Safe and rapid resolution of severe hypertriglyceridaemia in two patients with intravenous insulin

AIM

To rapidly reduce serum triglyceride to a safe serum level. Severe hypertriglyceridaemia is associated with uncontrolled diabetes, obesity and poor physical activity. Even moderate increases in triglyceride levels (> 5mmol/L) confer an increased risk of pancreatitis and coronary artery disease. We present two patients with diabetes and serum triglyceride levels of greater than 85mmol/L despite polypharmacy intervention.

METHOD

72-hour intravenous insulin infusion was administered.

RESULTS

Serum triglyceride levels fell to 9.4 and 4.6 mmol/L respectively, without adverse events and sustained effect over several months.

CONCLUSION

We suggest the use of intravenous insulin infusion where lifestyle and oral drug therapies have failed can impact on severe hypertriglyceridaemia.

Coping style and depression influence the healing of diabetic foot ulcers: observational and mechanistic evidence

AIMS/HYPOTHESIS

Experimental evidence suggests that the healing of diabetic foot ulcers is affected by psychosocial factors such as distress. We examined this proposal in a prospective study, in which we considered the role of psychological distress and coping style in the healing of diabetic foot ulcers over a 24 week period. We also explored the role of salivary cortisol and matrix metalloproteinases (MMPs) as potential mechanisms.

METHODS

For this prospective observational study we recruited 93 (68 men; mean age 60 years) patients with neuropathic or neuroischaemic diabetic foot ulcers from specialist podiatry clinics in secondary care. Clinical and demographic determinants of healing, psychological distress, coping, salivary cortisol and both MMP2 and MMP9 were assessed at baseline. Ulcers were assessed at baseline and at 6, 12 and 24 weeks post-baseline. The primary outcome was ulcer status at 24 weeks, i.e. healed vs not healed.

RESULTS

After controlling for clinical and demographic determinants of healing, ulcer healing at 24 weeks was predicted by confrontation coping, but not by depression or anxiety. Patients with unhealed ulcers exhibited greater confrontation coping (model including depression: OR 0.809, 95% CI 0.704-0.929, p = 0.003; model including anxiety: OR 0.810, 95% CI 0.704-0.930, p = 0.003). However, change in ulcer size over the observation period was associated with depression only (p = 0.04, d = 0.31). Healed ulcers by 24 weeks were also associated with lower evening cortisol, higher precursor MMP2 and a greater cortisol awakening response.

CONCLUSIONS/INTERPRETATION

Confrontation coping and depression predict ulcer healing. Our preliminary enquiry into biological mechanisms suggests that cortisol and precursor MMP2 may underlie these relationships.

A hepatitis C virus core polypeptide expressed in chloroplasts detects anti-core antibodies in infected human sera

Hepatitis C virus (HCV) is a major disease agent affecting approximately 3% of the world's population. Expression in plant chloroplasts enables low-cost production of the conserved HCV core protein used in diagnostic tests to combat virus spread in developing countries with high infection rates. The bactericidal activity of the 21 kDa precore protein hinders cloning the core gene in plastid expression cassettes, which are active in bacteria due to the similarities between bacterial and plastid promoters and ribosome binding sites. This was overcome by using a topology-dependent expression cassette containing tandem rrn and psbA plastid promoters, whose activity was shown to be dependent on temperature. The viral core gene and a codon-optimised gene encoding a C-terminal truncated 16 kDa core polypeptide were expressed in tobacco chloroplasts. The codon-optimised gene increased monocistronic core mRNA levels by at least 2-fold and core polypeptides by over 5-fold, relative to the native viral gene. Expression of the 16 kDa core polypeptide was stable in leaves of different ages. Anti-core antibodies in HCV-infected human sera were detected by the 16 kDa core polypeptide in total leaf protein fractionated on Western blots providing a first step towards developing a chloroplast-based HCV diagnostic method.

