DNA damage increases sensitivity to vinca alkaloids and decreases sensitivity to taxanes through p53-dependent repression of microtubule-associated protein 4

Taxanes and Vinca alkaloids are among the most active classes of drugs in the treatment of cancer. Yet, fewer than 50% of previously untreated patients respond, and clinicians have few ways of predicting who will benefit from treatment and who will not. Mutations in p53 occur in more than half of human malignancies and may alter the sensitivity to a variety of anticancer therapies. We have shown that the transcriptional status of p53 determines the sensitivity to antimicrotubule drugs and that this is mediated through the regulation of microtubule-associated protein 4 (MAP4). Expression of MAP4 is transcriptionally repressed by wild-type p53. Increased expression of MAP4, which occurs when p53 is transcriptionally inactive, increases microtubule polymerization, paclitaxel binding, and sensitivity to paclitaxel, a drug that stabilizes polymerized microtubules. In contrast, overexpression of MAP4 decreases microtubule binding and sensitivity to Vinca alkaloids, which promotes microtubule depolymerization. To determine whether induction of endogenous wild-type p53 by DNA-damaging agents alters the expression of MAP4 and changes the sensitivity to antimicrotubule drugs, we assayed cell lines with wild-type or mutant p53 for the expression of MAP4 and drug sensitivity before and after DNA damage. UV irradiation, bleomycin, and doxorubicin increased wild-type p53 expression and decreased MAP4 expression. These changes were associated with decreased sensitivity to paclitaxel and increased sensitivity to vinblastine. These changes in drug sensitivity were no longer observed when p53 and MAP4 returned to baseline levels. Changes in drug sensitivity following DNA-damaging agents were associated with decreased binding of paclitaxel and increased binding of Vinca alkaloids. In contrast, DNA damage did not alter the sensitivity to non-microtubule-active drugs, such as 1-beta-D-arabinofuranosylcytosine and doxorubicin. Changes in drug sensitivity following DNA-damaging drugs were not observed in cells with mutant p53. These studies demonstrate that induction of wild-type p53 by DNA-damaging agents can affect the sensitivity to antimicrotubule drugs through the regulation of MAP4 expression and may have implications for the design of clinical anticancer therapies.

Maternal and child constitutional factors and the frequency of melanocytic naevi in children

This study examined the association between numbers of benign melanocytic naevi in 7-year-old children in Oxfordshire born in 1988-9 with their mother's arm naevus count, and maternal and child pigmentation factors. We believe this is the first time that the relationship between child and maternal naevus counts has been reported. A high naevus count in the child was associated with male sex (P = 0.009), freckling (P = 0.001) and propensity of the child to burn in the sun (P = 0.05). A low naevus count was observed in red-haired children (P = 0.02). The strongest association of child's naevus count was with a high maternal arm naevus count, independent of the child's pigmentation factors (trend P < 0.0001). Maternal pigmentation factors were not associated with child's naevus count independent of the child's own pigmentation factors. Maternal arm naevus counts may be a better predictor of child naevus count than the child's own pigmentation factors and children. There has not been examination, however, of the relationship between naevus counts in children and those in their parents. We therefore conducted a study of the occurrence of naevi in children aged 7-8 years in Oxfordshire, examining, in addition to sex and pigmentation factors in the child, the relationship of maternal pigmentation factors and maternal naevus counts with naevi in their offspring.

Seizure frequency and duration of epilepsy are not risk factors for postoperative seizure outcome in patients with hippocampal sclerosis

PURPOSE

Despite accurate localization of the seizure focus, not all patients are seizure free after temporal lobectomy. This study determined risk factors for seizure recurrence in patients with proven hippocampal sclerosis.

METHODS

The outcome from surgery was assessed in 56 consecutive patients with proven hippocampal sclerosis. The age at surgery, duration of epilepsy, history and age of febrile seizures, age of onset of epilepsy, sex ratio, laterality of seizure focus, and seizure frequency were compared between patients seizure free and those not seizure free, and those seizure and aura free and those with seizure recurrence including auras.

