Clinical asthma phenotypes and therapeutic responses

Asthma is a heterogeneous disease that means not all asthmatics respond to the same treatment. We hypothesize an approach to characterize asthma phenotypes based on symptomatology (shortness of breath (SOB), cough, and wheezy phenotypes) in correlation with airway inflammatory biomarkers and FEV1. We aimed to detect whether those clinical phenotypes have an impact on the response to asthma medications. Two hundred three asthmatic children were allocated randomly to receive either montelukast (5 mg at bed time) or fluticasone propionate (100 ug twice daily) for 8 consecutive weeks. Serum concentrations of IL-2Rs, ICAM-1, VCAM-1, total IgE, eosinophilic %, eosinophil cationic protein (ECP), and FEV1 were done before and after treatment to patients and once to controls. Children who have SOB were found to have higher levels of total sIgE, older age, and longer disease duration, and they responded to fluticasone alone. Cough group was found to have higher levels of eosinophilic % and sECP, younger age, shorter disease duration and responded to montelukast alone. Wheezy group showed mixed pattern and responded to both medications. Conclusion. Although there is variability in response to ICS and LTRAs, we did identify characteristics of patient that should guide the clinician in the choice of asthma medications.

Predictors of ischaemic heart disease in a Malaysian population with the metabolic syndrome

AIMS

Cardiovascular disease is the foremost cause of mortality in Malaysia but little is known about the prevalence of the metabolic syndrome and its associations with other known cardiovascular risk markers. We undertook a population-based study to examine these.

METHODS

For the study, 4341 subjects were selected using a multistage stratified sampling method. Subjects were interviewed for personal and past medical history. Biomedical markers and anthropometric indices were measured. The metabolic syndrome was defined using the harmonized criteria. The associations between the metabolic syndrome and cardiovascular risk markers, including high-sensitivity C-reactive protein, microalbuminuria and HbA(1c) were examined.

RESULTS

The prevalence of the metabolic syndrome was 42.5%. Subjects with the metabolic syndrome are significantly more likely to have higher BMI (> 25 kg/m(2)), HbA(1c) [≥ 42 mmol/mol (6.0%)], LDL (≥ 2.6 mmol/l), elevated albumin:creatinine ratio (> 2.5 μg/mmol creatinine for men, 3.5 μg/mmol creatinine for women) and high-sensitivity C-reactive protein (> 3 mg/l); odds ratio 5.48, 6.14, 1.44, 3.68 and 1.84, respectively, P < 0.001. The presence of an elevated albumin:creatinine ratio and high-sensitivity C-reactive protein are strong predictors for the presence of a higher number of positive criteria of the metabolic syndrome. HbA(1c) > 48 mmol/mol (6.5%) is associated with increased relative risk of elevated albumin:creatinine ratio, high-sensitivity C-reactive protein and LDL (relative risk 3.10, 2.46 and 1.65 respectively, P < 0.001).

CONCLUSIONS

We confirmed the high prevalence of the metabolic syndrome in Malaysia. Our study revealed a strong relationship between risk markers of elevated BMI, HbA(1c), LDL, albumin:creatinine ratio and high-sensitivity C-reactive protein with the presence of the metabolic syndrome, putting them at a statistically high risk for cardiovascular mortality.

Influence of the narrow {111} planes on axial and planar ion channeling

We report channeling patterns where clearly resolved effects of the narrow {111} planes are observed in axial and planar alignments for 2 MeV protons passing through a 55 nm [001] silicon membrane. At certain axes, such as <213> and <314>, the offset in atomic rows forming the narrow {111} planes results in shielding from the large potential at the wide {111} planes, producing a region of shallow, asymmetric potential from which axial channeling patterns have no plane of symmetry. At small tilts from such axes, different behavior is observed from the wide and narrow {111} planes. At planar alignment, distinctive channeling effects due to the narrow planes are observed. As a consequence of the shallow potential well at the narrow planes, incident protons suffer dechanneled trajectories which are excluded from channeling within the wide planes, resulting in an anomalously large scattered beam at {111} alignment.

