Open label phase II studies of modified vaccinia ankara expressing the tumor antigen 5T4 given in conjunction with IFL and FOLFOX chemotherapy regimens: Final analysis of safety and immunogenicity of MVA 5T4 given before, during and after chemotherapy

2527

Background: 5T4 is a tumour associated antigen that is widely expressed on the surface of most human adenocarcinomas, including colorectal, but rarely in normal cells. Modified Vaccinia Ankara (MVA) has been employed as a vaccine vector to deliver 5T4. Previously, MVA-5T4 has been evaluated in a phase I/II clinical trial in stage IV colorectal cancer patients. MVA-5T4 was shown to be safe and well tolerated and induced 5T4 specific immune responses in most patients. Furthermore, 5T4 specific antibody titres correlated with clinical benefit. Methods: Two open label phase II clinical trials were initiated in which patients with advanced colorectal cancer received MVA-5T4 in conjunction with either 5-FU/leukovorin and irinotecan (TV2-IFL; n=19 patients) or 5-FU/leukovorin and oxaliplatin (TV2-FOLFOX; n=17 patients). MVA-5T4 was administered up to 6 times, 2 prior to, 2 during and 2 post-chemotherapy. The primary objectives were to assess the safety and immunogenicity of MVA-5T4 given in combination with chemotherapy. Results: Recruitment to both trials is complete and MVA-5T4 was well tolerated in all ITT patients, with no serious adverse events being associated with MVA-5T4. 5T4-specific cellular and humoral immune responses were monitored before, during and after chemotherapy in all 23 per protocol patients (n=12 for TV2-IFL and n=11 for TV2-FOLFOX). Following vaccination, all 23 patients mounted 5T4 cellular and/or humoral responses. Immune responses were detectable during chemotherapy in the majority of patients. IFNγ ELISPOT responses to 5T4 peptides revealed precursor frequencies as high as 1 in 1000 PBMCs. Assessment of clinical responses in all PP patients demonstrated an overall response rate of 65% across both trials. Conclusions: MVA-5T4 is safe and well tolerated when administered in conjunction with IFL and FOLFOX chemotherapy regimens. Furthermore, 5T4 specific immune responses are induced in all per protocol patients and can be boosted or maintained during chemotherapy. Encouraging clinical responses have been observed and 5T4 immune responses shown to correlate with clinical benefit.

[Table: see text]

Policies for the removal of short-term indwelling urethral catheters

BACKGROUND

Approximately 15% to 25% of all hospitalised patients have indwelling urethral catheters, mainly to assist clinicians to accurately monitor urine output during acute illness or following surgery, to treat urinary retention, and for investigative purposes.

OBJECTIVES

The objective of this review was to determine the best strategies for the removal of catheters from patients with a short-term indwelling urethral catheter.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group specialised register (searched 16 December 2002), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2004), MEDLINE (January 1966 to 12 October 2004), EMBASE (January 1980 to 12 October 2004), CINAHL (January 1982 to 12 October 2004), Nursing Collection (January 1995 to January 2002) and reference lists of relevant articles and conference proceedings were searched. We also contacted manufacturers and researchers in the field. No language or other restrictions were applied.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials (RCTs) that compared the effects of alternative strategies for removal of short-term indwelling urethral catheters on patient outcomes were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Eligibility of the trials for inclusion in the review, details of eligible trials and the methodological quality of the trials were assessed independently by two reviewers. Relative risks (RR) for dichotomous data and a weighted mean difference (WMD) for continuous data were calculated with 95% confidence intervals (CI). Where synthesis was inappropriate, trials were considered separately.

MAIN RESULTS

Eighteen trials involving a total of 1964 participants were included in the review. One trial included three treatment groups. In eight RCTs amongst 1020 people, removal at midnight was associated with large volumes of urine at first void, longer times to first void, and shorter lengths of hospitalisation. There was no significant difference in need for recatheterisation, although recatheterisation after removal at night was more likely to be during working hours. In eight trials amongst 822 participants early rather than delayed catheter removal was associated with shorter hospitalisation, but the estimates of other differences were all imprecise. In three trials involving 234 participants the data were too few to assess differential effects of catheter clamping compared with free drainage prior to withdrawal. No eligible trials compared flexible with fixed duration of catheterisation, or assessed prophylactic alpha sympathetic blocker drugs prior to catheter removal.

AUTHORS' CONCLUSIONS

There is suggestive but inconclusive evidence of a benefit from midnight removal of the indwelling urethral catheter. There are resource implications but the magnitude of these is not clear from the trials. The evidence also suggests shorter hospital stay after early rather than delayed catheter removal but the effects on other outcomes are unclear. There is little evidence on which to judge other aspects of management, such as catheter clamping.

Anaesthesia for hip fracture surgery in adults

BACKGROUND

The majority of people with hip fracture are treated surgically, requiring anaesthesia.