RESULTS

During a mean follow-up of 38 months, 48 (86%) of 56 are seizure free. The mean age at surgery (37 vs. 36 years), duration of epilepsy (26 vs. 22 years), age (1.6 vs. 1.1 years), and occurrence (58 vs. 75%) of febrile seizures, age of onset of epilepsy (11 vs. 14 years), sex ratio (50 vs. 75% female), laterality of seizure focus (42 vs. 50% left), greater than weekly seizures (40 vs. 38%), and a history of (69 vs. 75%) and frequency of (2.10 vs. 2.38 per year) secondarily generalized seizures did not differ significantly between the two groups. Similarly there was no significant difference between patients seizure and aura free and those with seizure recurrence including auras.

CONCLUSIONS

Clinical factors such as seizure frequency and duration of epilepsy are not risk factors for postoperative seizure recurrence.

Genetic basis of transferase-deficient galactosaemia in Ireland and the population history of the Irish Travellers

Transferase-deficient galactosaemia, resulting from deficient activity of galactose-1-phosphate uridyltransferase (GALT), is relatively common among the Travellers, an endogamous group of commercial/industrial nomads within the Irish population. This study has estimated the incidence of classical transferase-deficient galactosaemia in Ireland and determined the underlying GALT mutation spectrum in the Irish population and in the Traveller group. Based upon a survey of newborn screening records, the incidence of classical transferase-deficient galactosaemia was estimated to be 1 in 480 and 1 in 30,000 among the Traveller and non-Traveller communities respectively. Fifty-six classical galactosaemic patients were screened for mutation in the GALT locus by standard molecular methods. Q188R was the sole mutant allele among the Travellers and the majority mutant allele among the non-Travellers (89.1%). Of the five non-Q188R mutant alleles in the non-Traveller group, one was R333G and one F194L with three remaining uncharacterized. Anonymous population screening has shown the Q188R carrier frequency to be 0.092 or 1 in 11 among the Travellers as compared with 0.009 or 1 in 107 among the non-Travellers. The Q188R mutation was shown to be in linkage disequilibrium with a Sac I RFLP flanking exon 6 of the GALT gene. This represents the first molecular genetic description of classical transferase-deficient galactosaemia in Ireland and raises intriguing questions concerning the genetic history of the Irish Travellers.

Pax-3 regulates neurogenesis in neural crest-derived precursor cells

The peripheral nervous system consists of multiple neural lineages derived from the neural crest (NC). Pax-3 is expressed in the NC and when mutated in the splotch mouse (Sp) results in the loss of derivatives from this precursor cell population. We have investigated the role of Pax-3 in regulating the generation of neurons from NC-derived precursor cells in vitro. Pax-3 mRNA in NC cultures is initially expressed in all NC but is subsequently only retained in neurons, suggesting a role in their generation. To determine whether Pax-3 is involved in neuron development, we first examined the generation of sensory-like neurons in NC cultures from Sp mice. Fivefold less sensory-like neurons were generated in NC cultures from Sp homozygous mice as compared to wild-type littermates. The role of Pax-3 in sensory neuron generation was then directly examined in dorsal root ganglia cultures by down-regulating the expression of Pax-3 protein with antisense oligonucleotides. It was found that antisense oligonucleotides inhibited 80-90% of newly generated sensory neurons; however, there was no significant effect on the survival of sensory neurons or the precursor population. These results suggest that Pax-3 has a role in regulating the differentiation of peripheral neurons.

A multihospital effort to reduce inpatient lengths of stay for pneumonia

Three large hospitals in the metropolitan area of Syracuse, New York, implemented a cooperative project to reduce hospital stays and resource utilization without adversely affecting patient outcomes for community acquired pneumonia. The project occurred under the leadership of nurse case managers and nurse managers. It was supported by active physician involvement. The project was implemented over a three-year period. It resulted in reductions of hospital stays through the standardization of patient care for pneumonia throughout the community.

