Which injuries may indicate child abuse?

Making the decision as to whether an injury is a result of child abuse or not is stressful for both the family involved and the clinical team. It is not a decision that is taken lightly, and with an increasing expectation by the investigating agencies, lawyers and the public in general, to ensure that it is based on explicit 'evidence', clinicians need to be up to date with the latest scientific publications in the field. This article aims to summarise the current evidence in relation to all physical injuries except those pertaining to the central nervous system, which will form a separate article. It will examine the pattern of accidental and abusive bruises, fractures, burns, abdominal injuries and oral injuries focusing on discriminating features and necessary investigations.

What are the clinical and radiological characteristics of spinal injuries from physical abuse: a systematic review

AIM

Systematic review of 'What are the clinical and radiological characteristics of inflicted spinal injury?'

METHODS

Literature search of 20 electronic databases, websites, references and bibliographies (1950-2009) using selected keywords. Critical appraisal: by two trained reviewers, (a third review, if discrepant).

INCLUSION CRITERIA

primary studies of inflicted spinal injury in children <18 years, alive at presentation, with a high surety of diagnosis of abuse and sufficient detail to analyse.

RESULTS

19 studies of 25 children were included. Twelve children (median age 5 months) had cervical injury. In seven cases, the clinical signs of spinal injury were masked by respiratory symptoms and impaired levels of consciousness; six of these children had coexistent inflicted head trauma. Twelve children had thoraco-lumbar injury (median age 13.5 months), 10/12 had lesions at T11-L2, and 9/12 had fracture dislocations. All children had focal signs: 10/12 had lumbar kyphosis or thoraco-lumbar swelling, and two had focal neurology. One child had cervical, thoracic and sacral injuries.

CONCLUSIONS

Spinal injury is a potentially devastating inflicted injury in infants and young children. The published evidence base is limited. However, this case series leads us to recommend that any clinical or radiological indication of spinal injury warrants an MRI. In children undergoing brain MRI for abusive head trauma, consideration should be given to including an MRI of the spine. All skeletal surveys in children with suspected abuse should include lateral views of the cervical and thoraco-lumbar spine. Further prospective comparative studies would define the discriminating features of inflicted spinal injuries.

Intra-aortic mural thrombosis and splenic infarction in association with ulcerative colitis

BACKGROUND

Arterial thrombosis is a very rare, but recognised complication of inflammatory bowel disease that can result in significant morbidity and mortality.

CASE PRESENTATION

We present the case of a 48-year-old female with previously well-controlled ulcerative colitis who presented with severe left upper quadrant abdominal pain. Imaging investigations subsequently revealed a large intra-aortic mural thrombus extending into the coeliac axis complicated by splenic infarction. This occurred in the absence of other prothrombotic states such as thrombophilias or vasculitis.

CONCLUSION

This case highlights the frequently overlooked association between inflammatory bowel disease and arterial thrombosis.

Which clinical features distinguish inflicted from non-inflicted brain injury? A systematic review

AIM

A systematic review of the scientific literature to define clinical indicators distinguishing inflicted (iBI) from non-inflicted brain injury (niBI).

METHODS

An all language literature search of 20 electronic databases, websites, references and bibliographies from 1970-2008 was carried out. Relevant studies were independently reviewed by two trained reviewers, with a third review where required. Inclusion criteria included primary comparative studies of iBI and niBI in children aged <18 years, with high surety of diagnosis describing key clinical features. Multilevel logistic regression analysis was conducted, determining the positive predictive value (PPV) and odds ratios (OR) with p values for retinal haemorrhage, rib/long bone/skull fractures, apnoea, seizures and bruising to head/neck.

RESULTS

8151 studies were identified, 320 were reviewed and 14 included, representing 1655 children, 779 with iBI. Gender was not a discriminatory feature. In a child with intracranial injury, apnoea (PPV 93%, OR 17.06, p<0.001) and retinal haemorrhage (PPV 71%, OR 3.504, p = 0.03) were the features most predictive of iBI. Rib fractures (PPV 73%, OR 3.03, p = 0.13) had a similar PPV to retinal haemorrhages, but there were less data for analysis. Seizures and long bone fractures were not discriminatory, and skull fracture and head/neck bruising were more associated with niBI, although not significantly so.

CONCLUSIONS

This systematic review shows that apnoea and retinal haemorrhage have a high odds ratio for association with iBI. This review identifies key features that should be recorded in the assessment of children where iBI is suspected and may help clinicians to define the likelihood of iBI.

What neuroimaging should be performed in children in whom inflicted brain injury (iBI) is suspected? A systematic review

AIMS

To investigate the optimal neuroradiological investigation strategy to identify inflicted brain injury (iBI).