OBJECTIVES

To compare different types of anaesthesia for surgical repair of hip fractures (proximal femoral fractures) in adults.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (November 2003), MEDLINE (1996 to February week 2 2004), EMBASE (1988 to 2004 week 10) and reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing different methods of anaesthesia for hip fracture surgery in adults. The primary focus of this review was the comparison of regional (spinal or epidural) anaesthesia versus general anaesthesia. The use of nerve blocks preoperatively or in conjunction with general anaesthesia is evaluated in another review. The primary outcome was mortality.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Twenty two trials, involving 2567 predominantly female and elderly patients, comparing regional anaesthesia with general anaesthesia were included. All trials had methodological flaws and many do not reflect current anaesthetic practice. Pooled results from eight trials showed regional anaesthesia to be associated with a decreased mortality at one month (56/811 (6.9%) versus 86/857 (10.0%)); however, this was of borderline statistical significance (relative risk (RR) 0.69, 95% confidence interval (CI) 0.50 to 0.95). The results from six trials for three month mortality were not statistically significant, although the confidence interval does not exclude the possibility of a clinically relevant reduction (86/726 (11.8%) versus 98/765 (12.8%), RR 0.92, 95% CI 0.71 to 1.21). The reduced numbers of trial participants at one year, coming exclusively from two trials, preclude any useful conclusions for long-term mortality (80/354 (22.6%) versus 78/372 (21.0%), RR 1.07, 95% CI 0.82 to 1.41).Regional anaesthesia was associated with a reduced risk of deep venous thrombosis (39/129 (30%) versus 61/130 (47%); RR 0.64, 95% CI 0.48 to 0.86). However, this finding is insecure due to possible selection bias in the subgroups in whom this outcome was measured. Regional anaesthesia was also associated with a reduced risk of acute postoperative confusion (11/117 (9.4%) versus 23/120 (19.2%), RR 0.50, 95% CI 0.26 to 0.95). There was insufficient evidence to draw any conclusions from a further four included trials, involving a total of 179 participants, which compared other methods of anaesthesia (a 'light' general with spinal anaesthesia; intravenous ketamine; nerve blocks).

REVIEWERS' CONCLUSIONS

Overall, there was insufficient evidence available from trials comparing regional versus general anaesthesia to rule out clinically important differences. Regional anaesthesia may reduce acute postoperative confusion but no conclusions can be drawn for mortality or other outcomes.

Survival of Escherichia coli O157:H7, O111:H− and O26:H11 in artificially contaminated chocolate and confectionery products

To date, the survival of Escherichia coli O157:H7 and other verocytotoxin-producing E. coli (VTEC) in chocolate and other confectionery products has not been fully established, unlike Salmonella, which have been responsible for occasional outbreaks of infection linked to contaminated chocolate and related products, although none of these outbreaks have been related to products produced in the United Kingdom. The United Kingdom Biscuit, Cake, Chocolate and Confectionery Alliance commissioned this study to obtain information on the decline and potential survival of E. coli, particularly verocytotoxin-producing strains, in reduced aw confectionery products chocolate, biscuit cream and mallow. These products were artificially contaminated with high (4 log10 cfu/g) and low (2 log10 cfu/g) levels of E. coli O157:H7, O111:H- and O26:H11 and their survival, as affected by storage temperature (10, 22 and 38 degrees C), was monitored over 12 months. Preliminary studies to establish the best inoculation and recovery procedures indicated that differences between counts on selective and non-selective media used were not sufficiently different to influence the outcome of this study. Irrespective of sample type, rapid decline was observed in products stored at 38 degrees C and increased survival occurred in products stored at 10 degrees C. In chocolate (average aw 0.40), these bacteria were detected for up to 43 days in samples stored at 38 degrees C. At 22 degrees C they survived for up to 90 days and in product stored at 10 degrees C they could still be detected after 366 days storage. In biscuit cream (average aw 0.75) they survived for 2 days at 38 degrees C, 42 days at 22 degrees C and 58 days at 10 degrees C. Whilst mallow (aw ca. 0.73) was not stored at 38 degrees C, these bacteria could still be detected in samples stored for up to 113 and 273 days at 22 and 10 degrees C, respectively. The observed prolonged survival of these bacteria under conditions of reduced aw and lowered storage temperature in this study is supported by previous studies with Salmonella and E. coli O157:H7 in other foods. In the same way that Salmonella bacteria can survive for long periods, in excess of 12 months, in chocolate, this study provides evidence that E. coli, including pathogenic strains, can also survive for similar periods of time. Assuming the routes of transmission are similar, controls currently used by the confectionery industry to prevent contamination by Salmonella should also be effective against E. coli, including VT-producing strains, providing that all raw materials have been suitably processed, stored and handled before and during manufacture.

National symptom surveillance using calls to a telephone health advice service--United Kingdom, December 2001-February 2003

INTRODUCTION

Recent terrorist activity has highlighted the need to improve surveillance systems for the early detection of chemical or biologic attacks. A new national surveillance system in the United Kingdom (UK) examines symptoms reported to NHS Direct, a telephone health advice service.

OBJECTIVES

The aim of the surveillance system is to identify an increase in symptoms indicative of early stages of illness caused either by a deliberate release of a biologic or chemical agent or by common infections.

METHODS

Data relating to 10 key syndromes (primarily respiratory and gastrointestinal) are received electronically from 23 call centers covering England and Wales. Data are analyzed daily and statistically significant excesses, termed exceedances, in calls are automatically highlighted and assessed by a multidisciplinary team.

RESULTS

During December 2001-February 2003, a total of 1,811 exceedances occurred, of which 126 required further investigation and 16 resulted in alerts to local or national health-protection teams. Examples of these investigations are described.

CONCLUSION

Surveillance of call-center data has detected substantial levels of specific syndromes at both national and regional levels. Although no deliberate release of a biologic or chemical agent has been detected thus far by this or any other surveillance system in the UK, the NHS Direct surveillance system continues to be refined.

Preoperative saline versus gelatin for hip fracture patients; a randomized trial of 396 patients

BACKGROUND

The aim of this study was to determine if the preoperative administration of 500 ml of a gelatin colloid solution intravenously before hip fracture surgery improves outcome, compared with a conventional i.v. fluid regime with a crystalloid solution.