Subjective efficacy of nasal CPAP therapy in obstructive sleep apnoea syndrome: a prospective controlled study

The response to nasal continuous positive airways pressure (nCPAP) of a wide variety of symptoms recognized to be associated with obstructive sleep apnoea syndrome (OSAS) was examined. Fifty-six consecutive patients with OSAS, confirmed by polysomnography (mean (SD) apnoea-hypopnoea index (AHI) 49.6 (22.6) events x h(-1), Epworth score 15.4 (5.0)), were asked to complete paired symptom evaluation questionnaires, before treatment and again after 4 months of nCPAP. The response rate was 80%. A control group of 21 consecutive OSAS patients of similar age, body mass index (BMI), AHI and Epworth score to the treated group but managed with conservative measures, completed the same questionnaires on two occasions, 4 months apart. The nCPAP-treated group showed significant reductions (Wilcoxon matched pairs test) in the symptoms of daytime sleepiness, restless sleep, heartburn, nocturia, enuresis, headache and nocturnal sweating, whereas controls showed no significant changes in these symptoms. There were no changes in BMI, smoking, alcohol consumption or exercise habits in either group. It was concluded that, in addition to improvements in symptoms of daytime sleepiness and restless sleep, a wide range of other symptoms may improve significantly with nasal continuous positive airways pressure therapy.

Changing trends in prostatic cancer

OBJECTIVES

To examine the diagnosis and treatment of prostatic cancer in a population-based study, reporting incidence trends and survival, in the decade before the introduction of prostate-specific antigen (PSA) testing, and thus determine whether the overall incidence of prostatic cancer is increasing or not.

PATIENTS AND METHODS

The study included all men registered as having prostatic cancer in the Yorkshire region between 1981 and 1990. The Northern and Yorkshire Cancer Registry and Information Service has an active registration policy and after notification, the information received is validated by histopathology reports and case-note review. Of the patients registered, 68% were over 70 years old at the time of diagnosis (mean age 74 years). Prostatic cancer was often diagnosed incidentally, after prostatectomy for presumed benign disease. Indications for treatment were not recorded, but most patients had treatment which was designed to control outlet bladder symptoms rather than with intent to cure cancer.

RESULTS

In all, 8118 patients with prostatic cancer were registered, of whom 6587 had histological confirmation. There was a 30% increase in the age-standardized incidence of prostatic cancer during the study period (P<0.001). The mortality from prostatic cancer increased by 35% (P<0.001) and the percentage of patients known to have metastases at the time of presentation increased from 18% to 24%. These changes were seen in all age groups. The overall survival was 49% at 5 years and 34% at 10 years.

CONCLUSIONS

There has been a real increase in the incidence of prostatic cancer which pre-dates the use of serum PSA testing. The percentage relative survival of patients with prostatic cancer in Yorkshire during the study period is similar to that seen in other parts of the UK, but compares badly with reported survival in other countries.

Use of videophones and low-cost standard telephone lines to provide a social presence in telepsychiatry

Research findings suggest that the value added by the video channel of currently available video conferencing technology is limited to the creation of a social presence of the other party. Almost all clinical information exchange takes place on the audio channel, while the interpersonal interactions (nods, blinks, facial expressions, and body language), which are so important in a face-to-face meeting, may not be adequately captured by the video. Several of our case studies are presented which suggest that, consistent with the social presence role for video, low-cost videophones may be effectively substituted for expensive ISDN-based systems in many mental health applications.

Gene expression and production of the monokine induced by IFN-gamma (MIG), IFN-inducible T cell alpha chemoattractant (I-TAC), and IFN-gamma-inducible protein-10 (IP-10) chemokines by human neutrophils

