Development of an advanced database for clinical trials integrated with an electronic patient record system

Secondary use of patient databases is essential in healthcare if clinical trials are to progress efficiently to planned time and target and imperative if the planned UK expansion of research and development (R&D) at point of care is to be achieved. Integration of effective databases primarily designed to facilitate patient care with R&D requirements is needed but represents a complex challenge. We present a system that achieves an integrated approach with online management of complex datasets for clinical trials within care records using a specific study as an example to show functionality in practice; illustrating how this system provides an ideal resource to meet the needs of both clinicians and researchers.

A real-time qPCR assay for the detection of the nifH gene of Methanobrevibacter smithii, a potential indicator of sewage pollution

AIMS

To develop a quantitative, real-time PCR assay to detect the nifH gene of Methanobrevibacter smithii. Methanobrevibacter smithii is a methanogenic archaea found in the intestinal tract of humans that may be a useful indicator of sewage pollution in water.

METHODS AND RESULTS

Quantification standards were prepared from Meth. smithii genomic DNA dilutions, and a standard curve was used to quantify the target gene and calculate estimated genome equivalency units. A competitive internal positive control was designed and incorporated into the assay to assess inhibition in environmental extracts. Testing the assay against a panel of 23 closely related methanogen species demonstrated specificity of the assay for Meth. smithii. A set of 36 blind water samples was then used as a field test of the assay. The internal control identified varying levels of inhibition in 29 of 36 (81%) samples, and the Meth. smithii target was detected in all water samples with known sewage input.

CONCLUSIONS

The quantitative PCR assay developed in this study is a sensitive and rapid method for the detection of the Meth. smithii nifH gene that includes an internal control to assess inhibition. Further research is required both to better evaluate host specificity of this assay and the correlation with human health risks.

SIGNIFICANCE AND IMPACT OF THE STUDY

This research is the first description of the development of a rapid and sensitive quantitative assay for a methanogenic archaeal indicator of sewage pollution.

The use of sublingual glyceryl trinitrate and aspirin in angina patients and enhancement of coronary heart disease databases

Focal points

Effects of draw reins on limb kinematics

REASONS FOR PERFORMING STUDY

No data exist on the GRF-kinematics relation due to changes caused by equestrian interventions.

HYPOTHESIS

Through the judicious use of draw reins the rider can influence the kinematics of the horse to meet stated goals of dressage training. Relating the results to previously published kinetic data of the same experiment implies a possible relationship between kinetics and kinematics.

METHODS

The kinematics of 8 sound Swedish Warmblood horses were measured whilst the horses were being ridden with and without draw reins. Three conditions were evaluated: 1) draw reins only (DR), 2) combination of draw reins and normal reins (NR+DR) and 3) normal reins only (NR).

RESULTS

Head and neck angles were significantly decreased by the draw rein but 4-5 times more so for DR when with NR+DR. The forelimb position at hoof lift-off was significantly more caudal with DR. In the hind limb the hip joint extended more quickly and the hock joint flexed more with NR+DR than with NR. Compared to DR the hip joint angular pattern was not significantly different, but the pelvis was more horizontal.

CONCLUSION

Riding with a draw rein can have significant influence on the kinematics of the horse. Some of the observed changes can be coupled to changes in kinetics. The hock joint angle seems to be a fairly reliable indicator of load on the hind limb and the angle of femur appears important for hind limb propulsion, when considered in conjunction with the orientation of the pelvis.

POTENTIAL RELEVANCE

These findings are important for riders and trainers, as kinematic changes are what trainers observe. It is thereby important to ascertain which kinematic changes are consistently coupled to changes in kinetics in order for trainers to be able to judge correctly the success of intended goals. Further studies are warranted to validate and confirm suggested relationships between kinetics and kinematics.

Relationships between fore- and hindlimb ground reaction force and hoof deceleration patterns in trotting horses

REASONS FOR PERFORMING STUDY

The transmission of shockwaves following hoof impact is proposed to be one major source of stress to the limb. In the forelimb, there are indications that the period of horizontal deceleration of the hoof is related to the attenuation of shockwaves. In the hindlimb, information about the hoof deceleration has been lacking.

OBJECTIVE

To compare hoof deceleration patterns between the fore- and hindlimbs.

METHODS

Seven Standardbreds were trotted by hand over a force plate covered with sand, with triaxial accelerometers mounted on the fore and hind hooves. Variables representative of decelerations (first 2 main vertical deceleration peaks; characteristic minimum and maximum values in the craniocaudal deceleration; hoof braking time) and ground reaction forces (vertical loading rates; maximum and the following local minimum of the craniocaudal force) of the initial part of the stance phase, and the differences between individual fore- and hindlimb time and amplitude variables were used for statistical analyses.