METHODS

Randomized, double blind, controlled trial of i.v. saline vs colloid for 396 patients having hip fracture surgery admitted to a district general hospital. Patients were followed up for 1 yr.

RESULTS

There was no statistically significant difference between groups for mortality (30-day mortality 9/198 for saline group vs 19/198 for colloid group, 95% confidence intervals 0.21-1.02), length of hospital stay (22.5 days vs 17.3 days, 95% CI -10.78 to 0.38), or occurrence of postoperative complications.

CONCLUSIONS

The inclusion of 500 ml of colloid solution to the i.v. fluid regime before hip fracture surgery does not improve outcome.

Sex-specific foraging behaviour in a monomorphic seabird

Sexual differences in the foraging behaviour of parents have been observed in a number of sexually sizedimorphic birds, particularly seabirds, and the usual inference has been that these sex-specific differences are mediated primarily by differences in body size. To test this explanation, we compared the foraging behaviour of parents in a monomorphic seabird species, the northern gannet Morus bassanus. Using specially designed instruments and radio telemetry we found that individuals of both sexes were consistent in the directions and durations of their foraging trips. However, there were significant differences in the foraging behaviour of males and females. Female gannets were not only more selective than males in the areas where they foraged, but they also made longer, deeper dives and spent more time on the sea surface than males. As the sexes are morphologically similar in this species, then these differences are unlikely to have been mediated by body size. Our work highlights the need to investigate sexual differences in the foraging behaviour of seabirds and other species more closely, in order to test alternative theories that do not rely on differences in body size.

Water for wound cleansing

BACKGROUND

Various solutions have been recommended for cleansing wounds, however normal saline is favoured as it is an isotonic solution and does not interfere with the normal healing process. Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost effective, however, there is an unresolved debate about its use.

OBJECTIVES

The objective of this review was to assess the effects of water compared to other solutions for wound cleansing.

SEARCH STRATEGY

Randomised and quasi-randomised controlled trials were identified by electronic searches of Cochrane Wounds Group Specialised Trials Register, MEDLINE, EMBASE, CINAHL, and the Cochrane Controlled Trials Register. Primary authors, company representatives and content experts were contacted to identify eligible studies. Reference lists from included trials were also searched.

SELECTION CRITERIA

Randomised and quasi randomised controlled trials that compared the use of water with other solutions for wound cleansing were eligible for inclusion. Additional criteria were outcomes that included objective or subjective measures of wound infection or healing.

DATA COLLECTION AND ANALYSIS

Trial selection, data extraction and quality assessment were carried out independently by two reviewers and checked by a third reviewer. Differences in opinion were settled by discussion. Some data were pooled using a random effects model.

MAIN RESULTS

Three trials were identified that compared rates of infection and healing in wounds cleansed with water and normal saline, two compared cleansing with no cleansing and one compared procaine spirit with water. There were no standard criteria for the assessment of wound infection across the trials which limited the ability to pool the data. The major comparisons were water vs normal saline, and tap water vs no cleansing. For chronic wounds, the odds of developing an infection when cleansed with tap water compared with normal saline was 0.16, 95 % Confidence Interval (CI) 0.01, 2.96. Use of tap water to cleanse acute wounds was associated with a lower rate of infection than saline (OR 0.52, 95 % CI 0.28, 0.96). No statistically significant differences in infection rates were seen when wounds were cleansed with tap water or not cleansed at all (OR 1.06, 95 % CI 0.06, 17.47). Similarly there was no difference in the infection rate in wounds cleansed with water or procaine spirit and those cleansed with isotonic saline, distilled water and boiled water (OR 0.55, 95 % CI 0.18,1.62).

REVIEWER'S CONCLUSIONS

Although the evidence is limited one trial has suggested that the use of tap water to cleanse acute wounds reduces the infection rate and other trials conclude that there is no difference in the infection and healing rates between wounds that were not cleansed and those cleansed with tap water and other solutions. However the quality of the tap water should be considered prior to its use and in the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents.

Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures

BACKGROUND

Various nerve blocks using local anaesthetic agents have been used in order to reduce pain after hip fracture.

OBJECTIVES

To determine the effects of nerve blocks (inserted either pre-operatively, operatively or post-operatively) as part of the treatment for a hip fracture.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (October 2001), MEDLINE -OVID WEB (1996 to October 2001) and reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials involving the use of nerve blocks as part of the care of a hip fracture patient.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality, by use of a nine item scale, and extracted data. Wherever appropriate, results of outcome measures were pooled.

MAIN RESULTS

Eight randomised or quasi-randomised trials involving 328 patients were included. Three trials related to insertion of a nerve block pre-operatively and the remaining five to peri-operative insertion. Nerve blocks resulted in a reduction of the quantity of parenteral or oral analgesia administered to control pain from the fracture/operation or during surgery and/or a reduction in reported pain levels. It was not possible to demonstrate if this reduction in analgesia use was associated with any other clinical benefit.

REVIEWER'S CONCLUSIONS

Because of the small number of patients included in this review and the differing type of nerve blocks and timing of insertion, it is not possible to determine if nerve blocks confer any significant benefit when compared with other analgesic methods as part of the treatment of a hip fracture. Further trials with larger numbers of patients and full reporting of clinical outcomes would be justified.