Use of serum progesterone measurements to reduce need for follow-up in women with pregnancies of unknown location

OBJECTIVE

To assess the efficacy of a progesterone-based algorithm for the management of women with pregnancies of unknown location (PULs) and explore the feasibility of developing a single-visit strategy in those with a low risk of requiring medical intervention.

METHODS

All clinically stable women in whom pregnancy could not be identified on ultrasound scan were managed by a pre-defined protocol based on measurement of serum progesterone and beta-human chorionic gonadotropin (beta-hCG). Intervention in the form of surgery or medical treatment with methotrexate was offered to all women with persistent or worsening symptoms and non-declining serum beta-hCG. Decision-tree analysis was used to develop a protocol for the management of women with resolving pregnancies who are at low risk of requiring medical intervention.

RESULTS

1110 women were included in the data analysis: normal intrauterine pregnancy was diagnosed in 248 (22.3%; 95% CI, 19.9-24.8) women. 761 (68.6%; 95% CI, 65.8-71.3) abnormal pregnancies resolved spontaneously on expectant management, while the remaining 101 (9.1%; 95% CI, 7.4-10.8) women with abnormal pregnancies required some form of medical intervention. Intervention rates in patients presenting with initial serum progesterone levels of <or= 20 nmol/L and <or= 10 nmol/L, were 3.9% (95% CI, 2.4-5.4) and 2.1% (95% CI, 0.9-3.3), respectively. In women presenting with progesterone <or= 10 nmol/L and beta-hCG < 450 IU/L, the intervention rate was 1.3% (95% CI, 0.2-2.5).

CONCLUSION

Women with PULs with progesterone <or= 10 nmol/L at presentation are at low risk of requiring medical intervention and may not benefit from attending routine follow-up visits.

Levels of soluble HLA-I and beta2M in patients with acute myeloid leukemia and advanced myelodysplastic syndrome: association with clinical behavior and outcome of induction therapy

beta-2 Microglobulin (beta2M), a subunit of human leukocyte antigen-class I (HLA-I), is well established as a marker of prognosis in various solid tumors and hematologic malignancies. The prognostic role of intact free-circulating HLA-I (sHLA-I) is less well understood. We compared the clinical relevance of plasma levels of sHLA-I and beta2M in patients with acute myeloid leukemia (AML; n=209) or advanced myelodysplastic syndrome (MDS; n=98). sHLA-1 and beta2M levels were significantly higher in AML and MDS patients than in control subjects, but did not differ significantly between the two disease groups. In AML patients, multivariate analysis showed both sHLA-1 and beta2-M to be highly predictive of complete remission (CR), survival and duration of complete response (CRD). In MDS, the predictive value of the two markers differed substantially from one another: beta2M was associated with survival, CR and CRD, whereas sHLA-I was not. These findings not only establish the role of sHLA-I as a tumor marker in AML but also support that MDS is clinically and biologically distinct from AML. sHLA-I has been reported to be an immunomodulator inhibiting the cytotoxic effects of T-lymphocytes, which may offset its predictive value for disease aggressiveness in patients with MDS.

The value of specific radiological features in the classification of acetabular fractures

Specific radiological features identified by Brandser and Marsh were selected for the analysis of acetabular fractures according to the classification of Letournel and Judet. The method employs a binary approach that requires the observer to allocate each radiological feature to one of two groups. The inter- and intra-observer variances were assessed. The presence of articular displacement, marginal impaction, incongruity, intra-articular fragments and osteochondral injuries to the femoral head were analysed by a similar method. These factors were termed ‘modifiers’ and are generally considered when planning operative intervention and, critically, they may influence prognosis.

