Mutations in CHD7 in patients with CHARGE syndrome cause T-B + natural killer cell + severe combined immune deficiency and may cause Omenn-like syndrome

More than 11 genetic causes of severe combined immunodeficiency (SCID) have been identified, affecting development and/or function of T lymphocytes, and sometimes B lymphocytes and natural killer (NK) cells. Deletion of 22q11.2 is associated with immunodeficiency, although less than 1% of cases are associated with T-B + NK + SCID phenotype. Severe immunodeficiency with CHARGE syndrome has been noted only rarely Omenn syndrome is a rare autosomal recessive form of SCID with erythroderma, hepatosplenomegaly, lymphadenopathy and alopecia. Hypomorphic recombination activating genes 1 and 2 mutations were first described in patients with Omenn syndrome. More recently, defects in Artemis, RMRP, IL7Ralpha and common gamma chain genes have been described. We describe four patients with mutations in CHD7, who had clinical features of CHARGE syndrome and who had T-B + NK + SCID (two patients) or clinical features consistent with Omenn syndrome (two patients). Immunodeficiency in patients with DiGeorge syndrome is well recognized--CHARGE syndrome should now be added to the causes of T-B + NK + SCID, and mutations in the CHD7 gene may be associated with Omenn-like syndrome.

Immune effects of decreasing low-molecular weight hemoglobin components of hemoglobin-based oxygen carriers (HBOC) in a swine model of severe controlled hemorrhagic shock

Hemoglobin-based oxygen carriers (HBOCs) show potential as safe, efficacious, pre-hospital resuscitation fluids. The major criticism of HBOC-201 is its vasoactive property, attributed partially to low-molecular weight (low-MW) tetrameric/dimeric (TD) hemoglobin (Hb) in HBOC solution. Here we sought to determine whether resuscitation with decreasing concentrations of low-MW Hb component of HBOC affects immune responses in hemorrhagic swine. 28 anesthetized swine underwent a soft muscle crush and controlled hemorrhage of 55% blood volume, followed by resuscitation with HBOC containing 31%, 2%, or 0.4% low-MW Hb in four 10 ml/kg infusions at 20, 30, 45 and 60 minutes before hospital arrival at 75 minutes. IL-10, cell activation and adhesion markers and CD4:CD8 ratio remained unchanged in all 3 groups compared to baseline. Leukocyte apoptosis was equally elevated across all groups. Purification from 31% to 0.4% low-MW Hb in HBOC solution did not alter immune effects in a swine model of severe controlled hemorrhagic shock.

Quantifying adherence to treatment and its relationship to quality of life in a well-characterized haemophilia population

It is known that chronically ill patients adhere to medical treatment plans only 50% of the time. Adherence to treatment with factor infusion therapy in haemophilia patients is essential to stop bleeding. It also prevents both acute and chronic life and limb threatening complications. This study, performed in a well-described haemophilia population, was completed in an effort to understand the critical issue of adherence in patients with haemophilia. A major component of the methodology of this study was the development of a unique scoring system to quantify adherence. Adherence scores in patients on On-Demand treatment strategies were then compared to those on High Intensity treatment strategies. Quality of life (QoL) studies were also performed on the study population to assess the association of treatment regimen and adherence scores to QoL measures. Results of this study demonstrated that adherence to On-Demand therapy was significantly greater than adherence to High Intensity treatment regimens and in children, High Intensity treatment regimens, which included prophylaxis, correlated with better QoL scores in body pain. It is envisioned that the development of an objective scoring system for adherence will prove useful in future studies of adherence as well as in the development of intervention strategies that can overcome barriers to adherence in haemophilia patients.