Characterization of the 1H-cyclopentapyrimidine-2,4(1H,3H)-dione derivative (S)-CPW399 as a novel, potent, and subtype-selective AMPA receptor full agonist with partial desensitization properties

(S)-CPW399 (2b) is a novel, potent, and subtype-selective AMPA receptor full agonist that, unlike (S)-willardiine and related compounds, in mouse cerebellar granule cells, stimulated an increase in [Ca(2+)](i), and induced neuronal cell death in a time- and concentration-dependent manner. Compound 2b appears to be a weakly desensitizing, full agonist at AMPA receptors and therefore represents a new pharmacological tool to investigate the role of AMPA receptors in excitotoxicity and their molecular mechanisms of desensitization.

Increased reproductive effort results in male-biased offspring sex ratio: an experimental study in a species with reversed sexual size dimorphism

Adaptive sex-ratio theory predicts that parents should overproduce the more beneficial offspring sex. Based on a recent experimental study of lesser black-backed gulls, we tested this hypothesis with the great skua, Catharacta skua, a bird species closely related to gulls but where females are the larger sex. When in poor body condition, the gulls overproduced daughters, the smaller and more viable sex under those circumstances. To discriminate between a mandatory physiological overproduction of female (i.e. non-male) eggs versus the overproduction of the smaller and presumably more viable sex, we conducted an egg-removal experiment with the great skua. Since the males are smaller, larger size and being male are separated. Through egg removal we induced females to increase egg production effort. Eggs were sexed using a DNA-based technique. Manipulated pairs produced a significant male bias at the end of the extended laying sequence, while the sex ratio in the control group did not differ from unity. Our results present an example of facultative sex-ratio manipulation and support the hypothesis that in sexually dimorphic birds parents overproduce the smaller sex under adverse conditions.

Identification and characterization of a novel class of interleukin-1 post-translational processing inhibitors

Lipopolysaccharide (LPS)-activated monocytes and macrophages produce large quantities of pro-interleukin (IL)-1beta but externalize little mature cytokine. Efficient post-translational processing of the procytokine occurs in vitro when these cells encounter a secretion stimulus such as ATP, cytolytic T cells, or hypotonic stress. Each of these stimuli promotes rapid conversion of 31-kDa pro-IL-1beta to its mature 17-kDa species and release of the 17-kDa cytokine. In this study, two novel pharmacological agents, CP-424,174 and CP-412,245, are identified as potent inhibitors of stimulus-coupled IL-1beta post-translational processing. These agents, both diarylsulfonylureas, block formation of mature IL-1beta without increasing the amount of procytokine that is released extracellularly, and they inhibit independently of the secretion stimulus used. Conditioned medium derived from LPS-activated/ATP-treated human monocytes maintained in the absence and presence of CP-424,174 contained comparable quantities of IL-6, tumor necrosis factor-alpha (TNFalpha), and IL-1RA, but 30-fold less IL-1beta was generated in the test agent's presence. As a result of this decrease, monocyte conditioned medium prepared in the presence of CP-424,174 demonstrated a greatly diminished capacity to promote an IL-1-dependent response (induction of serum amyloid A synthesis by Hep3B cells). Oral administration of CP-424,174 to mice resulted in inhibition of IL-1 in the absence of an effect on IL-6 and TNFalpha. These novel agents, therefore, act as selective cytokine release inhibitors and define a new therapeutic approach for controlling IL-1 production in inflammatory diseases.

The effect of treatment with Campath-1H in patients with autoimmune cytopenias

We describe 21 patients with severe and life-threatening autoimmune cytopenias resistant to standard immunosuppression who were treated with the monoclonal antibody Campath-1H. Four patients had autoimmune neutropenia, four had autoimmune haemolytic anaemia, four had pure red cell aplasia, one had immune thrombocytopenia purpura (ITP), three had autoimmune haemolytic anaemia and ITP (Evan's syndrome), three had autoimmune pancytopenia (ITP, autoimmune neutropenia and autoimmune haemolytic anaemia), one had ITP (associated with acquired Glanzmann's disease) and autoimmune neutropenia, and one had ITP and red cell aplasia. Campath-1H was administered at a dose of 10 mg/d as an intravenous infusion for 10 d. Responses were seen in 15 patients, which were sustained in six. Relapse occurred in eight patients after Campath-1H treatment. Patients entering the study later, received cyclosporine after Campath-1H in an attempt to reduce the incidence of relapse. Three patients received a second course of Campath-1H; all responded but later relapsed. Fourteen patients are alive at a median of 12 months (range 4-61) after Campath-1H. Campath-1H represents an alternative therapeutic option for severe, refractory autoimmune cytopenias.

Developing evidence-based clinicians

Evidence-based care has heralded an advancement for health with extensive rhetoric and incentives encouraging clinicians to become active participants in practice change. This paper explores two mechanisms-research utilization and systematic reviews--as processes to develop empowerment in clinicians, and develop an ethos of basing practice on research. The intent of these approaches is to create an environment that enables clinicians to seek solutions to practice problems, inform practice decisions and develop practice policy using evidence from research. The goal is to develop evidence-based clinicians who remain active and interested in their practice and who are committed to promoting the application of research to practice. The strengths and weaknesses of these methods are explored within two case studies where they are applied to the management of hypothermia and the efficacy of postoperative observations. Key points of application for each of the methods are outlined in the conclusions.