Ovarian VEGF(165)b expression regulates follicular development, corpus luteum function and fertility

Angiogenesis and vascular regression are critical for the female ovulatory cycle. They enable progression and regression of follicular development, and corpora lutea formation and regression. Angiogenesis in the ovary occurs under the control of the vascular endothelial growth factor-A (VEGFA) family of proteins, which are generated as both pro-(VEGF(165)) and anti(VEGF(165)b)-angiogenic isoforms by alternative splicing. To determine the role of the VEGF(165)b isoforms in the ovulatory cycle, we measured VEGF(165)b expression in marmoset ovaries by immunohistochemistry and ELISA, and used transgenic mice over-expressing VEGF(165)b in the ovary. VEGF(165)b was expressed in the marmoset ovaries in granulosa cells and theca, and the balance of VEGF(165)b:VEGF(165) was regulated during luteogenesis. Mice over-expressing VEGF(165)b in the ovary were less fertile than wild-type littermates, had reduced secondary and tertiary follicles after mating, increased atretic follicles, fewer corpora lutea and generated fewer embryos in the oviduct after mating, and these were more likely not to retain the corona radiata. These results indicate that the balance of VEGFA isoforms controls follicle progression and luteogenesis, and that control of isoform expression may regulate fertility in mammals, including in primates.

Abstract P4-11-17: Can We Specifiy the Minimum Breast Size at Which Therapeutic Mammoplasty Should Be Considered To Mitigate Radiotherapy Toxicity in Patients Undergoing Breast Conserving Surgery for Breast Cancer?

Background

For breast cancer patients undergoing breast conserving surgery, local complications after breast radiotherapy have in the past been shown to be proportional to breast size. Therapeutic mammoplasty is an option to extend the role of breast conserving surgery. In our units, it has been used in larger breasted women undergoing breast conserving surgery to reduce the risk of local radiotherapy complications.

Aim

The aim of this multicentre study was to determine, with modern radiotherapy dosing schedules, if it is possible to specify a minimum bra cup size at which therapeutic mammoplasty should be considered.

Methods

Recurrence free breast cancer patients (at least 3 years post conservative surgery and radiotherapy) were identified from three oncology follow up clinics in the United Kingdom.

50Gy in 25 fractions over 5 weeks prescribed to the 100% isodose at the ICRU reference point, on the central outline of the breast had been a typical dosing schedule. Radiotherapy effects were graded using the Late Effects of Normal Tissue-Subjective Objective Management Analytical (LENT-SOMA) score. A score of two or above was taken as representing that the particular toxicity variable was present. The relationship between radiotherapy toxicity variables was calculated using the Pearson correlation co-efficient.

Results

479 breast cancer patients were assessed. Increasing cup size correlated with oedema (Pearson correlation co-efficient r=0.30, p=&lt;0.0001), induration (r=0.31, p=&lt;0.0001), telangiectasia (r=0.24, p=&lt;0.0001), breast retraction (r=0.15, p=0.002) and pain (r=0.10, p=0.030). 2.3% of patients with cup size AA/A exhibited fibrosis, 6.6% with cup size B or C, 11.8% cup size D and 25.5% with cup size DD and above. Conclusion

Local radiotherapy complications following breast conserving surgery for breast cancer remain proportional to breast size even with modern radiotherapy equipment and dosing schedules. This effect is most pronounced in women with a bra cup size D and above. For these women, therapeutic mammoplasty should be considered. Further work to identify the genetic determinants of normal-tissue radiation damage is underway to optimise the surgical decision.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-11-17.

Genotoxicity of two pathogenic strains of zoosporic fungi (Achlya klebsiana and Aphanomyces laevis) on erythrocytes of Nile tilapia Oreochromis niloticus niloticus

In the present work we have described the genotoxic potential of two pathogenic strains of zoosporic fungi (Achlya klebsiana and Aphanomyces laevis) on erythrocytes of Nile tilapia Oreochromis niloticus niloticus for the first time by three complementary tests: micronucleus test (MN), nuclear lesions (NL) and comet assay (CA). The groups exposed to the zoosporic fungi subjected to the MN and NL test showed statistically significant differences in MN and NL frequencies with respect to the control one. Also, a significant increase (p<0.001) in micronuclei and nuclear lesions frequencies were recorded with the increase in exposure time. A correlation was observed between the frequencies of MN and NL, suggesting the importance for recording this anomaly in order to improve the information obtained with the MN test. Therefore, our results suggest that the nuclear lesions found here should be considered indicators of genotoxicity, in addition to the typical micronuclei forms. The result of the comet assay showed a significant difference in the percentages of the damaged DNA in the comet tail (%TDNA) of the treated groups comparing to the control. A significant (p<0.001) increase in the DNA damage of the treated groups with the increase in exposure time was recorded, confirming the results of the MN and the NL tests. The results of the current study will be useful for future work involving the biomonitoring of regions where Nile tilapia survive. These data allow us to consider O. niloticus niloticus as a good bioindicator of the effects of genotoxic agents that might be present in the aquatic habitat.