Production of 89Sr in solution reactor

The new method for medical (89)Sr production in a reactor with solution fuel is proposed which is characterized by simplicity, high production efficiency and low buildup of radioactive waste. The main advantages of the new technology were validated by numerous experiments. The proposed new technology selectively extracts (89)Sr from a fuel of solution reactor and precludes penetration of (90)Sr into the final product. This method is based on the presence of gaseous radionuclide (89)Kr (T(1/2)=190.7s) in the decay chain (89)Se-->(89)Br-->(89)Kr-->(89)Rb-->(89)Sr. The performed experiments on taking the gas probes from internal volume of the solution 20 kW mini-reactor "Argus" have confirmed that the mechanism for (89)Sr delivery to the sorption volume of the reactor experimental loop is based on transport of gaseous (89)Sr predecessor-radionuclide (89)Kr. According to the measurements of radioactive impurities in a final (89)SrCl(2) solution, the filtration of the gas flow with cermet filters followed by cleaning of (89)Sr chloride solution in chromatographic columns with DOWEX-50 x 8 or Sr-Resin ensures reception of (89)Sr fully meeting the requirements for medical application. The experimental estimations have shown that the proposed new technology is multiply more productive than the traditional industrial methods of (89)Sr reception.

Rapid prototyping in the assessment, classification and preoperative planning of acetabular fractures

AIM

To evaluate the use of rapid prototyping in the assessment, classification and preoperative planning of acetabular fractures.

INTRODUCTION

The complex three-dimensional anatomy of the pelvis and acetabulum make assessment, classification and treatment of fractures of these structures notoriously difficult. Conventional imaging only provides two-dimensional images of these fractures. While interpretation of traditional imaging techniques becomes better with experience, novel techniques may assist in the understanding of these complex injuries.

METHODS

Twenty patients with acetabular fractures were studied. Life size three-dimensional models were manufactured from standardised CT scans, using the rapid prototyping process, selective laser sintering. Each model was presented to the operating surgeon prior to surgery. The surgeons found that the models greatly assisted in their understanding of the personality of the fracture. Three consultant orthopaedic surgeons and three senior trainees were asked to classify each fracture using conventional radiographs (AP pelvis, Judet views and CT scans) and then using the model. The kappa statistic was used to evaluate inter- and intraobserver agreement.

RESULTS

Interobserver agreement was not absolute using either conventional radiographs or the models. For the consultants the kappa statistic using conventional radiographs was 0.61 while the kappa value using the model was 0.76 (p<0.05). For the trainees the kappa value was 0.42, using conventional radiographs and 0.71 using the model (p<0.01).

CONCLUSION

Full sized models of acetabular fractures greatly assisted surgeons understand the personality of complex fractures prior to surgery and have been shown in this study to significantly reduced the degree of interobserver variability in fracture classification. This effect is particularly evident for less experienced surgeons. This technique is available and relatively inexpensive. The use of these models should prove invaluable as a tool to aid clinical practice.

Plant-made vaccines: biotechnology and immunology in animal health

The use of plants as production systems for vaccine antigens has been actively investigated over the last 15 years. The original research focused on the value of this expression system for oral delivery based on the hypothesis that plant-expressed antigens would be more stable within the digestive tract and would allow for the use of the oral route of administration to stimulate a mucosal immune response. However, while first conceived for utility via the oral route, plant-made antigens have also been studied as classical immunogens delivered via a needle to model animal systems. Antigens have been expressed in a number of whole plant and cell culture systems. Several alternative expression platforms have been developed to increase expression of antigens or to elicit preferred immunological responses. The biotechnological advances in plant expression and the immunological testing of these antigens will be reviewed in this paper focusing primarily on diseases of livestock and companion animals.

Coagulation patterns following haemoglobin-based oxygen carrier resuscitation in severe uncontrolled haemorrhagic shock in swine