A role for fractalkine and its receptor (CX3CR1) in cardiac allograft rejection

The hallmark of acute allograft rejection is infiltration of the inflamed graft by circulating leukocytes. We studied the role of fractalkine (FKN) and its receptor, CX(3)CR1, in allograft rejection. FKN expression was negligible in nonrejecting cardiac isografts but was significantly enhanced in rejecting allografts. At early time points, FKN expression was particularly prominent on vascular tissues and endothelium. As rejection progressed, FKN expression was further increased, with prominent anti-FKN staining seen around vessels and on cardiac myocytes. To determine the capacity of FKN on endothelial cells to promote leukocyte adhesion, we performed adhesion assays with PBMC and monolayers of TNF-alpha-activated murine endothelial cells under low-shear conditions. Treatment with either anti-FKN or anti-CX(3)CR1-blocking Ab significantly inhibited PBMC binding, indicating that a large proportion of leukocyte binding to murine endothelium occurs via the FKN and CX(3)CR1 adhesion receptors. To determine the functional significance of FKN in rejection, we treated cardiac allograft recipients with daily injections of anti-CX(3)CR1 Ab. Treatment with the anti-CX(3)CR1 Ab significantly prolonged allograft survival from 7 +/- 1 to 49 +/- 30 days (p < 0.0008). These studies identify a critical role for FKN in the pathogenesis of acute rejection and suggest that FKN may be a useful therapeutic target in rejection.

Development of an instrument to assess readiness to recover in anorexia nervosa

OBJECTIVE

The degree to which patients with anorexia nervosa demonstrate readiness to recover from their illness has received scant theoretical or empirical attention. Investigating the prevalence and degree of amotivation for recovery in anorexia nervosa, its role in outcome, and the effectiveness of interventions designed to enhance readiness to recover necessitates the existence of a reliable and valid measure of motivational issues relevant to the disorder. The present study aimed to develop and evaluate an instrument for assessing readiness to recover in anorexia nervosa, namely, the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ), a 23-item self-report questionnaire based on Prochaska and DiClemente's stages of change model.

METHOD

Seventy-one inpatients with anorexia nervosa participated in the study. On several occasions during their admission, participants completed the ANSOCQ as well as questionnaires assessing readiness to recover, anorexic symptomatology, general distress, and social desirability.

RESULTS

The ANSOCQ demonstrated good internal consistency (.90) and 1-week test-retest reliability (.89). Various aspects of validity were also supported, such as significant relationships with other instruments assessing readiness to recover and the prediction of weight gain during different periods of treatment.

DISCUSSION

The results suggest that the ANSOCQ is a psychometrically sound instrument that may prove useful in investigating the role of readiness to recover in anorexia nervosa.

Possible role for the FosB/JunD AP-1 transcription factor complex in glutamate-mediated excitotoxicity in cultured cerebellar granule cells

The potent excitatory and neurotoxic actions of glutamate are known to influence the expression of a variety of genes, including those encoding the AP-1 transcription factor, which comprises proteins belonging to the Fos and Jun families. However, the precise role of Fos- and Jun-like transcription factors in these events remains elusive. Here we demonstrate, using primary cultures of mouse brain cerebellar granule cells as an in vitro model system, a possible involvement of the FosB/JunD heterodimer in excitotoxicity. Granule cells were grown for either 2 or 7 days in vitro (DIV) before exposure to varying concentrations (1-3000 microM) of the excitotoxin glutamate. In 7-DIV cells, glutamate induced a concentration-dependent neuronal death, whereas, in 2-DIV cells, no glutamate-induced neuronal damage was seen. We were particularly interested in comparing the protein composition of the AP-1 transcription factor complex in cells exposed to excitotoxic and to nontoxic conditions. AP-1 DNA binding activity was demonstrated by gel shift analysis in nuclear extracts derived from 7-DIV cells following exposure to either a nontoxic (10 microM) or an excitotoxic (250 microM) dose of glutamate and was similarly observed in extracts of 2-DIV cells exposed to the same levels of glutamate. Gel supershift analysis using antibodies against the different Fos and Jun family members allowed differentiation between AP-1 DNA binding in nuclear extracts as a function of both 1) viability status and 2) the stage of development. Of major significance was the finding that FosB could be detected as a component of AP-1 in 7-DIV cells only under excitotoxic conditions, whereas c-Fos, Fra-2, and JunD proteins were detectable under both excitotoxic and nontoxic conditions in cells of this age. In 2-DIV cells (in which glutamate is nontoxic), AP-1 comprised combinations of only Fra-1, Fra-2, c-Jun, and JunD. Because Fos family members are unable to form homodimers, this finding raises the possibility that the FosB/JunD heterodimer may have special significance in the mechanism of excitotoxic neuronal death.

Development of a client-generated health outcome measure for community nursing

OBJECTIVE

To develop a client-generated outcome measure for use in community nursing.

METHOD

Participants for the study were identified from the case load of community health nurses, from a nursing home service and from residents of a retirement village. All participants had a diagnosis of venous leg ulcer (VLU) and/or type 2 diabetes. Preliminary development of the measure involved focus groups of community clients and health professionals, and pilot testing of an existing quality of life (QoL) measure, the Patient-Generated Index. The resulting Client-Generated Index was tested for reliability and validity.

RESULTS

The Pearson's correlation coefficient between administration of the CGI at T1 and T2 was 0.526 (n = 51; p = 0.0001). The CGI correlated significantly with four of eight dimensions of the SF-36, and with pain as a clinical marker for VLU r = 0.54 (p = 0.001). Overall, participants with VLU reported a lower QoL (mean CGI score 2.8) compared to those with diabetes (mean CGI score 4.1).

CONCLUSIONS

The CGI was developed to measure outcomes in community health settings. Some measures of its reliability and validity are demonstrated and further research is needed to validate the instrument using other client groups.

IMPLICATIONS

If routine assessment and evaluation is to contribute to measures of outcome, the instruments need to be concise and acceptable to health care providers. The CGI has all these properties.