Six observers independently assessed 30 sets of plain radiographs and CT scans on two separate occasions, 12 weeks apart. They were asked to determine the presence or absence of specific radiological features. This simple binary approach to classification yields an inter- and intra-observer agreement which ranges from moderate to near-perfect (κ = 0.49 to 0.88 and κ = 0.57 to 0.88, respectively). A similar approach to the modifiers yields only slight to fair inter-observer agreement (κ = 0.20 to 0.34) and slight to moderate intra-observer agreement (κ = 0 to 0.55).

Simplified sensitive method for the detection of B-cell clonality in lymphoid malignancies

Molecular response and monitoring of minimal residual disease (MRD) is becoming an essential part of most protocols for treating leukemia and lymphoma patients. Detection of abnormal clones by PCR analysis of complementarity determining regions (CDRs) in immunoglobulin genes is currently standard practice for diagnosis, but is not widely used to monitor MRD because of the low sensitivity of assays that use consensus primers. Use of specific primers can improve the sensitivity of the assay, but is a cumbersome, expensive, and time-consuming process. We developed a simple and cost-effective approach to detect MRD in B-cell malignancies that is usable in clinical laboratories. The new assay uses ligase chain reaction (LCR) to detect clonality. The sensitivity of the LCR assay is 1 per 500,000 cells, and it can detect all subclones that were present in the pretherapy diagnostic sample.

Characterization of the porcine FSCN3 gene: cDNA cloning, genomic structure, mapping and polymorphisms

Fascin 3 (FSCN3)is a testis-specific actin-bundling protein involved in spermatid development. Here we describe the molecular characterisation of the porcine FSCN3 gene. The 1,800-bp cDNA sequence contains a 1,497-bp open reading frame encoding a protein of 498 amino acids with a calculated molecular mass of 56.2 kDa and an isoelectric point of 6.82. The porcine FSCN3 protein shares high identity with other mammalian FSCN3. The FSCN3 gene contains seven exons, spans approximately 9 kb, and maps to pig chromosome 18. We also identified 24 DNA polymorphisms.

Reuse of reactive dyes for dyeing of jute fabric

The aim of the work was to find out suitable method of dyeing so that costly reactive dye can be reused without draining them. The bleached jute fabric was dyed with four different class of reactive dyes namely, cold brand, hot brand, vinyl sulphone and high exhaustion (HE) brand. It is found that the two-step two-bath method of reactive dyeing, where exhaustion and fixation step is separated, is most ideal for reuse of dye bath. Separate original samples produced K/S value same as that of original sample and the K/S value of separate reuse sample varied from 50% to 80% of the original sample depending on the class of dye. In case of same bath method, colour yield of original reuse samples varies from only 10% to maximum 30% of the original samples depending on the class of dyes. Reuse of reactive dyes following separate bath method is particularly suitable for higher depth of shade (4% and above). This process not only utilises costly reactive dyes to the maximum extent but it also produces low water pollution as the effluent contain minimum amount of dye. So the process is economic and eco-friendly as well.

Hepatocellular carcinoma in association with cirrhosis in a patient with cystic fibrosis

BACKGROUND

Cystic fibrosis liver disease (CFLD) occurs in 37% of patients with CF. To date and to the best of our knowledge, there has not been a documented case of hepatocellular carcinoma in association with cirrhosis and CF.

CASE REPORT

A 32-year-old lady with cystic fibrosis (CF) presented for her annual review. She had been diagnosed with CFLD since early adolescence. A routine ultrasound of her liver revealed lesions consistent with hepatocellular carcinoma. This was confirmed on histology. She had no risk factors for hepatitis, and thorough investigation revealed no other cause for her chronic liver disease. She was also found to be pregnant at the time of diagnosis. Her tumour was considered too large for resection and liver transplantation and she was referred to a national centre for laser ablative therapy.

CONCLUSION

It is our concern that with the increased life expectancy of patients with CF and the chronic nature of CFLD that this may be an increasingly recognised complication amongst the CF adult population. Therefore, we have changed our practice to more intense surveillance of patients with established CFLD to incorporate biannual ultrasound imaging of the hepatic system and yearly serum concentration measurements of alpha-fetoprotein.