Massive blood loss due to penetrating trauma and internal organ damage can cause severe haemorrhagic shock (HS), leading to a severely compromised haemostatic balance. This study evaluated the effect of bovine polymerized haemoglobin (Hb) (Hb-based oxygen carrier, HBOC) resuscitation on haemostasis in a swine model of uncontrolled HS. Following liver injury/HS, swine received HBOC (n= 8), Hextend (HEX) (n= 8) or no resuscitation (NON) (n= 8). Fluids were infused to increase mean arterial pressure above 60 mmHg and to reduce heart rate to baseline. At 4 h, the animals were eligible for blood transfusions. Prothrombin time (PT), activated partial thromboplastin time, fibrinogen, thromboelastography (TEG) and platelet function analyser closure time (PFA-CT) were compared by using mixed statistical model. At 4 h, blood loss (% estimated blood volume) was comparable for HBOC (65.5 +/- 18.5%) and HEX (80.8 +/- 14.4%) and less for NON (58.7 +/- 10.1%; P < 0.05). Resuscitation-induced dilutional coagulopathy was observed with HBOC and HEX, as indicated by reduced haematocrit, platelets and fibrinogen (P < 0.05). At 4 h, PT was higher in HEX than in HBOC groups (P < 0.01). In the early hospital phase, a trend to increased TEG reaction time and PFA-CT indicates that dilutional effects persist in HBOC and HEX groups. PFA-CT returned to baseline later with HBOC than with HEX (48 vs. 24 h) following blood transfusion. At 4 h, all surviving HEX animals (n= 3) required transfusion, in contrast to no HBOC (n= 7) or NON (n= 1) animals. In this severe uncontrolled HS model, successful resuscitation with HBOC produced haemodilutional coagulopathy less than or similar to that produced by resuscitation with HEX.

Thrower's fracture of the humerus with radial nerve palsy: an unfamiliar softball injury

A fracture of the normal humerus in a healthy young adult most commonly results from significant direct trauma. Throwing sports have become increasingly popular outside of North America and bring with them a novel injury mechanism for clinicians. A 21 year old woman sustained a "thrower's fracture" of the distal humerus and radial nerve palsy while throwing a softball. She was treated by internal fixation. Her fracture united, and radial nerve neurapraxia resolved after 8 weeks. Clinicians should be aware of this entity so that prodromal symptoms can be recognised early and thrower's fractures are not investigated unnecessarily.

Primary total hip replacement--a survey of current practice and identifying changing trends

Primary total hip replacement (THR) surgery is the most commonly performed and successful reconstructive procedure in orthopaedic surgery. We performed a survey of Irish Orthopaedic consultants to elucidate current practices of primary THR in elderly and young patients and identify changing trends. There was an 83% response rate. Most respondents use a cemented THR in elderly patients. 69% use a different THR in younger patients compared to older patients. 9% refer younger patients to hip replacement specialist consultant colleagues. 70% report changing to a new implant or new technique in younger patients and 45% use a hybrid THR, 15% an uncemented THR, 15% perform hip resurfacing and 47% use different bearing surfaces. Only 17% use the Charnley hip prosthesis in younger patients. Young and active patients will place high demands on a new THR and newer techniques, implants and bearing surfaces are being adopted in the hope of better outcomes.

Movements at the low back during normal walking

We present a technique for measuring the kinematics of the functional low back during normal gait. We have used a similar technique previously to measure low back movement simultaneously with hip, knee, and ankle movement during the toe-touching manoeuvre. We noted that movements at the low back were biphasic. The greatest low back movements were found to occur in the transverse plane (mean = 23 degrees), whereas a mean of 17 degrees movement occurred in the coronal plane and only 5 degrees movement in the sagittal plane. These findings confirm, using a non-invasive technique, that there are significant ranges of movement at the low back during walking and lend some support to the theory that rotational movement at the low back is a major component of human locomotion.

Kinematics of the toe touching test: An investigation using motion analysis

We describe a technique for measuring dynamic motion at the low back along with the major lower limb joints during the toe touching maneuver. This type of motion analysis was carried out on eight normal volunteers. Flexion during the toe touching maneuver involves not only low back and hip movement but also ankle plantar flexion and a varying degree of knee movement. The low back and ankle movements were highly correlated within each subject to an extent that suggests a functional connection between the lower limb and low back movements. The significance of our work is two-fold. First, we emphasize that the toe touching test represents a combined movement of the low back, the hips, the knees, and the ankles and it is reasonable to suggest that abnormalities of these joints may affect the clinical relevance of the test as an indicator of back movement. Second, we point out that the guidelines of the American Medical Association in using the test to determine hip movement are incorrect as they do not take into account the effect of knee and ankle movements on the estimation of hip movement.