RESULTS

Force plate data showed significantly greater vertical loading rate (mean +/- s.d. 6.5 +/- 5.9 N/sec) and horizontal loads (190.4 +/- 110.2 N) in the forelimb than the hindlimb, but the parameters from accelerometer data showed no significant differences.

CONCLUSIONS

No significant difference was found in the hoof deceleration, but the deceleration curves displayed a common pattern that described in detail the kinematics of the fore and hind hooves during the initial period of hoof braking.

POTENTIAL RELEVANCE

These results contribute to further knowledge about the characteristics of these potential risk factors in the development of subchondral bone damage in the horse. Further studies are required on the influence of hoof braking pattern at higher speed, different shoeing and ground surfaces with different properties.

Kinematic evaluation of the back in the sport horse with back pain

REASONS FOR PERFORMING STUDY

Earlier studies have developed a clinical tool to evaluate objectively the function of the equine back. The ability to differentiate horses with back pain from asymptomatic, fully functioning horses using kinematic measures from this tool has not been evaluated.

OBJECTIVES

To compare the kinematics of the back at walk and trot in riding horses with back dysfunction to the same parameters in asymptomatic sport horses.

METHODS

The kinematics of the back in 12 horses with impaired performance and back pain were studied at walk and trot on a treadmill. Data were captured for 10 sees at 240 Hz. Range of movement (ROM) and intravertebral pattern symmetry of movement for flexion and extension (FE), lateral bending (LB) and axial rotation (AR) were derived from angular motion pattern data and the results compared to an earlier established database on asymptomatic riding horses.

RESULTS

At walk, horses with back dysfunction had a ROM smaller for dorsoventral FE in the caudal thoracic region (T13 = 7.50 degrees, T17 = 7.71 degrees; P<0.05), greater for LB at T13 (8.13 degrees; P<0.001) and smaller for AR of the pelvis (10.97 degrees; P<0.05) compared to asymptomatic horses (FE-T13 = 8.28 degrees, FE-T17 = 8.49 degrees, LB-T13 = 6.34 degrees, AR-pelvis = 12.77 degrees). At trot, dysfunctional horses had a smaller (P<0.05) ROM for FE at the thoracic lumbar junction (T17 = 2.46 degrees, L1 = 2.60 degrees) compared to asymptomatic horses (FE-T17 = 3.07 degrees, FE-L1 = 3.12 degrees).

CONCLUSIONS

The objective measurement technique can detect differences between back kinematics in riding horses with signs of back dysfunction and asymptomatic horses. The clinical manifestation of back pain results in diminished flexion/extension movement at or near the thoracic lumbar junction. However, before applying the method more extensively in practice it is necessary to evaluate it further, including measurements of patients whose diagnoses can be confirmed and long-term follow-ups of back patients after treatment.

POTENTIAL RELEVANCE

Since the objective measurement technique can detect small movement differences in back kinematics, it should help to clinically describe and, importantly, objectively detect horses with back pain and dysfunction.

Relationship between scintigraphic and radiographic evaluations of spinous processes in the thoracolumbar spine in riding horses without clinical signs of back problems

REASONS FOR PERFORMING STUDY

Radiography and scintigraphy are used to aid diagnosis of the cause of back pain, but a large variation in appearance and radiopharmaceutical uptake in fully functioning horses make diagnosis difficult.

OBJECTIVES

To describe the range of and compare scintigraphic and radiographic findings in the spinous processes of horses without clinical signs of back problems.

METHODS

Thirty-three apparently normal riding horses underwent scintigraphic and radiographic examinations of the spinous processes in the thoracolumbar spine. Scintigraphic images were evaluated in a continuous blue, green and red colour scale, and the level of radiopharmaceutical uptake in the spinous processes from T10-L2 was graded into none, mild, moderate or severe increased radiopharmaceutical uptake. Structural changes along the borders of the spinous processes and the width of the interspinous spaces from T10-L2 were recorded.

RESULTS

Only 7 horses had no scintigraphic or radiographic findings. Nine horses had no increased radiopharmaceutical uptake, 17 had no sclerosis, 21 had no radiolucencies and 11 had normal spacing of the spinous processes (>4 mm wide). The majority of findings in 26 horses were located from T13-18 and were mild.

CONCLUSIONS

The findings of a wide spectrum of scintigraphic and radiographic changes leads to the conclusion that changes within this range found in affected horses cannot be interpreted as clinically significant.

POTENTIAL RELEVANCE

To determine whether scintigraphy and/or radiography can be used to separate horses with back pain from horses without clinical signs, the results from this study should be compared to the scintigraphic and radiographic findings in horses with clinical signs.