MATERIALS AND METHODS

A systematic review of studies published between 1970-2008 in any language was conducted, searching 20 databases and four websites, using over 100 keywords/phrases, supplemented by hand-searching of references. All studies underwent two independent reviews (with disagreements adjudicated by a third reviewer) by trained reviewers from paediatrics, paediatric neuroradiology and related disciplines, using standardized critical appraisal tools, and strict inclusion/exclusion criteria. We included primary studies that evaluated the diagnostic yield of magnetic resonance imaging (MRI), in addition to initial computed tomography (CT), or follow-up CT or ultrasound in children with suspected iBI.

RESULTS

Of the 320 studies reviewed, 18 met the inclusion criteria, reflecting data on 367 children with iBI and 12 were published since 1998. When an MRI was conducted in addition to an abnormal early CT examination, additional information was found in 25% (95% CI: 18.3-33.16%) of children. The additional findings included further subdural haematoma, subarachnoid haemorrhage, shearing injury, ischaemia, and infarction; it also contributed to dating of injuries. Diffusion-weighted imaging (DWI) further enhanced the delineation of ischaemic changes, and assisted in prognosis. Repeat CT studies varied in timing and quality, and none were compared to the addition of an early MRI/DWI.

CONCLUSIONS

In an acutely ill child, the optimal imaging strategy involves initial CT, followed by early MRI and DWI if early CT examination is abnormal, or there are ongoing clinical concerns. The role of repeat CT imaging, if early MRI is performed, is unclear, as is the place for MRI/DWI if initial CT examination is normal in an otherwise well child.

Anaesthetic management of a woman with autosomal recessive limb-girdle muscular dystrophy for emergency caesarean section

We report the successful management of a 28-year-old parturient with an autosomal recessive limb-girdle muscular dystrophy with severe restrictive lung disease, who required non-invasive positive pressure ventilation in the third trimester of her pregnancy. At 37 weeks' gestation she had combined spinal-epidural anaesthesia for emergency caesarean section and had an uncomplicated intra- and postoperative course. The anaesthetic management is discussed and the literature briefly reviewed.

Which radiological investigations should be performed to identify fractures in suspected child abuse?

AIMS

To determine which radiological investigations should be performed and which children should be investigated.

MATERIALS AND METHODS

An all language literature search of original articles; from 1950-October 2005. Two reviewers independently reviewed each article. A third was carried out on disagreement. Each study was assessed using standardised data extraction, critical appraisal and evidence forms.

RESULTS

Thirty-four studies were included. Fifteen addressed the question: which investigation has a higher yield, skeletal surveys (SS) or bone scintigraphy (BS)? Studies gave conflicting results. Overall neither investigation is as good as the two combined. BS predominately missed skull, metaphyseal and epiphyseal fractures, whereas SS commonly missed rib fractures. Two studies showed that a repeat SS 2 weeks after the initial study provided significant additional information about tentative findings, the number and age of fractures. A comparative study evaluated additional oblique views of ribs in 73 children and showed improved diagnostic sensitivity, specificity and accuracy. Four studies addressed the diagnostic yield for occult fractures with respect to age. This was significant for children under 2-years old.

CONCLUSIONS

In children under 2-years old, where physical abuse is suspected, diagnostic imaging of the skeleton should be mandatory. SS or BS alone is inadequate to identify all fractures. It is recommended that all SS should include oblique views of the ribs. This review suggests that the following options would optimize the diagnostic yield. However, each needs to be evaluated prospectively: SS that includes oblique views, SS and BS, a SS with repeat SS or selected images 2 weeks later or a BS plus skull radiography and coned views of metaphyses and epiphyses.

Spontaneous common bile duct rupture in pregnancy

This report describes how a rare condition in pregnancy can present with features resembling more common diagnoses in the unwell obstetric patient. Our patient presented in late pregnancy initially with clinical features similar to mild preeclampsia, with proteinuric hypertension, epigastric pain and mildly deranged liver function tests. She went on to develop signs of acute abdomen associated with a persistent tachycardia and hypotension; there was evidence of fetal compromise. Following resuscitation, emergency caesarean section was performed and evolved into a laparotomy. The diagnosis was not clear clinically at this stage, but a retrospective amylase sample suggested acute pancreatitis. There was no clinical evidence of biliary perforation, but ongoing clinical suspicion prompted a CT of the abdomen. This proved unhelpful and our diagnostic dilemma was only resolved by endoscopic retrograde cholangiopancreatography, which demonstrated a biliary leak. A stent was placed with subsequent improvement in the patient's condition. With anaesthetists increasingly involved in the multi-disciplinary management of acutely sick obstetric patients, our case highlights the need for every practitioner involved in such cases to assess each individual fully, and be constantly aware that the diagnosis might not be obvious.

Can you age bruises accurately in children? A systematic review

AIMS

To investigate whether it is possible to determine the age of a bruise in a child in clinical practice by means of a systematic review.

