The management of common gastrointestinal disorders in general practice A survey by the European Society for Primary Care Gastroenterology (ESPCG) in six European countries

BACKGROUND

Gastrointestinal (GI) disorders account for 10% of all consultations in primary care. Little is known about the management of GI disorders by general practitioners (GP) across different European countries.

AIM AND METHODS

We undertook a postal survey of randomly selected samples of GPs in six European countries (UK, Holland, Spain, Greece, Poland, Czech Republic) to determine patterns of diagnosis, management and service use in GI disorders.

RESULTS

We received 939 responses, response rate 32%. Over 80% of GPs were aware of at least three national guidelines for gastrointestinal disease. The availability of open access endoscopy ranged from 28% (Poland) to over 80% (Holland, Czech and UK). For uninvestigated dyspepsia the preferred first line management was proton pump inhibitor therapy (33-82%), Helicobacter pylori test and treat (19-47%), early endoscopy (5-32%), specialist referral (2-21%). Regarding irritable bowel syndrome, 23% of respondents were familiar with one or more diagnostic criteria, but between 7% (Netherlands) and 32% (Poland) would ask for a specialist opinion before making the diagnosis.

CONCLUSION

The wide variation between GPs both between and within countries partly reflects variations in health care systems but also differing levels of knowledge and awareness, factors which are relevant to educational and research policy.

Structure and content of the Entamoeba histolytica genome

The intestinal parasite Entamoeba histolytica is one of the first protists for which a draft genome sequence has been published. Although the genome is still incomplete, it is unlikely that many genes are missing from the list of those already identified. In this chapter we summarise the features of the genome as they are currently understood and provide previously unpublished analyses of many of the genes.

Visuospatial memory deficits in adolescent onset schizophrenia

Visuospatial memory encoding deficits have been reported in adults with schizophrenia, while adolescents with schizophrenia have not been specifically investigated with visuospatial memory encoding and retrieval paradigms. A cross sectional study of delayed matching-to-sample performance in 19 right handed, male, anti-psychotic medication naïve adolescents with undifferentiated schizophrenia and 28 age, gender, IQ and handedness matched healthy participants was completed. The adolescent-onset schizophrenia group demonstrated significant impairment in visuospatial memory, independent of the degree of delay, consistent with an encoding impairment. The impaired encoding phase of visuospatial memory in the adolescent-onset schizophrenia group is consistent with findings in adult onset schizophrenia samples, suggesting a developmental stage-independent deficit.

Syphilitic acute posterior placoid chorioretinitis in nonimmuno-compromised patients

PURPOSE

To describe the clinical and angiographic features of three cases of secondary syphilis in immunocompetent patients, which presented as acute posterior placoid chorioretinitis (APPC) to the ophthalmologist.

METHODS

Interventional case series. The aetiology of the APPC was confirmed by serology to be secondary syphilis. Optical coherence tomography, electrophysiology, fundus fluorescein, and indocyanine green (ICG) angiography were performed at presentation and after resolution. Appropriate treatment for secondary syphilis was instituted in each patient.

RESULTS

The clinical features, fundus fluorescein and ICG angiography, multifocal electroretinography (mfERG), and optical coherence tomography findings of APPC are described. All three patients had a satisfactory resolution of the APPC with improvement in visual acuity.

CONCLUSIONS

APPC in secondary syphilis can occur even in immunocompetent patients. A high index of suspicion is required for early diagnosis of this condition resulting in a good visual outcome with adequate treatment. mfERG and optical coherence tomography are useful in the diagnosis and follow-up of these patients.

Visuospatial working memory deficits in adolescent onset schizophrenia

This study determines that visuospatial working memory (VSWM) deficits are evident in adolescent-onset schizophrenia, while the spatial strategy and spatial span components of VSWM are spared. These findings imply that frontal-striatal-parietal neural networks are dysfunctional in adolescent-onset schizophrenia, while mid-dorsolateral and ventrolateral PFC functions remain intact: the current conceptualisation of schizophrenia as a progressive neurodevelopmental disorder is consistent with these results.

A novel technique using preformed metal crowns for managing carious primary molars in general practice - a retrospective analysis

BACKGROUND

There is a high level of untreated dental decay in primary teeth in Scotland. Despite evidence for the efficacy of preformed metal crowns (PMCs) for the restoration of primary molars, few are placed in general practice, possibly due to the interventive nature of the clinical procedure. There is, however, a novel way of placing PMCs involving no local anaesthesia, no caries removal and no preparation of the tooth: the Hall technique.

AIM

To investigate the survival of carious primary teeth treated with PMCs placed using a novel, simplified method - the Hall technique.