Effect of local analgesia on movement of the equine back

REASONS FOR PERFORMING STUDY

Diagnostic infiltration of local anaesthetic solution is commonly used in cases of equine back pain. Evaluation is subjective and it is not known how local analgesia of the back affects horses without clinical signs of back pain.

OBJECTIVES

To evaluate the effect of infiltration of local anaesthetics on the movement of the back in horses without clinical signs of back pain, and to evaluate the usefulness of kinematic studies as an objective and quantitative tool in evaluating local analgesia in clinical practice.

METHODS

The kinematics of the back in 10 clinically sound horses were measured on 2 occasions at walk and trot before and after injections with mepivacaine and sodium chloride around the interspinous spaces between T16 and L2. The kinematics were compared between the 2 occasions before injections and before and after each injection.

RESULTS

The range of motion (ROM) for dorsoventral flexion-extension (FE) of the back was increased significantly in all measured segments other than T10 at walk, as was lateral bending (LB) at T10, L3 and L5 after injection of mepivacaine. For lateral excursion (LE), total movement increased at all measured segments. At trot the only affected segment was L3, where the injection with mepivacaine decreased the ROM for FE. After injection of sodium chloride the ROM for FE increased at T13 and T17 at walk. Lateral bending and LE were not affected at walk. At trot, LB increased at L3 and L5.

CONCLUSIONS AND POTENTIAL RELEVANCE

Diagnostic infiltration of local anaesthetic solution affects the function of the back in clinically sound horses, which must be considered when interpreting the use of this clinical aid in assessing clinical cases of back dysfunction. Kinematics can qualitatively and quantitatively evaluate the effect of local analgesia of the back.

The influence of head and neck position on kinematics of the back in riding horses at the walk and trot

REASONS FOR PERFORMING STUDY

A common opinion among riders and in the literature is that the positioning of the head and neck influences the back of the horse, but this has not yet been measured objectively.

OBJECTIVES

To evaluate the effect of head and neck position on the kinematics of the back in riding horses.

METHODS

Eight Warmblood riding horses in regular work were studied on a treadmill at walk and trot with the head and neck in 3 different predetermined positions achieved by side reins attached to the bit and to an anticast roller. The 3-dimensional movement of the thoracolumbar spine was measured from the position of skin-fixed markers recorded by infrared videocameras.

RESULTS

Head and neck position influenced the movements of the back, especially at the walk. When the head was fixed in a high position at the walk, the flexion-extension movement and lateral bending of the lumbar back, as well as the axial rotation, were significantly reduced when compared to movements with the head free or in a low position. At walk, head and neck position also significantly influenced stride length, which was shortest with the head in a high position. At trot, the stride length was independent of head position.

CONCLUSIONS

Restricting and restraining the position and movement of the head and neck alters the movement of the back and stride characteristics. With the head and neck in a high position stride length and flexion and extension of the caudal back were significantly reduced.

POTENTIAL RELEVANCE

Use of side reins in training and rehabilitation programmes should be used with an understanding of the possible effects on the horse's back.

Medical ethics and law for doctors of tomorrow: the 1998 Consensus Statement updated

Knowledge of the ethical and legal basis of medicine is as essential to clinical practice as an understanding of basic medical sciences. In the UK, the General Medical Council (GMC) requires that medical graduates behave according to ethical and legal principles and must know about and comply with the GMC's ethical guidance and standards. We suggest that these standards can only be achieved when the teaching and learning of medical ethics, law and professionalism are fundamental to, and thoroughly integrated both vertically and horizontally throughout, the curricula of all medical schools as a shared obligation of all teachers. The GMC also requires that each medical school provides adequate teaching time and resources to achieve the above. We reiterate that the adequate provision and coordination of teaching and learning of ethics and law requires at least one full-time senior academic in ethics and law with relevant professional and academic expertise. In this paper we set out an updated indicative core content of learning for medical ethics and law in UK medical schools and describe its origins and the consultative process by which it was achieved.

Development of a novel oral vaccine against Mycobacterium avium paratuberculosis and Johne disease: a patho-biotechnological approach

Mycobacterium avium subsp. paratuberculosis (MAP) is the etiological agent of Johne disease, a granulomatous enteritis of cattle and other domesticated and wild ruminant species. Johne disease is prevalent worldwide and has a significant impact on the global agricultural economy. Current vaccines against Johne are insufficient in stemming its spread, and associated side-effects prevent their widespread use in control programs. Effective and safe vaccine strategies are needed. The main purpose of this paper is to propose and evaluate the development of a novel oral subunit-vaccine using a patho-biotechnological approach. This novel strategy, which harnesses patho-genetic elements from the intracellular pathogen Listeria monocytogenes, may provide a realistic route towards developing an effective next generation subunit vaccine against Johne disease and paratuberculosis.