Preliminary evaluation of an in vitro test for assessment of excitotoxicity by measurement of early gene (c-fos mRNA) levels

Using primary cultures of mouse cerebellar granule cells as an in vitro model system, it has been demonstrated that different profiles of temporal expression of the c-fos proto-oncogene are observed under non-excitotoxic and excitotoxic conditions. A ratio has been derived previously for the steady-state level of c-fos mRNA after 30 min and 240 min which suggests that a 240 min/30 min ratio of greater than 1 correlates with excitotoxicity, whereas a ratio of less than 1 correlates with a non-excitotoxic outcome. Moreover, a positive correlation is seen with abrogation of excitotoxicity in response to selective excitatory amino acid receptor antagonists. This test, proposed as a specific biomarker for excitotoxicity is undergoing prevalidation. Excitotoxicity is defined as neuronal cell death mediated by hyperactivation of glutamate receptor subtypes and therefore might be expected to be prevented by selective glutamate receptor antagonists. In preliminary evaluation studies, we have conducted work under the direction of the European Center for Validation of Alternate Methods (ECVAM) using compounds specified by ECVAM that have been subdivided into four groups based on known or presumed actions. These groups comprise: Group 1-endogenous/synthetic excitotoxins; Group 2-environmental, putative excitotoxins; Group 3-neurotoxic but non-excitotoxic compounds, and Group 4-non-toxic compounds. The results of this study support the proposal that the c-fos mRNA time-ratio test is a specific biomarker of excitotoxicity. Just as importantly, this test has the potential for application in screening newly-designed EAA receptor antagonists in the search for clinically relevant drugs to treat a variety of neuropathologies.

Back to basics in anaesthesia

This is the last in the Back to Basics series of articles--for now at least. I would like to thank all the authors for their pieces. I've learnt and relearnt from each of them. The completed set of articles will be available as one document in October, and will be launched at Congress--yet another reason to attend! Bye for now.

Primary care groups. Serving from the shadows

A study of appointments to the boards of 59 PCGs covered by the 13 health authorities in the West Midlands found concerns about fairness, openness and transparency. There was concern about the lack of a competency framework for GP members. Health authorities questioned whether the lay members of boards were representative of the local population. Some health authorities provided no induction training for boards.

The 50-millilitre syringe as an inexpensive training aid in the application of cricoid pressure

A recent study in our department demonstrated that depressing the plunger of a 50-mL syringe was reliably and linearly related to the force applied between 20 N and 50 N. Using a 50-mL syringe we constructed a simple device to help train anaesthetic assistants to apply cricoid pressure correctly. We then tested anaesthetists, operating department practitioners (non-physicians) and nurses in our hospital to see if they could correctly apply forces of 20 and 40 N. All subjects were then trained using this apparatus and once confident were retested immediately afterwards, and again 1 week and 1 month later. The results show a wide variation in the force applied with only 30% of subjects applying appropriate force at 20 N, and 40% at 40 N. Training leads to a significant improvement in performance (P < 0.005 at 20 N and P < 0.001 at 40 N) which is maintained for 1 week for both 20 N (P < 0.05) and 40 N (P < 0.05) but not for 1 month. Therefore training should be practised on a weekly basis. This is an inexpensive and simple device that we believe to be useful in helping anaesthetic assistants to apply effective cricoid pressure.

Supportive pharmacology

We continue to explore the basics of anaesthesia with another article from Rachelle Griffiths, this month looking at supportive pharmacology. If you think this looks too complicated for a Back to Basics piece, read it in small chunks--and be grateful that you are not my spelling checker, which has gone berserk! This Back to Basics series is drawing to a close soon. However, if you have suggestions for any more articles, or perhaps an article itself, then do contact me via Headquarters.

A role for leukotrienes in cyclosporine nephrotoxicity

BACKGROUND

Nephrotoxicity associated with cyclosporine A (CsA) administration is characterized by marked renal vasoconstriction, interstitial fibrosis, and arteriolar hypertrophy. While the molecular mechanisms of CsA toxicity are not well characterized, previous studies have demonstrated that altered arachidonic acid (AA) metabolism plays a role its pathogenesis. Using a rat renal transplant model, the purpose of this study was to examine the effects of CsA on the 5-lipoxygenase (5-LO) pathway of AA metabolism.

METHODS

The PVG (RT1c) strain of rats underwent kidney transplantation, and recipients of nonrejecting kidney transplants were treated with either 50 mg/kg/day CsA or vehicle (N = 24). To determine the physiologic significance of increased leukotriene (LT) production, the peptidoleukotriene receptor antagonist SKF 106203 was administered to CsA-treated animals for six days.

RESULTS

CsA caused a substantial reduction in glomerular filtration rate (GFR) in the transplanted rats compared with the vehicle-treated controls (1.5 +/- 0.6 vs. 4.1 +/- 0.8 mL/min/kg, P < 0.05). The reduction in renal function was associated with enhanced urinary excretion of the peptidoleukotriene metabolites LTE4 (1431 +/- 207 vs. 953 +/- 125 pg/24 h, P < 0.05) and N-acetyl-LTE4 (4411 +/- 848 vs. 463 +/- 70 pg/24 h, P < 0.001). LT receptor blockade had a significant protective effect on renal transplant function in CsA-treated animals (GFR, 4.8 +/- 1.1 vs. 1.7 +/- 0.9 mL/min/kg, P < 0.05), such that CsA-treated animals that received SKF106203 maintained GFR at levels similar to controls that never received CsA (4.1 +/- 0.8 mL/min/kg). Peptidoleukotriene receptor blockade also prevented the histomorphological abnormalities caused by CsA, including tubular vacuolization.