C reactive protein and skin temperature post total knee replacement

We prospectively assessed 20 patients following uncomplicated total knee replacement (TKR). Clinical status, skin temperature and C-reactive protein (CRP) were measured preoperatively and at intervals up to 18 weeks. The CRP rose postoperatively up to 5-7 days but returned to normal values by 6 weeks. The skin temperature remained elevated up to 18 weeks. We concluded that in uncomplicated cases, the CRP should be within normal limits by 6 weeks after operation, but skin temperature may remain elevated up to 18 weeks. A sustained rise in these values may indicate the development of a complication such as infection and the patient must be closely monitored.

The Effect of Acute Normovolaemic Haemodilution on the Inflammatory Response and Clinical Outcome in Abdominal Aortic Aneurysm Repair—Results of a Pilot Trial

OBJECTIVES

To determine the effect of acute normovolaemic haemodilution (ANH) on the inflammatory response and clinical outcome in elective open abdominal aortic aneurysm (AAA) repair.

DESIGN

Randomised controlled clinical trial.

METHODS

Thirty-six patients were randomised to undergo ANH or act as controls. Cell salvage was permitted in both groups. Heterologous blood was transfused according to pre-determined triggers. Outcome measures were markers of the systemic inflammatory response in serum and urine observed at multiple time points, and clinical recovery.

RESULTS

Median 890 (range 670-1620) ml of blood was removed at ANH in 16 patients. There were no differences in peri-operative changes in neutrophil count ( P = 0.13), serum C-reactive protein ( P = 0.38), interleukin-6 ( P = 0.50), total antioxidant capacity ( P = 0.73), urinary secretion of albumin ( P = 0.97) or retinol binding protein ( P = 0.41). There were no differences in the mortality and morbidity rates, systemic inflammatory response syndrome, ITU or hospital stay.

CONCLUSIONS

ANH, when used in combination with cell salvage, made no impact on systemic inflammatory response and clinical outcome when compared to cell salvage alone after AAA repair. ANH cannot be recommended for routine use in patients undergoing abdominal aortic aneurysm surgery when cell salvage is available.

ESTs from the fibre-bearing stem tissues of flax (Linum usitatissimum L.): expression analyses of sequences related to cell wall development

In order to learn more about the diversity of genes expressed during flax fibre cell wall formation, expressed sequence tags (ESTs) were obtained from a cDNA library derived from the outer fibre-bearing tissues of flax (Linum usitatissimum) stems (cv Hermes) harvested at the mid-flowering stage. After elimination of vector and unreadable sequences, 927 ESTs were grouped into 67 clusters and 754 singletons. The flax ESTs have been submitted to the dbEST and GenBank databases with the accession numbers 25939634 - 25940560 (dbEST) and CV478070 - CV478996 (GenBank). Functional analysis allowed the grouping of ESTs into 13 functional categories and revealed that 62 % of ESTs were similar to known sequences, while 12.4 % of ESTs presented no similarity to any known sequences and 25.6 % of ESTs corresponded to proteins of unknown function. The most highly expressed transcripts belonged to four functional categories: protein maturation and metabolism (31 ESTs), signalling (22 ESTs), the cell wall (21 ESTs) and photosynthesis (19 ESTs). 4.4 % (41) of the total ESTs were potentially related to cell wall formation and maturation. The most highly expressed cell wall EST (15 ESTs) corresponded to a beta-xylosidase gene--potentially involved in cell wall remodelling during growth and development. Other cell wall-related ESTs corresponded to cellulose synthase, xyloglucan endotranglucosylase/hydrolase (XTH), beta-galactosidases, and peroxidases. The expression patterns of different cell wall-related ESTs were determined at different developmental stages in flax plants grown under different field conditions. The potential roles of gene products associated with cell wall related ESTs in fibre cell wall development is discussed.