An unusual anatomical variant of the vascular anatomy in the anterolateral thigh free flap

The anterolateral thigh flap is a fasciocutaneous flap based on the descending branch of the lateral circumflex femoral artery. The vascular pedicle and its perforators have a varied anatomical course that has led to difficulties in flap harvest. Many papers have described the anatomical variation in the origin and path of this vessel, but they all show one artery and two accompanying venae commitantes. The authors report the first case of duplication of the descending branch of the lateral circumflex femoral artery. They discuss whether this variation requires two arterial anastomoses.

Evaluation of vertebral fracture assessment by dual X-ray absorptiometry in a multicenter setting

SUMMARY

The utility of vertebral fracture assessment (VFA) by DXA to detect prevalent vertebral fracture in a multicenter setting was investigated by comparison to conventional radiography. While limited by lower image quality, overall performance of VFA was good but had a tendency to miss mild prevalent fractures.

INTRODUCTION

In osteoporosis clinical trials standardized spine radiographs are used to detect vertebral fractures as a study endpoint. Lateral spine imaging with dual X-ray absorptiometry (DXA) scanners, known as vertebral fracture assessment (VFA) by DXA, presents a potential alternative to conventional radiography with lower radiation dose and greater patient convenience.

METHODS

We investigated in a multicenter setting the ability of VFA to detect fractures in comparison with conventional radiography. The study examined 203 postmenopausal women who had imaging of the spine by DXA and radiography. Three radiologists experienced in vertebral fracture assessment independently read the VFA scans and radiographs using the Genant semiquantitative method on two occasions.

CONCLUSIONS

Analyzing the data from all readable vertebrae, the kappa statistic, sensitivity, and specificity ranged from 0.64-0.77, 0.65-0.84, and 0.97-0.98, respectively. Considering only moderate and severe fractures improved the kappa statistic (0.80-0.91) and sensitivity (0.70-0.86). While image quality of VFA is inferior to radiography, the detection of vertebral fractures using visual scoring is feasible. However, VFA underperformed due to unreadable vertebrae and reduced sensitivity for mild fractures. Nevertheless, VFA correctly identified most moderate and severe vertebral fractures. Despite this limitation, VFA by DXA provides an important tool for clinical research.

Kinetics and kinematics of the passage

REASONS FOR PERFORMING STUDY

The load acting on the limbs and the load distribution between fore- and hindlimbs while performing specific dressage exercises lack objective assessment.

HYPOTHESIS

The greater a horse's level of collection, the more load is shifted to the rear and that during the passage the vertical load on the limbs increases in relation to the accentuated vertical movement of the centre of mass.

METHODS

Back and limb kinematics, vertical ground reaction force and time parameters of each limb were measured in 6 Grand Prix dressage horses performing on an instrumented treadmill at the trot and the passage. Horses were ridden by their own professional rider.

RESULTS

At the passage, horses moved at a slower speed (-43.2%), with a lower stride frequency (-23.6%) and, therefore, higher stride impulses (+31.0%). Relative stance duration of fore- and hindlimbs and suspension duration remained unchanged. While at the trot the diagonal limbs impacted almost simultaneously, the hindlimbs always impacted first at the passage; the time dissociation between landing and lift-off remained unchanged. Because of the prolonged stride duration, stride impulse and consequently limb impulses were higher at the passage in the fore- as well as in the hindlimbs (+24.8% and +39.9%, respectively). Within the diagonal limb pair, load was shifted from the forehand to the hindquarters (percentage stride impulse carried by the forehand -4.8%). Despite the higher impulses, peak vertical forces in the fore- and hindlimbs remained unchanged because of the prolonged absolute stance durations in fore- and hindlimbs (+28.1% and +32.2%, respectively).

CONCLUSIONS

Based on the intralimb timing, the passage closely resembles the trot. Compared to other head-neck positions, the higher degree of collection resulted in a pronounced shift in impulse towards the hindquarters. Despite the higher limb impulses, peak forces acting on the limbs were similar to those observed at the trot.

POTENTIAL CLINICAL RELEVANCE

An understanding of load distribution between fore- and hindlimbs in relation to different riding techniques is crucial to prevent wear-and-tear on the locomotor apparatus.

Influence of different head-neck positions on vertical ground reaction forces, linear and time parameters in the unridden horse walking and trotting on a treadmill

REASONS FOR PERFORMING STUDY

It is believed that the head-neck position (HNP) has specific effects on the loading pattern of the equine locomotor system, but very few quantitative data are available.

OBJECTIVE

To quantify the effects of 6 different HNPs on forelimb-hindlimb loading and underlying temporal changes.

