 100% at cut-off of 50 µg/g and specificities of 44-93%. Few studies used point-of-care testing but that seemed as reliable as ELISA, though perhaps less specific. The evidence did not provide any grounds for preferring one test over others on clinical effectiveness grounds. FC testing in primary care could reduce the need for referral and colonoscopies. Any quality-adjusted life-year gains are likely to be small because of the low prevalence of IBD and the high sensitivities of all of the tests, resulting in few false negatives with IBD. However, considerable savings could accrue. Areas of uncertainty include the optimum management of people with borderline results (50-150 µg/g), most of whom do not have IBD. Repeat testing may be appropriate before referral.

CONCLUSIONS

Faecal calprotectin can be a highly sensitive way of detecting IBD, although there are inevitably trade-offs between sensitivity and specificity, with some false positives (IBS with positive calprotectin) if a low calprotectin cut-off is used. In most cases, a negative calprotectin rules out IBD, thereby sparing most people with IBS from having to have invasive investigations, such as colonoscopy.

STUDY REGISTRATION

PROSPERO CRD 42012003287.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Systematic review of the clinical effectiveness and cost-effectiveness, and economic evaluation, of denosumab for the treatment of bone metastases from solid tumours

BACKGROUND

Denosumab offers an alternative, or additional, treatment for the prevention of skeletal-related events (SREs) in patients with bone metastases from solid tumours.

OBJECTIVES

The aim of this review was to assess the clinical effectiveness and cost-effectiveness of denosumab, within its licensed indication, for the prevention of SREs in patients with bone metastases from solid tumours.

DATA SOURCES

Databases searched were MEDLINE (1948 to April 2011), EMBASE (1980 to March 2011), The Cochrane Library (all sections; Issue 1, 2011) and Web of Science with Conference Proceedings (1970 to May 2011).

REVIEW METHODS

Only randomised controlled trials (RCTs) assessing denosumab, bisphosphonates (BPs) or best supportive care (BSC) in patients with bone metastases were included. Systematic reviews and observational studies were used for safety and quality-of-life assessments. Study quality was assessed using the Cochrane risk of bias tool. Studies suitable for meta-analysis were synthesised using network meta-analysis (NMA). A systematic review was conducted for cost, quality-of-life and cost-effectiveness studies. The results of this informed the cost-utility modelling. This principally estimated the cost-effectiveness of denosumab relative to zoledronic acid for when BPs are currently recommended and relative to BSC when BPs are not recommended or are contraindicated.

RESULTS

A literature search identified 39 studies (eight suitable for NMA). Denosumab was effective in delaying time to first SRE and reducing the risk of multiple SREs compared with zoledronic acid. Generally speaking, denosumab was similar to zoledronic acid for quality of life, pain, overall survival and safety. The NMA demonstrated that denosumab was more effective in delaying SREs than placebo, but was limited by numerous uncertainties. Cost-utility modelling results for denosumab relative to zoledronic acid were driven by the availability of the patient access scheme (PAS) for denosumab. Without this, denosumab was not estimated to be cost-effective compared with zoledronic acid. With it, the cost-effectiveness ranged between dominance for breast and prostate cancer, to between £5400 and £15,300 per quality-adjusted life-year (QALY) for other solid tumours (OSTs) including non-small cell lung cancer (NSCLC) and £12,700 per QALY for NSCLC. Owing to small patient gains estimated, the cost-effectiveness of denosumab was very sensitive to the zoledronic acid price. Denosumab was not estimated to be cost-effective compared with BSC.

LIMITATIONS

Only subgroup data were available for denosumab for NSCLC, and OSTs excluding NSCLC. The NMA was subject to numerous uncertainties. Owing to small patient gains estimated, the cost-effectiveness of denosumab was very sensitive to the zoledronic acid price.

CONCLUSION

Denosumab, compared with zoledronic acid and placebo, is effective in delaying SREs, but is similar with regard to quality of life and pain. Cost-effectiveness showed that without the PAS denosumab was not estimated to be cost-effective relative to either zoledronic acid or BSC. With the PAS, denosumab was estimated to be cost-effective relative to zoledronic acid but not BSC.

STUDY REGISTRATION

PROSPERO number CRD42011001418.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Diabetes is predictive of longer hospital stay and increased rate of complications in spinal surgery in the UK

INTRODUCTION

Diabetes is a common co-morbidity of patients undergoing spinal surgery in the UK but there are no published studies from the UK, particularly with respect to length of hospital stay and complications. The aims of this study were to identify complications and length of hospital stay in patients with diabetes undergoing spinal surgery.