CONCLUSIONS

These studies identify a critical role for LTs in the pathophysiology of CsA nephrotoxicity and suggest that LT antagonists may be useful in preventing CsA-associated kidney toxicity.

Altered intragraft immune responses and improved renal function in MHC class II-deficient mouse kidney allografts

BACKGROUND

During renal allograft rejection, expression of MHC class II antigens is up-regulated on the parenchymal cells of the kidney. This up-regulation of MHC class II proteins may stimulate the intragraft alloimmune response by promoting their recognition by recipient CD4+ T cells. In previous studies, absence of donor MHC class II antigens did not affect skin graft survival, but resulted in prolonged survival of cardiac allografts.

METHODS

To further explore the role of MHC class II antigens in kidney graft rejection, we performed vascularized kidney transplants using donor kidneys from A(beta)b-deficient mice that lack MHC class II expression.

RESULTS

At 4 weeks after transplant, GFR was substantially depressed in control allografts (2.18+/-0.46 ml/min/kg) compared to nonrejecting isografts (7.98+/-1.62 ml/min/kg; P<0.01), but significantly higher in class II- allografts (4.38+/-0.60 ml/min/kg; P<0.05). Despite the improvement in renal function, class II- allograft demonstrated histologic features of acute rejection, not unlike control allografts. However, morphometric analysis at 1 week after transplantation demonstrated significantly fewer CD4+ T cells infiltrating class II- allografts (12.8+/-1.2 cells/mm2) compared to controls (25.5+/-2.6 cells/mm2; P=0.0007). Finally, the intragraft profile of cytokines was altered in class II- allografts, with significantly reduced expression of Th2 cytokine mRNA compared to controls.

CONCLUSIONS

These results support a role of MHC class II antigens in the kidney regulating immune cells within the graft. Further, effector pathways triggered by class II antigens promote renal injury during rejection.

Anaesthetic drugs

A mere glance at a BNF will demonstrate the huge variety of drugs which are now available to us. In this piece, Rachelle Griffiths takes us step by step through the basics of anaesthetic drugs. I am very aware of the enormity of this topic, and would recommend that you take the time to consider carefully the information provided in this piece. There will be further articles on drugs and their effects in this series.

Evaluation of the use of accelerated infusions for the determination of pharmacokinetic linearity

Accelerated infusions are potentially useful in the investigation of pharmacokinetic linearity. However, little information exists to validate this technique or to demonstrate its limitations. This investigation was performed to determine whether accelerated infusion regimens reliably estimate the range of pharmacokinetic linearity for molecules of varying pharmacokinetic properties, to evaluate the ability of accelerated infusions to identify pharmacokinetic nonlinearity, and to validate the accelerated infusion technique using compounds with known pharmacokinetic parameters. Simulations incorporating accelerated infusion as the input function resulted in the anticipated concentration-time profiles that contained an initial lag phase before reaching a linear slope. This lag phase increased with increasing distributional volume and in some instances was sufficiently great to obscure or prevent the linear portion of the profile. These simulations also revealed that clearance estimated from the apparently linear portion of the concentration-time profile can be erroneous under some conditions, as for large-volume compounds. Simulations of structured nonlinearity produced the predicted profiles for compounds with low to moderate volumes of distribution while demonstrating that modeling of data derived from compounds with large volumes of distribution may be inaccurate. Finally, experiments using accelerated infusions with various test compounds further demonstrated the usefulness of this technique while presenting limits imposed on the interpretation of the data. The results of this investigation indicate that the accelerated infusion may be used to determine pharmacokinetic linearity for compounds within certain pharmacokinetic boundaries, but that appropriate caution should be exercised in the extent of interpretation that should be extracted from such studies.

Perceived expressed emotion in the siblings and parents of hospitalized patients with anorexia nervosa

OBJECTIVE

The present study investigated the relationship between the level of perceived Expressed Emotion (EE) of the siblings and parents of patients hospitalized with anorexia nervosa and its effect on weight gain and psychological functioning.

METHOD

The Level of Expressed Emotion (LEE) Scale was administered on admission to 19 patients with anorexia nervosa who completed the LEE three times so as to identify their perceptions of their relationship with their closest age sibling, mother, and father. They were also required to complete the Eating Disorder Inventory 2 (EDI-2). Patients' closest age sibling completed the Family Attitude Scale (FAS). The patients' body mass index (BMI) was calculated 6 weeks later, and the EDI-2 readministered.

RESULTS

Perceived EE was not predictive of BMI change after 6 weeks of hospitalization. A composite perceived family EE score was a significant predictor of change on the Interpersonal Distrust, Maturity Fears, and Perfectionism subscales of the EDI-2.

DISCUSSION

These findings suggest that patients' perceptions of their relationships with their closest aged sibling, mother, and father are poor predictors of weight gain and improvement in psychological functioning following 6 weeks of inpatient treatment.

General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials

Hip fracture surgery is common and the population at risk is generally elderly. There is no consensus of opinion regarding the safest form of anaesthesia for these patients. We performed a meta-analysis of 15 randomized trials that compare morbidity and mortality associated with general or regional anaesthesia for hip fracture patients. There was a reduced 1-month mortality and incidence of deep vein thrombosis in the regional anaesthesia group. Operations performed under general anaesthesia had a reduction in operation time. No other outcome measures reached a statistically significant difference. There was a tendency towards a lower incidence of myocardial infarction, confusion and postoperative hypoxia in the regional anaesthetic group, and cerebrovascular accident and intra-operative hypotension in the general anaesthetic group. We conclude that there are marginal advantages for regional anaesthesia compared to general anaesthesia for hip fracture patients in terms of early mortality and risk of deep vein thrombosis.