Outcome after acetabular fracture. Prognostic factors and their inter-relationships

The aim of this study was to examine how commonly implicated prognostic factors are associated with late clinical outcome after reconstruction of acetabular fractures. The clinical outcomes of 180 fractures, treated by a single surgeon over a 10-year period, were assessed using the scoring system of Merle d'Aubigné and Postel. A statistical model was constructed comprising the clinical outcome and nine postulated prognostic factors. The association between these factors and sub-optimal outcome was explored by logistic regression and log linear analysis, and a model of causality was postulated. Associated fracture type, imperfect reduction (>3mm), the presence of local complications and heterotopic bone were prognostic factors independently associated with a sub-optimal outcome. The sex or age of the patient, the presence of hip dislocation, sciatic palsy, or an interval from injury to surgery of 1-18 days were factors which were not directly associated with a poor outcome. Imperfect reduction was itself affected by associated fracture type and increasing age, and it is the latter connection that may explain any apparent association between sub-optimal outcome and increasing age.

An Inquiry-Based Approach to Teaching Research Design: Asking the Right Questions

To describe an inquiry-based learning activity and discuss the advantages of using such activities to demonstrate research design to undergraduate psychology students the authors presented students with the research problem of eyewitness memory recall and asked students to solve the problem, using the information provided by the course. Working in small groups, students reviewed eyewitness studies and designed their own research materials, including a videotaped theft and a CD-ROM version of the eyewitness survey and potential suspect line-up. Poststudy interviews showed that the students enjoyed the activity and felt that they had a better understanding of experimental research design than they had before the exercise. It is proposed that this activity may be a useful hands-on tool for instructors who have difficulty teaching students fundamental topics such as literature reviews, hypothesis testing, reliability and validity of research measures, and experimental design.

An inquiry-based approach to teaching research design: asking the right questions

To describe an inquiry-based learning activity and discuss the advantages of using such activities to demonstrate research design to undergraduate psychology students the authors presented students with the research problem of eyewitness memory recall and asked students to solve the problem, using the information provided by the course. Working in small groups, students reviewed eyewitness studies and designed their own research materials, including a videotaped theft and a CD-ROM version of the eyewitness survey and potential suspect line-up. Poststudy interviews showed that the students enjoyed the activity and felt that they had a better understanding of experimental research design than they had before the exercise. It is proposed that this activity may be a useful hands-on tool for instructors who have difficulty teaching students fundamental topics such as literature reviews, hypothesis testing, reliability and validity of research measures, and experimental design.

Measuring movement at the low back

The clinical importance of movements of the human spine is increasingly being realized but their measurement is difficult to carry out. Traditionally, measurement of spinal motion focuses on the lumbar spine as the mobile region and movement at the lower thoracic spine is largely ignored. The aim of this study was to test the hypothesis that sagittal movement at the low back is not confined to the lumbar spine. The range of sagittal movement and the amount of skin distraction during trunk flexion was studied in 10 normal subjects. Angular movement in the sagittal plane between the vertebra prominens and S2 ranged between 40 degree and 83 degree among the subjects. Concomitant skin distraction showed that a mean of 32% (range 20-41%) of the movement between the upper thorax and sacropelvis occurred cranial to T12. We therefore suggest that the term "low back" should be applied to a series of mobile vertebrae in the lower thoracic and lumbar spines and that motion of this region in the sagittal plane should be considered as the movement of an immobile upper thoracic spine relative to the sacropelvis.

Comparison between clinical and radiologic outcome measures after reconstruction of acetabular fractures

OBJECTIVES

To compare clinical and radiologic outcome measures in patients after reconstruction of acetabular fractures and to investigate whether an objective radiologic outcome could be used as a proxy for a clinical outcome.

DESIGN

Follow-up survey with retrospective analysis of consecutive case records.

PATIENTS AND INTERVENTION

Over a ten-year period, 201 consecutive patients had open reduction and internal fixation of acetabular fractures performed by a single surgeon. The outcome measures on 166 fractures were available for analysis when the twenty-six patients who were lost to follow-up and the fourteen patients who had salvage total hip replacement were excluded.