METHODS

Vertical ground reaction forces of each limb and interlimb coordination were measured in 7 high level dressage horses walking and trotting on an instrumented treadmill in 6 predetermined HNPs: HNP1--unrestrained; HNP2--elevated neck, bridge of the nose in front of the vertical; HNP3--elevated neck, bridge of the nose behind the vertical; HNP4--low and flexed neck; HNP5--head and neck in extreme high position; and HNP6--forward downward extension of head and neck. HNP1 served as a velocity-matched control.

RESULTS

At the walk, the percentage of vertical stride impulse carried by the forehand (Iz(fore)) as well as stride length and overreach distance were decreased in HNP2, HNP3, HNP4 and HNP5 when compared to HNP1. At the trot, Iz(fore) was decreased in HNP2, HNP3, HNP4 and HNP5. Peak forces in the forelimbs increased in HNP5 and decreased in HNP6. Stance duration in the forelimbs was decreased in HNP2 and HNP5. Suspension duration was increased in HNP2, HNP3 and HNP5. Overreach distance was shorter in HNP4 and longer in HNP6.

CONCLUSIONS

In comparison to HNP1 and HNP6, HNPs with elevation of the neck with either flexion or extension at the poll as well as a low and flexed head and neck lead to a weight shift from the forehand to the hindquarters. HNP5 had the biggest effect on limb timing and load distribution. At the trot, shortening of forelimb stance duration in HNP5 increased peak vertical forces although Iz(fore) decreased.

POTENTIAL RELEVANCE

Presented results contribute to the understanding of the value of certain HNPs in horse training.

Kinetics and kinematics of the horse comparing left and right rising trot

REASONS FOR PERFORMING STUDY

At rising trot the rider sits alternately down on one diagonal pair of limbs and rises up on the other. The possible effects on asymmetry of locomotion induced by rising trot have rarely been studied.

OBJECTIVES

To demonstrate whether, and if so to what extent, rising trot causes asymmetrical loading in the vertical ground reaction force (VGRF) and/or asymmetrical effects on the locomotion pattern, comparing left and right side.

METHODS

Seven elite horses were ridden in left and right rising trot on a treadmill, while VGRF and kinematics were measured, with the horses' neck raised, the poll high and the bridge of the nose slightly in front of the vertical.

RESULTS

Force loading was generally increased in the limbs of the sitting diagonal. The lumbar back was lower between mid-stances of the sitting and nonsitting stance, pelvic roll was limited and the tuber coxae heights were lower on the sitting side. Maximal hindlimb protraction was decreased. Forelimb retraction was increased and the T6 height decreased.

CONCLUSION

The rider movement induces an uneven biphasic load that affects the back, pelvis and limb kinematics and VGRF.

POTENTIAL RELEVANCE

The generally advocated technique of alternating limbs when riding in rising trot is supported. The VGRF changes between rising on the left or right diagonal were distinct, but minor in absolute terms and therefore unlikely to have direct impact on the occurrence of locomotor injuries. Knowledge of an increase of asymmetry in rising trot is potentially useful for riders/trainers.

The effect of different head and neck positions on the caudal back and hindlimb kinematics in the elite dressage horse at trot

REASONS FOR PERFORMING STUDY

Dressage involves training of the horse with the head and neck placed in a position defined by the rider. The best position for dressage training is currently under debate among riders and trainers, but there are few scientific data available to confirm or disprove the different views.

OBJECTIVE

To evaluate the kinematic effects of different head and neck positions (HNPs) in elite dressage horses ridden at trot.

METHODS

Seven high-level dressage horses were subjected to kinetic and kinematic measurements when ridden on a treadmill with the head and neck in 5 different positions.

RESULTS

Compared to free trot on loose reins the HNP desired for collected trot at dressage competitions increased T6 vertical excursion, increased sacral flexion and decreased limb retraction after lift-off. Further increasing head or head and neck flexion caused few additional changes while an extremely elevated neck position increased hindlimb flexion and lumbar back extension during stance, increased hindlimb flexion during swing and further increased trunk vertical excursion.

CONCLUSIONS

The movements of the horse are significantly different when ridden on loose reins compared to the position used in collected trot. The exact degree of neck flexion is, however, not consistently correlated to the movements of the horse's limbs and trunk at collected trot. An extremely elevated neck position can produce some effects commonly associated with increased degree of collection, but the increased back extension observed with this position may place the horse at risk of injury if ridden in this position for a prolonged period.

POTENTIAL RELEVANCE

Head and neck positions influence significantly the kinematics of the ridden horse. It is important for riders and trainers to be aware of these effects in dressage training.

Use of the designation "shedder" in mucosal detection of herpes simplex virus DNA involving repeated sampling

OBJECTIVES

We evaluated two methods to describe detection of herpes simplex virus (HSV) from the genital mucosa.