Monokine induced by IFN-gamma (MIG), IFN-inducible T cell alpha chemoattractant (I-TAC), and IFN-gamma-inducible protein of 10 kDa (IP-10) are related members of the CXC chemokine subfamily that bind to a common receptor, CXCR3, and that are produced by different cell types in response to IFN-gamma. We have recently reported that human polymorphonuclear neutrophils (PMN) have the capacity to release IP-10. Herein, we show that PMN also have the ability to produce MIG and to express I-TAC mRNA in response to IFN-gamma in combination with either TNF-alpha or LPS. While IFN-gamma, alone or in association with agonists such as fMLP, IL-8, granulocyte (G)-CSF and granulocyte-macrophage (GM)-CSF, failed to influence MIG, IP-10, and I-TAC gene expression, IFN-alpha, in combination with TNF-alpha, LPS, or IL-1beta, resulted in a considerable induction of IP-10 release by neutrophils. Furthermore, IL-10 and IL-4 significantly suppressed the expression of MIG, IP-10, and I-TAC mRNA and the extracellular production of MIG and IP-10 in neutrophils stimulated with IFN-gamma plus either LPS or TNF-alpha. Finally, supernatants harvested from stimulated PMN induced migration and rapid integrin-dependent adhesion of CXCR3-expressing lymphocytes; these activities were significantly reduced by neutralizing anti-MIG and anti-IP-10 Abs, suggesting that they were mediated by MIG and IP-10 present in the supernatants. Since MIG, IP-10, and I-TAC are potent chemoattractants for NK cells and Th1 lymphocytes, the ability of neutrophils to produce these chemokines might contribute not only to the progression and evolution of the inflammatory response, but also to the regulation of the immune response.

Sonic hedgehog promotes neuronal differentiation of murine spinal cord precursors and collaborates with neurotrophin 3 to induce Islet-1

Sonic hedgehog (Shh) is strongly implicated in the development of ventral structures in the nervous system. Addition of Sonic hedgehog protein to chick spinal cord explants induces floor plate and motoneuron development. Whether Shh acts directly to induce these cell types or whether their induction is mediated by additional factors is unknown. To further investigate the role of Shh in spinal neuron development, we have used low-density cultures of murine spinal cord precursor cells. Shh stimulated neuronal differentiation; however, it did not increase the proportion of neurons expressing the first postmitotic motoneuron marker Islet-1. Moreover, Shh did induce Islet-1 expression in neural tube explants, suggesting that it acts in combination with neural tube factors to induce motoneurons. Another factor implicated in motoneuron development is neurotrophin 3 (NT3), and when assayed in isolated precursor cultures, it had no effect on Islet-1 expression. However, the combination of N-terminal Shh and NT3 induced Islet-1 expression in the majority of neurons in low-density cultures of caudal intermediate neural plate. Furthermore, in explant cultures, Shh-mediated Islet-1 expression was blocked by an anti-NT3 antibody. Previous studies have shown expression of NT3 in the region of motoneuron differentiation and that spinal fusimotor neurons are lost in NT3 knock-out animals. Taken together, these findings suggest that Shh can act directly on spinal cord precursors to promote neuronal differentiation, but induction of Islet-1 expression is regulated by factors additional to Shh, including NT3.

Psychological needs of patients with HIV disease: reviewing the literature using Nichols' (1985) Adjustment Reaction Model as a framework

Since the first manifestations of HIV infection presented in the United Kingdom in the early 1980s, there has been a dramatic increase in the incidence of HIV infection and a proliferation of diseases associated with HIV infection. HIV infection is now associated with physical, psychological, mental and neurological conditions. Many of these conditions are serious and pose a major threat to physical and mental health, with rapid deterioration of health status necessitating multiple hospital admissions to acute hospitals. The majority of people hospitalized with HIV diseases are currently being cared for on general wards. While physical needs are often well met, psychological needs are to a certain extent neglected. The literature cites numerous cases of neglect, discrimination and threats to confidentiality by health professionals, including nurses. Such psychological needs, emanating out of hospitalization, compound existing psychological needs. Nichols' (1985) Adjustment Reaction Model describes a number of stages patients may go through during the course of their illness, and to some extent the patient's psychological needs can be traced throughout the trajectory of the disease. The purpose of this paper is to review the literature and present a theoretical argument, using Nichols' model as a framework, on psychological needs of patients with HIV diseases, and attempt to outline to what extent psychological needs of patients with HIV are met in institutional care. The authors recommend further research to determine nurses' perception of the importance of meeting psychological needs of patients with HIV disease.