METHODS

An all language literature search up to 2004. Included studies assessed the age of bruises in live children less than 18 years old. Excluded: review articles, expert opinion, and single case reports. Standardised data extraction and critical appraisal forms were used. Two reviewers independently reviewed studies.

RESULTS

Of 167 studies reviewed, three were included: two studies described colour assessment in vivo and one from photographs. Although the Bariciak et al study showed a significant association between red/blue/purple colour and recent bruising and yellow/brown and green with older bruising, both this study and Stephenson and Bialas reported that any colour could be present in fresh, intermediate, and old bruises. Results on yellow colouration were conflicting. Stephenson and Bialas showed yellow colour in 10 bruises only after 24 hours, Carpenter after 48 hours, and Bariciak et al noted yellow/green/brown within 48 hours. Stephenson and Bialas reported that red was only seen in those of one week or less. The accuracy with which clinicians correctly aged a bruise to within 24 hours of its occurrence was less than 40%. The accuracy with which they could identify fresh, intermediate, or old bruises was 55-63%. Intra- and inter-observer reliability was poor.

CONCLUSION

A bruise cannot accurately be aged from clinical assessment in vivo or on a photograph. At this point in time the practice of estimating the age of a bruise from its colour has no scientific basis and should be avoided in child protection proceedings.

Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review

AIMS

To investigate what patterns of bruising are diagnostic or suggestive of child abuse by means of a systematic review.

METHODS

All language literature search 1951-2004. Included: studies that defined patterns of bruising in non-abused or abused children <18 years. Excluded: personal practice, review articles, single case reports, inadequate confirmation of abuse. Two independent full text reviews using standardised data extraction and critical appraisal forms. Studies ranked by study design and definition of abuse used.

RESULTS

Twenty three studies included: seven non-abusive bruising, 14 abusive bruising, and two both. Non-abusive: The prevalence, number, and location of bruises is related to increased motor development. Bruising in non-independently mobile babies is very uncommon (<1%). Seventeen per cent of infants who are starting to mobilise, 53% of walkers, and the majority of schoolchildren have bruises. These are small, sustained over bony prominences, and found on the front of the body. Abuse: Bruising is common in children who are abused. Any part of the body is vulnerable. Bruises are away from bony prominences; the commonest site is head and neck (particularly face) followed by the buttocks, trunk, and arms. Bruises are large, commonly multiple, and occur in clusters. They are often associated with other injury types that may be older. Some bruises carry the imprint of the implement used.

CONCLUSION

When abuse is suspected, bruising must be assessed in the context of medical, social, and developmental history, the explanation given, and the patterns of non-abusive bruising. Bruises in non-mobile infants, over soft tissue areas, that carry the imprint of an implement and multiple bruises of uniform shape are suggestive of abuse. Quality research across the whole spectrum of children is urgently needed.

Patient perception of the impact of sporting activity on rehabilitation in a spinal cord injuries unit

OBJECTIVE

To establish patients' perception of the effect of sport on rehabilitation.

DESIGN

Single investigator telephone questionnaire survey.

SETTING

Spinal Cord Injuries Unit, Musgrave Park Hospital, Belfast, Northern Ireland, UK.

METHOD

A telephone questionnaire was administered to patients admitted over a 12-month period. Information on patient demographics, sports participation before and after injury and patients' perception of the impact of sports on rehabilitation was recorded.

RESULTS

In all, 33 (84.6%) of the 39 patients could be contacted and all completed the questionnaire. Of the respondents 27 (81.8%) had a diagnosis of spinal cord injury. Six (18.2%) were female and 20 (60.6%) were below 45 years.A total of 15 (45.5%) patients previously participated in regular sporting activity. At least 24 (72.7%) tried one sport during admission. In all, 14 reported taking part in regular sporting activity after discharge, although 23 expressed a desire to do so. Of those 60% who had regularly exercised continued to do so and 27% of those who reported no regular sport, before injury, commenced regular active exercise. A general benefit of sporting activity was recognised by 78.8% and a rehabilitation benefit by 69.7%. Self-reported benefits included increase in fitness, quality of life, confidence and social contact.

CONCLUSION

A high proportion of patients perceived sporting activity as beneficial. Patients exercising before injury were more likely to exercise after injury. All inpatients were introduced to sport by staff, emphasising the importance of this rehabilitation opportunity in planning in-patient care.

Catheter policies for management of long term voiding problems in adults with neurogenic bladder disorders

BACKGROUND

Management of the neurogenic bladder has the primary objectives of maintaining continence, ensuring low bladder pressure (to avoid renal damage) and avoiding or minimising infection. Options include intermittent urethral catheterisation, indwelling urethral or suprapubic catheterisation, timed voiding, use of external catheter (for men), drug treatment, augmentation cystoplasty and urinary diversion.