METHODS

We assessed genital swabs from HSV-2 seropositive people participating in longitudinal studies of HSV DNA detection at the University of Washington Virology Research Clinic. We determined the length of observation period necessary to ensure some HSV detection for most individuals. We compared two measures to assess differences in shedding according to HIV status, the shedding rate ratio, defined as the proportion of total samples with detectable HSV in HIV-1 seropositive versus HIV-1 seronegative participant, and the ratio of "shedders", defined as the proportion of people with any shedding over the interval in HIV-1 seropositive versus HIV-1 seronegative people.

RESULTS

While only 17% (51/308) of HSV-2 seropositive people shed on their first day on study, 77% (238/308) had some genital shedding over 30 days (any HSV DNA detected on genital swabs). Shedding rate ratios (SRR) for HIV-seropositive versus HIV-seronegative people varied from SRR = 1.42 using 10 samples to SRR = 1.35 using 50 samples. The ratio of "shedders" (RS) approached 1 as the observation period increased (RS = 1.13 using 10 samples to RS = 1.01 using 50 samples). In a hypothetical case, the ratio of "shedders" was shown to exceed 1 when shedding rates were equal.

CONCLUSIONS

Most HSV-2 seropositive people shed HSV from the genital mucosa. Dichotomisation of people into "shedders" and "non-shedders" or "high" and "low" shedders yields inferences that depend upon sampling interval length. Overall shedding rates provide consistent measures regardless of the number of swabs collected.

Spray deposition of steam treated and functionalized single-walled and multi-walled carbon nanotube films for supercapacitors

Steam purified, carboxylic and ester functionalized single-walled carbon nanotube (SWNT) and multi-walled carbon nanotube (MWNT) films with homogeneous distribution and flexible control of thickness and area were fabricated on polymeric and metallic substrates using a modified spray deposition technique. By employing a pre-sprayed polyelectrolyte, the adhesion of the carbon nanotube (CNT) films to the substrates was significantly enhanced by electrostatic interaction. Carboxylic and ester functionalization improved electrochemical performance when immersed in 0.1 M H(2)SO(4) and the specific capacitance reached 155 and 77 F g(-1) for carboxylic functionalized SWNT and MWNT films respectively. Compared with existing techniques such as hot pressing, vacuum filtration and dip coating, the ambient pressure spray deposition technique is suggested as particularly well suited for preparing CNT films at large scale for applications including providing electrodes for electrochemical supercapacitors and paper batteries.

Plasma vitamin B12 status and cerebral white-matter lesions

BACKGROUND AND OBJECTIVE

Elevated homocysteine has been associated with a higher prevalence of cerebral white-matter lesions and infarcts, and worse cognitive performance. This raises the question whether factors involved in homocysteine metabolism, such as vitamin B(12), are also related to these outcomes. This study examined the association of several markers of vitamin B(12) status with cerebral white-matter lesions, infarcts and cognition.

METHODS

The study evaluated the association of plasma concentrations of vitamin B(12), methylmalonic acid, holotranscobalamin and transcobalamin saturation with cerebral white-matter lesions and infarcts at baseline and cognition at baseline and during follow-up among 1019 non-demented elderly participants of the population-based Rotterdam Scan Study. Analyses were adjusted for several potential confounders, including homocysteine and folate concentration.

RESULTS

Poorer vitamin B(12) status was significantly associated with greater severity of white-matter lesions, in particular periventricular white-matter lesions, in a concentration-related manner. Adjustment for common vascular risk factors (including blood pressure, smoking, diabetes and intima media thickness) did not alter the associations. Adjustment for homocysteine and folate modestly weakened the associations. No association was observed for any of the studied markers of vitamin B(12) status with presence of brain infarcts and baseline cognition or cognitive decline during follow-up.

CONCLUSIONS

These results indicate that vitamin B(12) status in the normal range is associated with severity of white-matter lesions, especially periventricular lesions. Given the absence of an association with cerebral infarcts, it is hypothesised that this association is explained by effects on myelin integrity in the brain rather than through vascular mechanisms.

When should renal replacement therapy for acute kidney injury be initiated and discontinued?

BACKGROUND

Critically ill patients with acute kidney injury (AKI) are at high risk for death and frequently require initiation of renal replacement therapy (RRT). There is wide variation in clinical practice on the indications for and timing of initiation and discontinuation of RRT. Numerous clinical and biochemical factors (i.e. uremic, metabolic, fluid balance) have been used; however, at present there is no consensus to guide clinicians on the most favorable time to initiate and/or discontinue RRT to optimize patient outcomes.