SETTING

General dental practice, in Scotland.

METHOD

A retrospective analysis of practice records from one general practitioner, from 1988 to 2001. The majority of the 978 PMCs fitted on 259 children, using the Hall technique, were placed when there was clinical evidence of approximal caries into dentine. The Kaplan-Meier approach was used to analyse survival times and the Mantel-Haenszel Log rank test for comparison between tooth types.

RESULTS

For all tooth types, the probability of surviving three years without being extracted or the PMC being lost, was 73.4% (95% confidence interval 70.1% to 76.4%), and for five years was 67.6% (95% confidence interval 63.3% to 71.5%). The probability of surviving without extraction alone for three years was 86.0% (95% confidence interval 83.2% to 88.4%), and for five years was 80.5% (95% confidence interval 76.5% to 83.9%).

CONCLUSIONS

Hall technique restorations placed on primary molars with decay clinically into dentine, by a single operator in general dental practice, have a similar success rate to some other, more conventional, restorative techniques. The technique requires further evaluation through a prospective randomised control clinical trial before its use could be generally recommended.

The genome of the social amoeba Dictyostelium discoideum

The social amoebae are exceptional in their ability to alternate between unicellular and multicellular forms. Here we describe the genome of the best-studied member of this group, Dictyostelium discoideum. The gene-dense chromosomes of this organism encode approximately 12,500 predicted proteins, a high proportion of which have long, repetitive amino acid tracts. There are many genes for polyketide synthases and ABC transporters, suggesting an extensive secondary metabolism for producing and exporting small molecules. The genome is rich in complex repeats, one class of which is clustered and may serve as centromeres. Partial copies of the extrachromosomal ribosomal DNA (rDNA) element are found at the ends of each chromosome, suggesting a novel telomere structure and the use of a common mechanism to maintain both the rDNA and chromosomal termini. A proteome-based phylogeny shows that the amoebozoa diverged from the animal-fungal lineage after the plant-animal split, but Dictyostelium seems to have retained more of the diversity of the ancestral genome than have plants, animals or fungi.

Laparoscopy assists surgical decision making in infants with necrotizing enterocolitis

BACKGROUND

Lack of specific indications for surgical intervention is not uncommon in critically ill infants with necrotizing enterocolitis (NEC). The authors hypothesized that knowledge of the extent of intestinal disease would assist in deciding the operative treatment of choice. The authors report that initial experience with laparoscopy in infants with NEC.

METHODS

Prospective evaluation was done of 11 infants with a clinical diagnosis of NEC who were deteriorating despite maximal medical therapy. All underwent laparoscopy on the intensive care unit (ICU).

RESULTS

Median gestational age at birth was 29 weeks (range, 24 to 34) and median weight at the time of laparoscopy was 1.2 kg (range, 0.6 to 2.9). Laparoscopy was tolerated well in all cases. NEC was excluded because of the normal intestinal appearance in 2 infants and confirmed in the remaining 9. Urgent laparotomy was avoided in 8 infants, in one of whom a laparoscopically guided ileostomy was performed. In 5 infants, a Penrose drain was inserted at laparoscopy; 3 of these did not require further surgery, and the remaining 2 underwent delayed laparotomy. Three infants, all with intestinal gangrene, died.

CONCLUSIONS

Laparoscopy performed in the ICU can provide information regarding intestinal viability which can guide further surgical management. It is feasible and tolerated well even in critically ill neonates less than 1,000 g.

Adult midgut expressed sequence tags from the tsetse fly Glossina morsitans morsitans and expression analysis of putative immune response genes

BACKGROUND

Tsetse flies transmit African trypanosomiasis leading to half a million cases annually. Trypanosomiasis in animals (nagana) remains a massive brake on African agricultural development. While trypanosome biology is widely studied, knowledge of tsetse flies is very limited, particularly at the molecular level. This is a serious impediment to investigations of tsetse-trypanosome interactions. We have undertaken an expressed sequence tag (EST) project on the adult tsetse midgut, the major organ system for establishment and early development of trypanosomes.

RESULTS

A total of 21,427 ESTs were produced from the midgut of adult Glossina morsitans morsitans and grouped into 8,876 clusters or singletons potentially representing unique genes. Putative functions were ascribed to 4,035 of these by homology. Of these, a remarkable 3,884 had their most significant matches in the Drosophila protein database. We selected 68 genes with putative immune-related functions, macroarrayed them and determined their expression profiles following bacterial or trypanosome challenge. In both infections many genes are downregulated, suggesting a malaise response in the midgut. Trypanosome and bacterial challenge result in upregulation of different genes, suggesting that different recognition pathways are involved in the two responses. The most notable block of genes upregulated in response to trypanosome challenge are a series of Toll and Imd genes and a series of genes involved in oxidative stress responses.