The role of laboratory investigations in identifying body fluids

In diverse clinical situations it may be important to establish the nature and origin of fluid samples. This article sets out to provide some practical guidance on the role of laboratory investigations in this process.

Randomized trial of nurse-assisted strategies for smoking cessation in primary care

BACKGROUND

Brief advice to stop smoking from general practitioners (GPs) has been repeatedly shown to increase smoking cessation by a small, but measurable amount. Some studies have suggested that adding more intensive interventions to brief advice may increase its effectiveness, but it is unclear whether this is true in general practice.

AIMS

To determine whether brief advice from a doctor together with counselling and follow-up from a trained practice nurse is more effective than brief advice alone in helping people to stop smoking.

METHODS

The design was a randomized controlled trial. Four hundred and ninety-seven general practice patients aged older than 18 years and smoking at least one cigarette per day in six general practices in Oxfordshire, Berkshire, and Buckinghamshire were randomized to one of two interventions: brief verbal or written advice from a GP plus extended counselling and follow-up from a trained practice nurse; brief advice from a GP alone. The primary outcome was sustained abstinence from smoking at three and 12 months. A secondary outcome was forward movement in the stages of change cycle.

RESULTS

The proportion showing sustained abstinence was 3.6% in the extended counselling group, and 4.4% in the brief advice group (difference = -0.8%; 95% confidence interval = -4.3% to 2.6%). Seventy-four (30%) of those randomized to extended counselling actually took up this offer. No significant progression in stages of change was detected between the two groups.

CONCLUSIONS

In unselected general practice patients who smoke, brief advice from a GP combined with intensive intervention and follow-up by a practice nurse is no more effective than brief advice alone.

Nodular lymphoid lesion of the liver: an immune-mediated disorder mimicking low-grade malignant lymphoma

Three cases of unusual lymphoid infiltrate forming nodular macroscopic masses in the liver were studied in the authors' surgical pathology laboratory. These lesions posed difficulty in diagnosis, and their differentiation from low-grade lymphoma was not possible on histopathologic evaluation alone. The liver masses were analyzed histologically and immunohistochemically as well as for clonal immunoglobulin heavy chain (IgH) and T-cell receptor gamma (TCR-gamma) gene rearrangements. The lesions were seen as solitary grossly distinct firm nodules in all three patients, measuring 0.4, 0.7, and 1.5 cm, respectively, in their greatest dimensions. Two were found in livers removed because of end-stage primary biliary cirrhosis at the time of orthotopic liver transplantation, and the third was an incidental finding during laparotomy. Microscopically, these were nodules composed of small lymphocytes, plasma cells, and immunoblasts, with varying degrees of admixed acute inflammatory cells and scattered lymphoid follicles. By immunohistochemistry and molecular studies, these were found to be reactive lymphoid proliferations. All patients are alive and well at 2, 4, and 13 years, respectively. It is concluded that these cases represent a unique type of nodular lymphoid lesion, which is probably an immune-mediated benign reactive hyperplasia. It constitutes an entity by itself and must be distinguished from low-grade lymphoma. For a definitive diagnosis, immunohistochemistry and molecular studies are required.

Suppression subtractive hybridization identifies high glucose levels as a stimulus for expression of connective tissue growth factor and other genes in human mesangial cells