Circulation and invasive monitoring

Circulation is very important to theatre nurses everywhere. (Excuse the pun, but 2000 - or YK2 as we are now to call it - has got to me.) Rachelle Griffiths continues our Back to Basics series with a consideration of cardiovascular circulation and monitoring. What topics would you like to see in the future in this series? Let me know via the editorial staff at NATN Headquarters.

General versus spinal/epidural anaesthesia for surgery for hip fractures in adults

BACKGROUND

The majority of hip fracture patients are treated surgically, requiring anaesthesia.

OBJECTIVES

To compare different types of anaesthesia for surgical repair of hip fractures (proximal femoral fractures) in adults. This is primarily regional (spinal or epidural) anaesthesia versus inhalation general anaesthesia, but also includes ketamine anaesthesia versus inhalation general anaesthesia.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline, selected orthopaedic and anaesthetic journals and conference proceedings, and reference lists of relevant articles. Date of the most recent search: August 1998.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing different methods of anaesthesia for hip fracture surgery in skeletally mature persons. Trials comparing the use of local nerve blocks are not considered in this review. Neither are trials using different types of drugs or techniques with one type of anaesthesia. The primary outcome was mortality.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality, using a nine item scale, and extracted data. The other two reviewers independently checked these results. Wherever appropriate and possible, results were pooled.

MAIN RESULTS

Fifteen trials, involving 2162 patients, which compared regional anaesthesia with general anaesthesia, were included. All trials had methodological flaws. Regional anaesthesia was associated with a decreased mortality at one month (49/766 (6.4%) versus 76/812 (9.4%)) of borderline statistical significance (Peto odds ratio 0.66, 95% confidence interval 0.46 to 0.96)). The results for three month mortality were not statistically significant, although the confidence interval does not exclude the possibility of a clinically relevant reduction (86/726 (11.8%) versus 98/765 (12.8%), Peto odds ratio 0.91, 95% confidence interval 0.67 to 1.24). The reduced numbers at one year, coming exclusively from two studies, preclude any useful conclusions for long term mortality (80/354 (22.6%) versus 78/372 (21.0%), Peto odds ratio 1.10, 95% confidence interval 0.77 to 1.57). Regional anaesthesia was associated with a tendency to a longer operation (weighted mean difference 4.8 minutes, 95% confidence interval 1.1 to 8.6 minutes), and a reduced risk of deep venous thrombosis (39/129 (30%) versus 61/37(76%); Peto odds ratio 0. 41, 95% confidence interval 0.23 to 0.72), although this conclusion is insecure due to possible selection bias in the subgroups in whom this outcome was measured. No other statistically significant differences in outcome were identified. There was insufficient evidence to draw any conclusions from a further two included trials, involving a total of 100 patients, which compared other types of anaesthesia.

REVIEWER'S CONCLUSIONS

Regional anaesthesia and general anaesthesia appear to produce comparable results for most of the outcomes studied. Regional anaesthesia may reduce short-term mortality but no conclusions can be drawn for longer term mortality.

Breathing circuits and their uses

Returning to our theme of anaesthesia, Rachelle Griffiths, from Great Ormond Street, takes us through breathing circuits and their uses. A timely reminder for some, and basic information offering a handy reference for us all!

Preferences for ultraviolet partners in the blue tit

The preference of female blue tits, Parus caeruleus, is correlated with the brightness of the ultraviolet (UV) crest; there is also assortative mating with respect to the crest's UV/violet chroma. However, manipulation of plumage reflectance is necessary to infer a direct causal link between UV plumage and mate choice. We gave both male and female blue tits a choice between a UV-reflecting ('UV+') partner and a partner whose UV plumage reflectance had been removed ('UV-'). Male blue tits significantly preferred UV+ females. Similarly, female blue tits tended to prefer UV-reflecting males, but their UV+ preferences were nonsignificant. Neither sex showed a preference when conspecifics were replaced by a heterospecific. This study suggests mutual mate choice but male choice may be more strongly influenced by the visual appearance of potential mates. This is one of a few studies to show male mate preferences and the first demonstration of a direct relationship between UV reflectance and male mate choice. Copyright 1999 The Association for the Study of Animal Behaviour.

The effectiveness of AN-DRGs in classification of acute admitted patients with diabetes

The Australian National Diagnosis Related Groups (AN-DRGs) classification is intended to assign acute admitted patient episodes to classes which are iso-resource and clinically homogeneous. It has been widely used to good effect, but its performance has been questioned with respect to the classification of patients with chronic conditions. The primary aim of this study was to investigate the extent to which AN-DRGs classify episodes of care for a chronic disorder (in this case diabetes) into classes which are relatively homogeneous in terms of clinical attributes and the resources used in the provision of care. The records of 2094 patients admitted during 1994-95 to four hospitals in the Illawarra Area Health Service with at least one diabetes diagnosis recorded in the discharge summary were reviewed. We found that the source data used for assignment contained errors of medical documentation, abstraction and sequencing, and coding. The sampled patients were distributed among many AN-DRGs in a way which was neither clinically coherent nor obviously descriptive of resource-use differences. The AN-DRG logic appears to ignore or otherwise under-estimate the effects of diabetes as a secondary diagnosis.