The Spinal Cord Independence Measure (SCIM) version III: Reliability and validity in a multi-center international study

PURPOSE

To examine the third version of the Spinal Cord Independence Measure (SCIM III) for reliability and validity in a multi-center cohort study.

METHOD

Four hundred and twenty-five patients with spinal cord lesions from 13 spinal cord units in six countries from three continents were assessed with SCIM III and the Functional Independence measure (FIM) on admission to rehabilitation and before discharge.

RESULTS

Total agreement between raters was above 80% in most SCIM III tasks, and all kappa coefficients were statistically significant (P<0.001). The coefficients of Pearson correlation between the paired raters were above 0.9, and intraclass correlation coefficients were above 0.94. Cronbach's alpha was above 0.7. The coefficient of Pearson correlation between FIM and SCIM III was 0.790 (P<0.01). SCIM III was more responsive to changes than FIM in the subscales of Respiration and sphincter management and Mobility indoors and outdoors.

CONCLUSIONS

The results support the reliability and validity of SCIM III in a multi-cultural setup. Despite several limitations of the study, the results indicate that SCIM III is an efficient measure for functional assessment of SCL patients and can be safely used for clinical and research trials, including international multi-center studies.

Inhibitory effect of morinda citrifolia L. On lipoprotein lipase activity

Efficacy of Morinda citrifolia L. leaf (MLE) and fruit extracts (MFE) in inhibiting lipoprotein lipase (LPL) was determined in vitro. The result of the study showed that the highest inhibition on the LPL activity was exhibited by MLE (66%+/- 2.1%), which is significantly higher than that demonstrated by MFE (54.5%+/- 2.5%), green tea extract (GTE) (54.5%+/- 2.6%), and catechin (43.6%+/- 6.1%). Percent of LPL inhibition increase with concentration of the extracts. Quantitative analysis of the extracts revealed the presence of high levels of (+)-catechin at 63.5 +/- 17 and 53.7 +/- 5.7 mg/g in MLE and MFE, respectively, although not as high as that found in GTE (530.6 +/- 42 mg/g). Appreciable amount of epicatechin was found in all extracts tested, while rutin was only found in MLE and MFE. The study suggested that both leaf and fruit of M. citrifolia may be used as antiobesity agents in body weight management.

Successful commercialisation of locally fabricated bioceramics for clinical applications

This paper chronicled the development of a locally produced bone graft substitute based on calcium phosphate bioceramics called "GranuMaS--from concepts to clinics, and finally to its successful commercialization all within 5-year duration. It was a Prioritized Research (PR) collaborative project of 5 institutions namely SIRIM, ANM, USM, UKM and IIUM, funded by MOSTI to the amount of approximately RM2.5 millions under RM8. This paper also highlighted the requirements needed in terms of technical expertise/manpower, facilities and infrastructure, and government/institutional supports, as well as the challenge faced in developing and commercializing such product.

Neuroleptic-induced tardive dyskinesia among Arab psychotic patients

We carried out a retrospective descriptive study to determine prevalence and risk factors for tardive dyskinesia (TD) among psychotic patients treated with conventional neuroleptics in 4 centres in Saudi Arabia. Records of patients who had been taking > or = 1 conventional neuroleptic for > or = 6 months from January 1997 to December 2000 were examined; 151 patients were included in the final analysis. Only 51 had TD; another 59 (6.8%) patients had drug-induced Parkinson disease. Duration of treatment (P < 0.001), higher doses of neuroleptics (P < 0.01) and age over 40 years (P < 0.01) were associated with TD. A statistically significant difference in prevalence was found between Arabs (23.5%) and Afro-Arabs (45.5%) (P < 0.01). Overall prevalence of TD among psychotic patients was 5.9%.