METHODS

In this review, we appraise the available clinical studies that have assessed timing of initiation and/or discontinuation of RRT for critically ill patients with AKI. 'Timing' of initiation has been variably defined including use of conventional biomarkers (i.e. serum urea and creatinine), urine output, fluid balance, and time relative to intensive care unit admission.

CONCLUSIONS

Numerous studies consistently point toward a survival benefit to early initiation of RRT; however, there is a paucity of high-quality randomized trials. If early RRT is associated with clinical benefit, it remains uncertain whether this is attributable to more rapid metabolic/uremic control, management of fluid balance or a combination of clinical factors. In addition, timing of RRT initiation is likely context-specific and varies by clinical factors and/or etiology of AKI. There is also little data to accurately distinguish in advance between the injured kidney that will need extracorporeal renal support and one that retains capacity for early recovery. Fewer studies have evaluated the process of weaning of RRT or ideal methods to predict sufficient recovery to avoid re-initiation. Longer duration of RRT support, higher illness severity and lower urine output (independent of diuretic therapy) have all predicted need for re-initiation. Additional investigations on these issues are clearly warranted and urgently needed.

Vitamin B12 status and rate of brain volume loss in community-dwelling elderly

OBJECTIVES

To investigate the relationship between markers of vitamin B(12) status and brain volume loss per year over a 5-year period in an elderly population.

METHODS

A prospective study of 107 community-dwelling volunteers aged 61 to 87 years without cognitive impairment at enrollment. Volunteers were assessed yearly by clinical examination, MRI scans, and cognitive tests. Blood was collected at baseline for measurement of plasma vitamin B(12), transcobalamin (TC), holotranscobalamin (holoTC), methylmalonic acid (MMA), total homocysteine (tHcy), and serum folate.

RESULTS

The decrease in brain volume was greater among those with lower vitamin B(12) and holoTC levels and higher plasma tHcy and MMA levels at baseline. Linear regression analysis showed that associations with vitamin B(12) and holoTC remained significant after adjustment for age, sex, creatinine, education, initial brain volume, cognitive test scores, systolic blood pressure, ApoE epsilon4 status, tHcy, and folate. Using the upper (for the vitamins) or lower tertile (for the metabolites) as reference in logistic regression analysis and adjusting for the above covariates, vitamin B(12) in the bottom tertile (<308 pmol/L) was associated with increased rate of brain volume loss (odds ratio 6.17, 95% CI 1.25-30.47). The association was similar for low levels of holoTC (<54 pmol/L) (odds ratio 5.99, 95% CI 1.21-29.81) and for low TC saturation. High levels of MMA or tHcy or low levels of folate were not associated with brain volume loss.

CONCLUSION

Low vitamin B(12) status should be further investigated as a modifiable cause of brain atrophy and of likely subsequent cognitive impairment in the elderly.

Management of the giant frontal sinus--a simple method to improve cosmesis

Frontal bossing can be caused by many craniofacial syndromes, however an enlarged frontal sinus is a rare cause. Because of this the management of this condition is variable. One option is to remove the anterior wall of the frontal sinus and dividing this into segments which are then fixed in the desired position using miniplates.This however may prove difficult in thin bone and in these cases the periosteum can be left intact to splint the fragments which are then repositioned using resorbable sutures.

Ploidy and karyotype complexity are powerful prognostic indicators in the Ewing's sarcoma family of tumors: a study by the United Kingdom Cancer Cytogenetics and the Children's Cancer and Leukaemia Group

Ewing's sarcoma family tumors (ESFT) are characterized by the presence of EWSR1-ETS fusion genes. Secondary chromosome changes are frequently described, although their clinical significance is not clear. In this study, we have collected and reviewed abnormal karyotypes from 88 patients with primary ESFT and a rearrangement of 22q12. Secondary changes were identified in 80% (70/88) of tumors at diagnosis. Multivariate analysis showed a worse overall and relapse free survival (RFS) for those with a complex karyotype (overall survival, P = 0.005; RFS, P = 0.04), independent of metastatic disease. Univariate survival analysis showed that a chromosome number above 50 or a complex karyotype was associated with a worse overall survival (>50 chromosomes, P = 0.05; complex karyotype, P = 0.04). There was no association between type of cytogenetic abnormality and the presence of metastatic disease at diagnosis. Univariate and multivariate survival analysis of a small subgroup with trisomy 20 indicated that trisomy 20 was associated with a worse overall and RFS. There was no difference in outcome associated with other recurrent trisomies (2, 5, 7, 8, or 12) or the common recurrent secondary structural rearrangements (deletions of 1p36, 9p12, 17p13, and 16q, and gain of 1q), although numbers were small. These data demonstrate the continued value of cytogenetics as a genome-wide screen in ESFT and illustrates the potential importance of secondary chromosome changes for stratification of patients for risk. Specifically, karyotype complexity appears to be a powerful predictor of prognosis, and the presence of trisomy 20 may be a marker of a more aggressive subset of this group.