METHODS

Data were collected retrospectively for 111 consecutive patients with diabetes (and 97 age and sex matched control patients, identified using computer records) who underwent spinal surgery between 2004 and 2010 in a single centre. The data collected included operative time, blood loss, details of surgery, Clavien complications and length of hospital stay.

RESULTS

No significant differences were found by group in operative time, blood loss, instrumentation, use of graft or revision surgery. Overall complication rates were higher in the patients with diabetes than in the controls (28.8% vs 15.5%). The mean hospital stay was significantly longer for patients with diabetes than for control patients (4.6 vs 3.2 days, p<0.001).

CONCLUSIONS

This study identified a significantly higher Clavien grade I complication rate and length of hospital stay in patients with diabetes undergoing spinal surgery than control patients (p=0.02). This has resulted in a predictive model being generated. Of note, no infections were seen in patients with diabetes, suggesting that infection rates in this particular group of patients undergoing spinal surgery might not be as high as considered previously.

Medical tourism in the Caribbean region: a call to consider environmental health equity

Medical tourism, which is the intentional travel by private-paying patients across international borders for medical treatment, is a sector that has been targeted for growth in many Caribbean countries. The international development of this industry has raised a core set of proposed health equity benefits and drawbacks for host countries. These benefits centre on the potential investment in health infrastructure and opportunities for health labour force development while drawbacks focus on the potential for reduced access to healthcare for locals and inefficient use of limited public resources to support the growth of the medical tourism industry. The development of the medical tourism sector in Caribbean countries raises additional health equity questions that have received little attention in existing international debates, specifically in regard to environmental health equity. In this viewpoint, we introduce questions of environmental health equity that clearly emerge in relation to the developing Caribbean medical tourism sector These questions acknowledge that the growth of this sector will have impacts on the social and physical environments, resources, and waste management infrastructure in countries. We contend that in addition to addressing the wider health equity concerns that have been consistently raised in existing debates surrounding the growth of medical tourism, planning for growth in this sector in the Caribbean must take environmental health equity into account in order to ensure that local populations, environments, and ecosystems are not harmed by facilities catering to international patients.

Maternal experience of musculoskeletal pain during pregnancy and birth outcomes: significance of lower back and pelvic pain

AIM

to examine the association between back and pelvic pain during pregnancy and birth outcomes.

BACKGROUND

back and pelvic pain during pregnancy is a common occurrence. It is known to affect maternal functioning and well-being during pregnancy and can persist postnatally and beyond. However, there has been little examination of the impact upon birth outcomes such as birth mode, duration of labour and pain experience.

METHOD

five hundred and eighty mothers with an infant aged zero to six months completed a retrospective questionnaire documenting their pain during pregnancy and birth outcomes (e.g. mode, duration, interventions, perception of pain). Participants also rated overall pain and pain in specific body regions for each of the three trimesters. Estimations of fetal position before birth were given.

FINDINGS

higher pain ratings during the third trimester of pregnancy were associated with increased incidence of caesarean section, assisted delivery and a longer duration of labour. Specifically, lower back and pelvic pain were associated with an increase in complications, potentially due to occurrence of malpositioning of the fetus during pregnancy.

CONCLUSION

mothers who experience high levels of pain during pregnancy may be at increased risk of complications during labour. Explanations for this may be physiological, mechanical or psychological but greater awareness should be given to the potential impact of maternal pain ratings during pregnancy upon birth outcomes.

Relationship between measures of aerobic fitness, speed and repeated sprint ability in full and part time youth soccer players

AIM

The aim of the study was to investigate the relationship between repeated sprint ability (RSA) involving changes in direction, short linear sprinting and aerobic capacity in young elite soccer players. A secondary aim was to assess any differences in performance of these assessments between players of different age groups.

METHODS

Thirty-two male adolescent soccer players belonging to the same elite club academy were assessed for RSA comprising 6 x 40m efforts interspersed by 25s recovery, linear sprinting speed over 15m, and aerobic capacity via the YYIE2 assessment.

RESULTS

There was a significant correlation between performance in the YYIE2 and RSA total time, RSA fastest sprint and RSA percentage decrement (r = -0.71, -0.53, and -0.52 respectively. P<0.05). Significant differences were observed between age groups for distance covered in the YYIE2, RSA total time and RSA fastest sprint (P<0.01). No significant differences were observed for short linear sprinting.

CONCLUSION

Assessments of RSA over 40m and incorporating changes of direction appear to be significantly correlated with YYIE2 performance in young elite level soccer players. In addition older players performed significantly better in the YYIE2 assessment and RSA protocol but not in short linear sprinting. These results have implications for the design of assessment protocols for young elite soccer players of different ages.