The late radiotherapy normal tissue injury phenotypes of telangiectasia, fibrosis and atrophy in breast cancer patients have distinct genotype-dependent causes

The relationship between late normal tissue radiation injury phenotypes in 167 breast cancer patients treated with radiotherapy and: (i) radiotherapy dose (boost); (ii) an early acute radiation reaction and (iii) genetic background was examined. Patients were genotyped at single nucleotide polymorphisms (SNPs) in eight candidate genes. An early acute reaction to radiation and/or the inheritance of the transforming growth factor-β1 (TGFβ1 −509T) SNP contributed to the risk of fibrosis. In contrast, an additional 15 Gy electron boost and/or the inheritance of X-ray repair cross-complementing 1 (XRCC1) (R399Q) SNP contributed to the risk of telangiectasia. Although fibrosis, telangiectasia and atrophy, all contribute to late radiation injury, the data suggest that they have distinct underlying genetic and radiobiological causes. Fibrosis risk is associated with an inflammatory response (an acute reaction and/or TGFβ1), whereas telangiectasia is associated with vascular endothelial cell damage (boost and/or XRCC1). Atrophy is associated with an acute response, but the genetic predisposing factors that determine the risk of an acute response or atrophy have yet to be identified. A combined analysis of two UK breast cancer patient studies shows that 8% of patients are homozygous (TT) for the TGFβ1 (C-509T) variant allele and have a 15-fold increased risk of fibrosis following radiotherapy (95% confidence interval: 3.76–60.3; P=0.000003) compared with (CC) homozygotes.

A multicenter international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation

BACKGROUND

A third version of the Spinal Cord Independence Measure (SCIM III), made up of three subscales, was formulated following comments by experts from several countries and Rasch analysis performed on the previous version.

OBJECTIVE

To examine the validity, reliability, and usefulness of SCIM III using Rasch analysis.

DESIGN

Multicenter cohort study.

SETTING

Thirteen spinal cord units in six countries from North America, Europe, and the Middle-East.

SUBJECTS

425 patients with spinal cord lesions (SCL).

INTERVENTIONS

SCIM III assessments by professional staff members. Rasch analysis of admission scores.

MAIN OUTCOME MEASURES

SCIM III subscale match between the distribution of item difficulty grades and the patient ability measurements; reliability of patient ability measures; fit of data to Rasch model requirements; unidimensionality of each subscale; hierarchical ordering of categories within items; differential item functioning across classes of patients and across countries.

RESULTS

Results supported the compatibility of the SCIM subscales with the stringent Rasch requirements. Average infit mean-square indices were 0.79-1.06; statistically distinct strata of abilities were 3 to 4; most thresholds between adjacent categories were properly ordered; item hierarchy was stable across most of the clinical subgroups and across countries. In a few items, however, misfit or category threshold disordering were found.

CONCLUSIONS

The scores of each SCIM III subscale appear as a reliable and useful quantitative representation of a specific construct of independence after SCL. This justifies the use of SCIM in clinical research, including cross-cultural trials. The results also suggest that there is merit in further refining the scale.

Main haplotypes and mutational analysis of vitamin K epoxide reductase (VKORC1) in a Swedish population: a retrospective analysis of case records

BACKGROUND

Vitamin K epoxide reductase (VKORC1) is the site of inhibition by coumarins. Several reports have shown that mutations in the gene encoding VKORC1 affect the sensitivity of the enzyme for warfarin. Recently, three main haplotypes of VKORC1; *2, *3 and *4 have been observed, that explain most of the genetic variability in warfarin dose among Caucasians.

OBJECTIVES

We have investigated the main haplotypes of the VKORC1 gene in a Swedish population. Additional objective was to screen the studied population for mutations in the coding region of VKORC1 gene.

PATIENTS/METHODS

Warfarin doses and plasma S- and R-warfarin of 98 patients [with a target International Normalized Ratio (INR) of 2.0-3.0] have been correlated to VKORC1 haplotypes. Controls of 180 healthy individuals have also been haplotyped. Furthermore, a retrospective analysis of case records was performed to find any evidence indicating influence of VKORC1 haplotypes on warfarin response in the first 4 weeks (initiation phase) and the latest 12 months of warfarin treatment.

RESULTS AND CONCLUSIONS

Our result shows that VKORC1*2 is the most important haplotype for warfarin dosage. Patients with VKORC1*2 haplotype had more frequent visits than patients with VKORC1*3 or *4 haplotypes, higher coefficient of variation (CV) of prothrombin time-INR and higher percentage of INR values outside the therapeutic interval (i.e. 2.0-3.0) than patients with VKORC1*3 or *4 haplotypes. Also, there was a statistically significant difference in warfarin dose (P < 0.001) and R-warfarin plasma levels (P < 0.01) between VKORC1*2 and VKORC1*3 or 4 haplotypes. Patients with VKORC1*2 haplotype seem to require much lower warfarin doses than other patients.