ACE2 deficiency modifies renoprotection afforded by ACE inhibition in experimental diabetes

OBJECTIVE

The degradation of angiotensin (Ang) II by ACE2, leading to the formation of Ang 1-7, is an important step in the renin-angiotensin system (RAS) and one that is significantly altered in the diabetic kidney. This study examines the role of ACE2 in early renal changes associated with diabetes and the influence of ACE2 deficiency on ACE inhibitor-mediated renoprotection.

RESEARCH DESIGN AND METHODS

Diabetes was induced by streptozotocin in male c57bl6 mice and ACE2 knockout (KO) mice. After 5 weeks of study, animals were randomized to receive the ACE inhibitor perindopril (2 mg x kg(-1) x day(-1)). Wild-type mice were further randomized to receive the selective ACE2 inhibitor MLN-4760 (10 mg x kg(-1) x day(-1)) and followed for an additional 5 weeks. Markers of renal function and injury were then assessed.

RESULTS

Induction of diabetes in wild-type mice was associated with a reduction in renal ACE2 expression and decreased Ang 1-7. In diabetic mice receiving MLN-4760 and in ACE2 KO mice, diabetes-associated albuminuria was enhanced, associated with an increase in blood pressure. However, renal hypertrophy and fibrogenesis were reduced in diabetic mice with ACE2 deficiency, and hyperfiltration was attenuated. Diabetic wild-type mice treated with an ACE inhibitor experienced a reduction in albuminuria and blood pressure. These responses were attenuated in both diabetic ACE2 KO mice and diabetic mice receiving MLN-4760. However, other renoprotective and antifibrotic actions of ACE inhibition in diabetes were preserved in ACE2-deficient mice.

CONCLUSIONS

The expression of ACE2 is significantly modified by diabetes, which impacts both pathogenesis of kidney disease and responsiveness to RAS blockade. These data indicate that ACE2 is a complex and site-specific modulator of diabetic kidney disease.

Proteomic profiling identifies afamin as a potential biomarker for ovarian cancer

PURPOSE

To discover and validate serum glycoprotein biomarkers in ovarian cancer using proteomic-based approaches.

EXPERIMENTAL DESIGN

Serum samples from a "discovery set" of 20 patients with ovarian cancer or benign ovarian cysts or healthy volunteers were compared by fluorescence two-dimensional differential in-gel electrophoresis and parallel lectin-based two-dimensional profiling. Validation of a candidate biomarker was carried out with Western blotting and immunoassay (n = 424).

RESULTS

Twenty-six proteins that changed significantly were identified by mass spectrometric sequencing. One of these, confirmed by Western blotting, was afamin, a vitamin E binding protein, with two isoforms decreasing in patients with ovarian cancer. Validation using cross-sectional samples from 303 individuals (healthy controls and patients with benign, borderline, or malignant ovarian conditions and other cancers) assayed by ELISA showed significantly decreased total afamin concentrations in patients with ovarian cancer compared with healthy controls (P = 0.002) and patients with benign disease (P = 0.046). However, the receiver operating characteristic areas for total afamin for the comparison of ovarian cancer with healthy controls or benign controls were only 0.67 and 0.60, respectively, with comparable figures for CA-125 being 0.92 and 0.88 although corresponding figures for a subgroup of samples analyzed by isoelectric focusing for afamin isoform 2 were 0.85 and 0.79. Analysis of a further 121 samples collected prospectively from 9 patients pretreatment through to relapse indicated complementarity of afamin with CA-125, including two cases in whom CA-125 was noninformative.

CONCLUSIONS

Afamin shows potential complementarity with CA-125 in longitudinal monitoring of patients with ovarian cancer, justifying prospective larger-scale investigation. Changes in specific isoforms may provide further information.

A case report of Hailey-Hailey disease treated with alefacept (Amevive)

Hailey-Hailey disease (chronic benign familial pemphigus) is a chronic, recurrent blistering disorder characterized clinically by erosions occurring primarily in intertriginous regions and histologically by suprabasilar acantholysis. We report a case of Hailey-Hailey disease initially unresponsive to multiple topical corticosteroids, tetracycline, dapsone, ciclosporin, isotretinoin, prednisone, methotrexate, topical ciclopirox, tazarotene cream, pimecrolimus cream and tacrolimus ointment. Partial response of this patient's perineal disease was achieved with Amevive 15 mg weekly for 12 weeks, intramuscularly. To our knowledge, this case represents the first such published report of successful treatment of Hailey-Hailey disease using alefacept.