An outbreak of Legionnaires’ disease associated with a display spa pool in retail premises, Stoke-on-Trent, United Kingdom, July 2012

Binary file ES_Abstracts_Final_ECDC.txt matches

An outbreak of Legionnaires' disease associated with a display spa pool in retail premises, Stoke-on-Trent, United Kingdom, July 2012

Twenty-one confirmed cases of Legionnaires’ disease (Legionella pneumophila serogroup 1) were identified in the Stoke-on-Trent area of England with onsets since 2 July 2012. Sequence-based typing results are available for nine cases; all are a unique type (ST1268). Initial interviews highlighted a number of possible environmental sources. Inspection of premises of interest revealed an operating spa pool on display, from which the outbreak strain was identified. All cases had visited the retail premise with this spa pool.

Action on AMD. Optimising patient management: act now to ensure current and continual delivery of best possible patient care

In recent years, there have been significant advances in the clinical management of patients with wet age-related macular degeneration (wet AMD)—a rapidly progressing and potentially blinding degenerative eye disease. Wet AMD is responsible for more than half of registered severe sight impairment (blindness) in the United Kingdom, and patients who are being treated for wet AMD require frequent and long-term follow-up for treatment to be most effective. The clinical workload associated with the frequent follow-up required is substantial. Furthermore, as more new patients are diagnosed and the population continues to age, the patient population will continue to increase. It is thus vital that clinical services continue to adapt so that they can provide a fast and efficient service for patients with wet AMD. This Action on AMDdocument has been developed by eye health-care professionals and patient representatives, the Action on AMDgroup. It is intended to highlight the urgent and continuing need for change within wet AMD services. This document also serves as a guide for eye health-care professionals, NHS commissioners, and providers to present possible solutions for improving NHS retinal and macular services. Examples of good practice and service development are considered and can be drawn upon to help services meet the recommended quality of care and achieve best possible outcomes.

Subsurface iron and arsenic removal: low-cost technology for community-based water supply in Bangladesh

The principle of subsurface or in situ iron and arsenic removal is that aerated water is periodically injected into an anoxic aquifer through a tube well, displacing groundwater containing Fe(II). An oxidation zone is created around the tube well where Fe(II) is oxidised. The freshly formed iron hydroxide surfaces provide new sorption sites for soluble Fe(II) and arsenic. The system's efficiency is determined based on the ratio between abstracted volume with reduced iron/arsenic concentrations (V) and the injected volume (V(i)). In the field study presented in this paper, the small-scale application of this technology was investigated in rural Bangladesh. It was found that at small injection volumes (<1 m³) iron removal was successful and became more effective with every successive cycle. For arsenic, however, the system did not prove to be very effective yet. Arsenic retardation was only limited and breakthrough of 10 µg/L (WHO guideline) was observed before V/V(i)=1, which corresponds to arrival of groundwater at the well. Possible explanations for insufficient arsenic adsorption are the short contact times within the oxidation zone, and the presence of competing anions, like phosphate.

Spondylodiscitis (disc space infection) associated with negative microbiological tests: comparison of outcome of suspected disc space infections to documented non-tuberculous pyogenic discitis

Discitis, an infection of the disc space, is an uncommon diagnosis that, if missed, can lead to spinal deformity and neurological deterioration, although as many as 30% of these patients will have negative microbiological cultures. It was unclear, however, whether the prognosis differed between patients who had positive or negative cultures. A retrospective case note review was carried out to assess the differences in presentation and outcome between these two groups. There were 26 and 43 patients in the negative and positive groups, respectively. Those with a positive culture were more likely to present with pyrexia, have a neurological deficit and not be independently mobile at presentation. The mean CRP recorded at the time of presentation was 96 and 157 in the negative and positive groups respectively (p = 0.004). Similarly, the mean ESR in the positive group was 88 compared with 69 in the negative group (p = 0.02). In conclusion, these patients may be at different ends of a clinical spectrum: those patients with a positive culture having a greater local and systemic inflammatory reaction to the disc space infection.

Usefulness of the hydrogen sulfide test for assessment of water quality in Bangladesh

AIM

To evaluate the usefulness of the hydrogen sulfide (H(2)S) test for assessing water quality in Bangladesh.

METHODS AND RESULTS

We tested 382 water samples from a variety of sources using locally produced H(2)S test kits and laboratory-based membrane filtration for the detection of Escherichia coli. Compared with membrane filtration, H(2)S tests, when incubated for 24 h, had both a sensitivity and positive predictive value (PPV) of <40% when analysis was restricted to water samples with E. coli levels below 100 colony forming units (CFU) per 100 ml. In contrast, for E. coli levels from 1000 to 9999 CFU per 100 ml, sensitivity was 94% and PPV 88%; specificity was 97% and negative predictive value was 99%.