MAIN OUTCOME MEASUREMENTS

The assessment of patients was performed by one of two independent assessors, who used the Merle d'Aubigné (1954) clinical outcome score and a radiologic score of degenerative hip disease (Matta, 1994).

RESULTS

Although the overall correlation between the clinical and radiologic outcome grades was good (r = 0.63, p < 0.001), their agreement (i.e., the prediction of a specific clinical outcome by a corresponding radiologic one) was poor (Kappa = 0.24). The authors found that the clinical scoring system was difficult to apply specifically to acetabular trauma in 29 percent of fractures because of complications related to associated injuries. When the individual Merle d'Aubigné scores for pain, range of motion, and walking were correlated with the radiologic score, it was found that the walking score had a significant association with the radiologic score and the pain and range of movement scores.

CONCLUSIONS

The Merle d'Aubigné score has shortcomings as an outcome measure for acetabular fractures. Our aim to use a radiologic outcome as a proxy for this clinical grading system was not realized, but we propose that the patient's walking ability could be used as an objective local outcome measurement.

An empirical investigation of hospital profitability in the post-PPS era

In this study, we identify the empirical determinants of hospital profitability, as measured by return on assets, using a comprehensive sample of hospitals from all four U.S. regions over the post-PPS era. We augment previous empirical models of hospital profitability by considering the effects of additional economic and financial variables and the effects of conversion of ownership status. Our empirical findings suggest that the following factors are significant determinants of hospital profitability during the post-PPS era: geographic location, ownership status, teaching status, conversion of ownership status, adjusted number of employees, length of stay, competition, financial indebtedness, bed capacity, and occupancy rate. We also find that a nonlinear relationship characterizes the dependence of hospital profitability on bed capacity and occupancy rate.

New strategies for vaccination and imunomodulation in NHL

Knowledge of the genetic changes which occur in cancer cells is stimulating research aimed towards new therapies. Immunotherapeutic approaches, particularly antibody therapy, are already finding a place in treatment of hematological malignancies. Vaccination will build on experience in the field of infectious diseases, and it should be possible to design vehicles to deliver the expanding range of tumour antigens to the immune system. For DNA vaccines, fusion genes have the potential to activate and direct immune effector pathways. One candidate antigen for B-cell malignancies is the clonal idiotypic immunoglobulin and we have designed a fusion vaccine encoding idiotypic sequence fused to a sequence from a powerful antigen from tetanus toxin. This promotes protective immunity against lymphoma in models, and is now in clinical trial. One challenge is to bring patients into remission without significant damage to immune capacity. Another is to rethink the nature of clinical trials so that more pilot studies of efficacy can be carried out. There is no evidence so far of toxicity due to injection of DNA, but for antigens which are expressed by normal cells, the line between attack on tumour and autoimmunity will have to be carefully drawn.

Compartment syndrome without pain!

We report the case of a young male patient who underwent intra-medullary nailing for a closed, displaced mid-shaft fracture of tibia and fibula. He was commenced on patient controlled analgesia post-operatively. A diagnosis of compartment syndrome in the patient's leg was delayed because he did not exhibit a pain response. This ultimately resulted in a below-knee amputation of the patient's leg. We caution against the use of patient controlled analgesia in any traumatised limb distal to the hip or the shoulder.

DNA fusion vaccines against B-cell tumors

DNA vaccination is currently being explored as a potential strategy for combatting cancer. However, tumor antigens are often weak and the immune system of patients may be compromised. For B-cell tumors, immunoglobulin idiotypic antigens provide defined targets but are poorly immunogenic. Fusion of a sequence derived from tetanus toxin to the genes encoding idiotypic determinants has proved highly effective in activating protective anti-tumor immunity. DNA fusion vaccines containing immuno-enhancing sequences can augment and direct immune attack on a range of target antigens. Gene-based fusion vaccines offer ease of manipulation and flexible design to activate effective attack on cancer.