CONCLUSIONS

The project increases the number of known Glossina genes by two orders of magnitude. Identification of putative immunity genes and their preliminary characterization provides a resource for the experimental dissection of tsetse-trypanosome interactions.

Modulation of human swallowing behaviour by thermal and chemical stimulation in health and after brain injury

Few data support thermal or chemical stimulation as therapy for neurogenic dysphagia. Our aims were to explore the behavioural effects of thermal (cold) and chemical (citrus) modalities on water swallowing in health (n = 65, mean age 45 years, 44 females) and acute stroke (n = 22, mean age 67 years, eight females). Multiple randomized timed 50-mL swallowing tests were performed for each of four water conditions: (a) room temperature (RT), (b) cold (CD), (c) citrus (CT) and (d) combined cold and citrus (CD + CT). The inter-swallow interval (ISI), swallowing volume velocity (speed), and volume per swallow (capacity) were measured. In health, compared to RT, only CD + CT slowed the speed (12.3 +/- 0.5 vs 10.3 +/- 0.5 mL s(-1), P < 0.03) and decreased the capacity (16.4 +/- 0.9 vs 14.6 +/- 0.7 mL per swallow, P < 0.02) of swallowing. ISI was unaffected, except by CD + CT in healthy young subjects (<60 years) where it was reduced (1.44 +/- 0.02 vs 1.30 +/- 0.02 s, P < 0.02). Despite smaller volumes ingested by stroke patients, CD + CT, compared to RT, again slowed both the speed (3.8 +/- 0.4 vs 4.5 +/- 0.5 mL s(-1), P < 0.03) and capacity (7.6 +/- 0.7 vs 8.5 +/- 0.7 mL per swallow, P < 0.03) of swallowing but had no effect on ISI. We conclude that combined thermal and chemical modification of water consistently alters swallowing behaviour in health and after cerebral injury. These findings have relevance in the management of neurogenic swallowing problems.

Sequence of Plasmodium falciparum chromosomes 1, 3-9 and 13

Since the sequencing of the first two chromosomes of the malaria parasite, Plasmodium falciparum, there has been a concerted effort to sequence and assemble the entire genome of this organism. Here we report the sequence of chromosomes 1, 3-9 and 13 of P. falciparum clone 3D7--these chromosomes account for approximately 55% of the total genome. We describe the methods used to map, sequence and annotate these chromosomes. By comparing our assemblies with the optical map, we indicate the completeness of the resulting sequence. During annotation, we assign Gene Ontology terms to the predicted gene products, and observe clustering of some malaria-specific terms to specific chromosomes. We identify a highly conserved sequence element found in the intergenic region of internal var genes that is not associated with their telomeric counterparts.

T cryptantigen activation is associated with advanced necrotizing enterocolitis

BACKGROUND/PURPOSE

Thomsen-Friedenreich cryptantigen activation (TCA) exposes neonates with necrotizing enterocolitis NEC to the risk of hemolysis after transfusion of blood products. The authors aimed to determine the prevalence of TCA in neonates with NEC and to correlate TCA with severity of disease and outcome.

METHODS

One hundred four neonates with NEC were tested for TCA on admission. Patients with TCA requiring transfusion were given packed red cells, low-titer anti-T fresh frozen plasma, and washed platelets to avoid hemolysis.

RESULTS

Twenty-three infants had TCA, and 96% of these had stage III disease. The incidence of TCA was significantly higher in infants with stage III disease compared with those with stage II (30% v 4%; P <.01). A total of 91% of infants with TCA required laparotomy compared with 81% of those with no activation. At laparotomy, widespread disease was more common in the TCA group (71% v 55%). TCA did not significantly increase mortality rate (TCA, 39% v no TCA, 28%); this may reflect the transfusion policy of our unit.

CONCLUSIONS

Twenty-two percent of neonates with NEC referred to our unit had TCA. There is an association between TCA and advanced NEC. Screening of neonates with advanced NEC for TCA is advised to identify those at risk of hematologic complications.

Conservation of long-range synteny and microsynteny between the genomes of two distantly related nematodes

BACKGROUND

Comparisons between the genomes of the closely related nematodes Caenorhabditis elegans and Caenorhabditis briggsae reveal high rates of rearrangement, with a bias towards within-chromosome events. To assess whether this pattern is true of nematodes in general, we have used genome sequence to compare two nematode species that last shared a common ancestor approximately 300 million years ago: the model C. elegans and the filarial parasite Brugia malayi.