Accumulation of mesangial matrix is a pivotal event in the pathophysiology of diabetic nephropathy. The molecular triggers for matrix production are still being defined. Here, suppression subtractive hybridization identified 15 genes differentially induced when primary human mesangial cells are exposed to high glucose (30 mM versus 5 mM) in vitro. These genes included (a) known regulators of mesangial cell activation in diabetic nephropathy (fibronectin, caldesmon, thrombospondin, and plasminogen activator inhibitor-1), (b) novel genes, and (c) known genes whose induction by high glucose has not been reported. Prominent among the latter were genes encoding cytoskeleton-associated proteins and connective tissue growth factor (CTGF), a modulator of fibroblast matrix production. In parallel experiments, elevated CTGF mRNA levels were demonstrated in glomeruli of rats with streptozotocin-induced diabetic nephropathy. Mannitol provoked less mesangial cell CTGF expression in vitro than high glucose, excluding hyperosmolality as the key stimulus. The addition of recombinant CTGF to cultured mesangial cells enhanced expression of extracellular matrix proteins. High glucose stimulated expression of transforming growth factor beta1 (TGF-beta1), and addition of TGF-beta1 to mesangial cells triggered CTGF expression. CTGF expression induced by high glucose was partially suppressed by anti-TGF-beta1 antibody and by the protein kinase C inhibitor GF 109203X. Together, these data suggest that 1) high glucose stimulates mesangial CTGF expression by TGFbeta1-dependent and protein kinase C dependent pathways, and 2) CTGF may be a mediator of TGFbeta1-driven matrix production within a diabetic milieu.

The intubating laryngeal mask: use of a new ventilating-intubating device in the emergency department

The intubating laryngeal mask airway (ILM) was introduced in 1997 as a modification of the classic laryngeal mask airway. In addition to serving as an elective or emergency ventilating device, it is designed to allow blind intubation. We report 3 cases of airway management in the emergency department of Yale-New Haven Hospital where the ILM was used to establish ventilation and intubation in patients in whom direct laryngoscopy had failed. The 3 cases are representative of situations commonly seen in the ED: the obtunded and apneic ("crash airway") patient, failed rapid sequence intubation, and the recognized difficult airway/awake intubation. In all 3 cases, a clear airway was established on initial placement of the ILM, and intubation was achieved on the first attempt at blind advancement of the endotracheal tube. Although the ILM may be an important addition to the armamentarium of the emergency physician, proficiency in its use requires practice under controlled conditions. We suggest that the emergency physician seek out elective practice in either a teaching workshop or hospital operating theater.

Is the relationship between fertility of parents and children really weak?

The relationship between fertility of parents and children has been designated as "weak" by most investigators. This paper reviews the evidence over the past century and argues that, even allowing for problems with available data sources, the relationship was probably close to zero for pre-transitional populations. However, over time, the relationship has tended to become more substantial and is now of a similar order of magnitude in developed countries as other widely used explanatory variables. Possible mechanisms for the observed relationship are discussed, especially the roles of socialization and inherited factors. The types of data used are compared to the scientific questions posed, and the limitations of the common comparison of married-mother/married-daughter pairs are considered. Finally, some evidence from recent large-scale surveys in Britain and the United States is presented to show changes over recent periods and the relative effects of sibship size of fathers and mothers.

Procedural sedation and analgesia in the emergency department. Canadian Consensus Guidelines

Procedural sedation and analgesia are core skills in emergency medicine. Various specialty societies have developed guidelines for procedural sedation, each reflecting the perspective of the specialty group. Emergency practitioners are most likely to embrace guidelines developed by people who understand emergency department (ED) skills, procedures, conditions, and case mix. Recognizing this, the Canadian Association of Emergency Physicians (CAEP) determined the need to establish guidelines for procedural sedation in the ED. In March, 1996, a national emergency medicine (EM) working committee, representing adult and pediatric emergency physicians, was established. This committee teleconferenced with representatives of the Canadian Anesthetic Society (CAS) to identify problems, perspectives, and controversial issues, and to define a process for guideline development. The EM committee subsequently reviewed existing literature, determined levels of evidence, and developed the document, which evolved based on feedback from the CAS and CAEP Standards Committees. The final version was approved by the CAEP Standards Committee and the CAEP Board of Directors, then submitted for peer review. These guidelines discuss the goals, definitions, and principles of ED sedation, and make recommendations for pre-sedation preparation, patient fasting, physician skills, equipment and monitoring requirements, and post-sedation care. The guidelines are aimed at non-anesthesiologists practicing part-time or full-time emergency medicine. They are applicable to ED patients receiving parenteral analgesia or sedation for painful or anxiety-provoking procedures. They are intended to increase the safety of procedural sedation in the ED.