Cerebro-spinal decompression sickness: report of two cases

STUDY DESIGN

Two case reports.

OBJECTIVE

To describe two unusual cases of deep diving followed by cerebro-spinal decompression sickness (DCS).

SETTING

Midlands Centre for Spinal Injuries, England.

METHODS

Observation of the outcome of two different cases of cerebro-spinal DCS, who have received two different modalities of treatment.

RESULTS

The first patient's symptoms developed after he surfaced, he was treated according to the US Navy treatment table 6. He also received steroids for almost 3 weeks. His MRI of the brain and spinal cord, which was performed within 24 h of injury did not show any abnormality, while a repeat MRI 3 weeks later revealed abnormal signals in the brain and spinal cord. The second patient's symptoms started before he surfaced, he was treated with Comex 30 treatment table for 14 days and received no steroids, his MRI was performed 3 days after the injury showed high signals in the brain and spinal cord.

CONCLUSION

Both divers developed cerebro-spinal dysfunction. They had encephalopathy (manifested by loss of consciousness), which indicates bilateral cerebral dysfunction. DCS can occur even when dives are conducted according to the procedures described by the US Navy. The use of high-dose steroids has not been formally tested in DCS; their use is controversial.

Schistosoma infection inhibits cellular immune responses to core HCV peptides

Patients coinfected with hepatitis C virus (HCV) and the trematode, Schistosoma mansoni, have an increased incidence of viral persistence and accelerated fibrosis. To investigate immunological mechanisms responsible for this more aggressive natural history of HCV, the core HCV-specific T-cell responses were analysed in 44 donated blood units rejected because they had antibodies to HCV (anti-HCV). Half also had anti-S. mansoni antibodies, evidence of past or active infection. HCV-specific ELISPOT responses were examined using pools of 180 overlapping 9-mer peptides with offsets of one covering the core of HCV genotype 4a. Comparison of T-cell responses in blood units positive for both anti-HCV and anti-Schistosoma antibodies with blood units positive only for anti-HCV antibodies showed a significant decrease in core-specific T-cell IFN-gamma (505+/- 46 vs. 803 +/- 66 ISC/10(6) cells, P < 0.001), IL-4 (2 +/- 108 vs. 641 +/- 131 ISC/10(6) cells, P < 0.001), and IL-10 (159 +/- 105 vs. 466 +/- 407 ISC/10(6) cells, P < 0.002) responses. In contrast, there was no significant difference in cell-mediated immune response (CMI) to PHA mitogen between these two groups. Therefore, we concluded T cells from persons with anti-Schistosoma have reduced IFN-gamma, IL-4, and IL-10 secreting HCV-specific T-cell responses. This may explain why Schistosoma coinfection increases persistence and severity of HCV infection.

The medical school curriculum at University Malaysia Sabah

The integrated curriculum at the newly established medical school at University Malaysia Sabah is examined from aspects of the objectives of the medical training in achieving development of the required skills and knowledge as well as personal and professional development. The teaching is spread over five years with an emphasis on basic medical sciences in the first two years although the students are exposed to clinical skills right from the onset. A gradual transition to emphasis on the acquisition of clinical skills occurs from the third year onwards. However, community medicine and professional development are incorporated into the programme from the first year and are carried over to the final year. Although there are examinations to be passed in all the courses taught every semester, with a Cumulative Grade Point Average (CGPA) of 3.0 (65 percentile score) and the candidate has to pass all the examinations in that year to clear a particular year, two professional examinations are administered, one at the end of the Third Year (end of the Phase I of the Medical Programme) and another at the end of the Fifth or Final year (end of the Phase II of the Medical Programme). Programmes for Postings, Shadow House Officers (SHOP) and Population Health are also incorporated into the curriculum. Delivery of the courses involve Lectures, Self-Learning Packages (SLP), Small Group Discussions (SGD), Seminars, Debates, Dramas, Video clips, Special Study Modules (SSM), Computer-Aided Instruction (CAI), Problem-based Learning (PBL), Problem-solving Sessions (PSS) and Clinical Skills Learning (CSL). The examination involves elements of continuous assessment and final end of semester or end of phases I and II Professional Examinations. Practical may involve Objective Structured Practical Examinations (OSPE) and/or Objective Structured Clinical Examinations (OSCE). They may also involve viva voce and/or short and long case presentations and assessment of log book entries.