CONCLUSIONS

The hydrogen sulfide test, when incubated at 24 h, is a promising alternative for assessing water quality where E. coli levels may be high. An improved understanding of the incremental impact of contamination level on health is needed to better determine its usefulness.

SIGNIFICANCE AND IMPACT OF THE STUDY

The hydrogen sulfide test is inexpensive, easy to use and portable. Its use may allow rapid assessment of water quality in situations where cost or logistics prevent use of other testing methods, such as in remote areas or during flood and other natural disasters.

Remodelling potential of paediatric cervical spine after type II odontoid peg fracture

We describe a case of odontoid process fracture below the synchondrosis associated with delayed diagnosis and anterior subluxation of C1 over C2. This was treated with an in situ posterior occipitocervical fusion. Long-term follow-up of 7 years showed excellent remodelling of the deformity.

Chlorine spot treatment of flooded tube wells, an efficacy trial

AIMS

To evaluate the water quality of recently flooded tube wells in Bangladesh and the effect of spot chlorination on improving bacteriological quality.

METHODS AND RESULTS

The study team identified and tested water samples from 127 tube wells that were flooded within the preceding 4 weeks. Twenty-six of the tube wells with the highest concentration of thermotolerant coliform bacteria were randomly assigned to spot chlorination vs control. On initial screening, water samples from 56 recently inundated tube wells (44%) were contaminated with thermotolerant coliforms. Among the 13 wells randomized to chlorination, there was no change in the proportion of water samples that had no detectable thermotolerant coliform bacteria immediately before chlorine treatment (n = 4, 23%) and 60 min following chlorine treatment (n = 4, 23%). Similarly, there was no difference in the proportion of water samples that had no detectable thermotolerant coliforms between chlorine spot treated and control tube wells 7-18 days later (31 vs 23%P = 0.66).

CONCLUSIONS

Spot chlorine treatment of inundated tube wells in Bangladesh three to 6 weeks after the flooding did not improve drinking water quality.

SIGNIFICANCE AND IMPACT OF THE STUDY

Unless modified methods improve effectiveness, resources should not be spent promoting spot chlorination of flooded tube wells.

Creating SunSmart schools

Kidskin was a sun-protection intervention study involving 1776 children attending 33 primary schools in Perth, Western Australia. There were three study groups: a control group, a moderate intervention group and a high intervention group. In addition to receiving a specially designed curricular intervention (1995-1998), the moderate and high intervention groups received an environmental intervention aimed at creating SunSmart schools (1996-1998). The environmental intervention focused on encouraging implementation of 'No hat, no play' policies and reducing sun exposure at lunchtime. In 1995 and 1998, observational methods were used to measure children's lunchtime sun exposure (i.e. polysulfone film badges) and hat wearing (i.e. video-taping of children). The proportion of children wearing broad-brimmed hats or legionnaire caps increased in seven of the eight high intervention schools between 1995 and 1998. In three schools, however, the impact was very positive with almost all children wearing these hats in 1998. There was no improvement in wearing these types of hats in either the moderate intervention group or the control group. In terms of sun exposure, there were only small non-significant differences among the three groups in terms of lunchtime sun exposure. The Kidskin program had a positive effect on hat wearing in the playground, but did not change children's use of shade at lunchtime. In this study, disseminating policy guidelines to schools using a mail-only strategy was ineffective, even when combined with an awards program. More information on 'champions' who bring about change in schools is required.

Insulin-treated diabetes and driving in the UK

Diabetes, and particularly insulin-treated diabetes, has important implications for motor vehicle driving, largely because of its association with potential hypoglycaemia. For this reason, most countries operate some driving restrictions on insulin-treated diabetic patients, as well as systems of intermittent reassessment of hypoglycaemic risk. In the UK, regulations are operated by the Driver and Vehicle Licensing Agency (DVLA), which is an agency of the Department of the Environment, Transport and the Regions (DETR). They are supported by an Expert Panel which advises the Secretary of State on diabetes-related issues relating to fitness to drive. The patient organization Diabetes UK is also concerned with diabetes and driving issues, largely from a position of lobbying policy-influencers and supporting individual cases. All parties involved with diabetes and driving issues recognize the need for more research on the subject, as the current literature is flawed in design, though no convincing excess of accidents amongst diabetic drivers has been conclusively demonstrated. Currently in the UK, Class 2 vehicles (large trucks and passenger vehicles) are barred to diabetic drivers on insulin. European law has recently extended this to so-called C1 (large vans and small lorries) and D1 (minibuses) vehicles, though the law has recently been revised to allow individual consideration for potential diabetic C1 drivers on insulin treatment. Diabetes and insulin-treated diabetes is an emotive and difficult issue, for which a stronger evidence base is urgently needed.