RESULTS

An 83 kb region flanking the gene for Bm-mif-1 (macrophage migration inhibitory factor, a B. malayi homolog of a human cytokine) was sequenced. When compared to the complete genome of C. elegans, evidence for conservation of long-range synteny and microsynteny was found. Potential C. elegans orthologs for II of the 12 protein-coding genes predicted in the B. malayi sequence were identified. Ten of these orthologs were located on chromosome I, with eight clustered in a 2.3 Mb region. While several, relatively local, intrachromosomal rearrangements have occurred, the order, composition, and configuration of two gene clusters, each containing three genes, was conserved. Comparison of B. malayi BAC-end genome survey sequence to C. elegans also revealed a bias towards intrachromosome rearrangements.

CONCLUSIONS

We suggest that intrachromosomal rearrangement is a major force driving chromosomal organization in nematodes, but is constrained by the interdigitation of functional elements of neighboring genes.

Linear and quadratic models of the southern Murray-Darling basin

Linear programming (LP), a well-established technique for modelling agricultural and other systems, has been extensively used to model irrigation systems in Australia. The models constructed have been used to assess the effects of changing water charges on farm incomes, water use, and the effects of trade in water allocations. An LP model that reflects actual farm behaviour requires a large amount of data. Moreover, demand and supply functions estimated with LP models are necessarily stepped rather than smooth. Howitt has suggested a way of escaping from these problems of LP models. His positive programming approach replaces an LP model with a simpler quadratic programming model. In this paper, Howitt's approach is used to develop a quadratic programming model from an existing LP model of irrigated agriculture in the southern Murray-Darling basin of Australia. A comparison of the quadratic and linear models indicates that the quadratic programming model is smaller and simpler to specify and that it produces similar results to the linear model, in terms of cropping, trade, and demand for irrigation water. The choice of modelling technique depends on the problem and the available resources. Positive programming can be a valuable addition to the farm modellers' arsenal.

Characterization of the human Xq21.3/Yp11 homology block and conservation of organization in primates

The Xq21.3/Yp11 homology block on the human sex chromosomes represents a recent addition to the Y chromosome through a transposition event. It is believed that this transfer of material occurred after the divergence of the hominid lineage from other great apes. In this paper we investigate the structure and evolution of the block through fluorescence in situ hybridisation, contig assembly, the polymerase chain reaction, exon trapping, sequence comparison, and annotation of sequence data. The overall structure is well conserved between the human X chromosome and the Y chromosome as well as between the X chromosomes from different primates. Although the sequence data reveal a high level of nucleotide sequence identity for the human X and Y, there are regions of significant divergence, such as that around the marker DXS214. These are presumably the consequence of multiple rearrangements during evolution and are of particular importance with respect to the potential gene content in this segment of the interval.

p50(Cdc37) can buffer the temperature-sensitive properties of a mutant of Hck

Genetic studies have previously revealed that Cdc37p is required for the catalytic competence of v-Src in yeast. We have reasoned that temperature-sensitive mutants of Src family kinases might be more sensitive to the cellular level of p50(Cdc37), the mammalian homolog of Cdc37p, than their wild-type counterpart, thus potentially providing a unique opportunity to elucidate the involvement of p50(Cdc37) in the folding and stabilization of Src family kinases. A temperature-sensitive mutant of a constitutively active form of Hck (i.e., tsHck499F) was created by mutating two amino acids within the kinase domain of Hck499F. Significantly, overexpression of p50(Cdc37) rescues the catalytic activity of tsHck499F at 33 degrees C, while partially buffering it against inactivation at higher temperatures (e.g., 37 and 39 degrees C). Hsp90 function is required for tsHck499F activity and its stabilization by p50(Cdc37), but overexpression of Hsp90 is not sufficient to stabilize tsHck499F. Overexpression of p50(Cdc37) promotes the association of tsHck499F with Hsp90, suggesting that the cellular level of p50(Cdc37) might be the rate-limiting step in the association of tsHck499F with Hsp90. A truncation mutant of p50(Cdc37) that cannot bind Hsp90 still has a limited capacity to rescue the catalytic activity of tsHck499F and promote its association with Hsp90. This is a particularly important observation, since it argues that rather than solely acting as a passive adapter protein to tether tsHck499F to Hsp90, p50(Cdc37) may also act allosterically to enhance the association of tsHck499F with Hsp90. The findings presented here might also have implications for our understanding of the evolution of protein kinases and tumor development.