OBJECTIVES

To assess the effects of using different types of urinary catheters and external (sheath) catheters in managing the neurogenic bladder, compared to alternative management strategies or interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group specialised register (searched 11 June 2003). We sought additional trials from other sources such as reference lists of relevant articles and contacting consultants in Spinal Cord Injury Centres throughout the United Kingdom.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials comparing methods of using catheters to manage urinary voiding in people with neurogenic bladder.

DATA COLLECTION AND ANALYSIS

Abstracts were independently inspected by the reviewers and full papers were obtained where necessary.

MAIN RESULTS

Approximately 400 studies were scrutinised. No trials were found that met the inclusion criteria, and five studies were excluded from the review.

REVIEWERS' CONCLUSIONS

Despite a comprehensive search no evidence from randomised or quasi-randomised controlled trials was found. It was not possible to draw any conclusions regarding the use of different types of catheter in managing the neurogenic bladder.

Pyogenic liver abscess

BACKGROUND

A current assessment of liver abscesses should allow for better understanding of the pathogenesis of the disease and improve the effectiveness of diagnosis and treatment. Amebic liver abscess occurs more commonly than pyogenic liver abscess on a worldwide basis. However, in the United States, pyogenic liver abscess predominates. The purpose of our study was to evaluate the etiology, management, morbidity, and mortality of all patients admitted to our medical center with diagnoses of pyogenic liver abscess between 1983 and 1996.

METHODS

A retrospective chart review was performed on all patients admitted to our medical center, Louisiana State University Medical Center, Shreveport, with diagnoses of pyogenic liver abscess.

RESULTS

Twenty patients were admitted with diagnoses of pyogenic liver abscess. The subjects were 65% (13/20) male and 65% (13/20) African-American and had an average age of 52 years. The most common presenting symptoms were fever and pain. The most common physical finding was right upper-quadrant tenderness. The most common etiologies of pyogenic liver abscesses were cryptogenic, trauma, and biliary, while portal vein was the source for only 10% of the cases. The right lobe of the liver was involved in 95% of the cases, and 70% of these liver abscesses were solitary. Computed tomography (CT)-and ultrasound-guided percutaneous drainage were performed in 85% (17/20) of patients with liver abscesses. One patient was treated by open drainage, three patients were treated with antibiotics alone, and three patients did not respond to aspiration and catheter placement, which subsequently required open drainage. The culture results were as follows: 50% were gram-negative organisms, 25% were gram-positive organisms, 10% were anaerobic organisms, and 15% of the abscess were sterile. Sixty percent of the positive abscess cultures were polymicrobial.

CONCLUSIONS

CT scan- and ultrasound-guided percutaneous drainage of pyogenic liver abscesses were safe and effective methods of treatment. The right lobe of the liver was involved in 95% of cases. Although no one species predominated, gram-negative bacteria were the most common organism cultured, and 60% of the abscesses were polymicrobial. There was no in-house mortality in this review.

Variability of Nt-proANP and C-ANP

BACKGROUND

Natriuretic peptides are frequently measured in patients with chronic cardiac failure (CCF). We set out to compare the variability of atrial natriuretic peptide (C-ANP) and its precursor N-terminal pro-ANP (Nt-proANP) to decide which would be more suitable for routine use.

METHODS

Ten males with compensated CCF (age range 62-76 years) were studied, with matched controls. Blood was withdrawn every 2 min for 90 min from a forearm vein, and plasma C-ANP and Nt-proANP were measured by radioimmunoassay.

RESULTS

Levels were elevated in the patient group [C-ANP: median 268 (range 171-423) vs. 40 (28-56) ng L-1, P < 0.0002 Mann-Whitney U-test; Nt-proANP: 1955 (562-4451) vs. 621 (409-961) pmol L-1, P < 0.003]. A similar number of 'peaks' was observed in both groups with both peptides, about one every 10 min, and their relative height was similar in both groups. Variability was greater for C-ANP than for Nt-proANP in both patients [coefficient of variation of means 51 (range 36-70) vs. 3.6 (2.1-6.2)%, P < 0.01; sign test] and controls [65 (49-83) vs. 8.9 (4.7-13.5)%, P < 0.01].

CONCLUSION

Nt-proANP is less variable than C-ANP and hence more suited for diagnostic or prognostic use.

Rrb1p, a yeast nuclear WD-repeat protein involved in the regulation of ribosome biosynthesis

Ribosome biogenesis is regulated by environmental cues that coordinately modulate the synthesis of ribosomal components and their assembly into functional subunits. We have identified an essential yeast WD-repeat-containing protein, termed Rrb1p, that has a role in both the assembly of the 60S ribosomal subunits and the transcriptional regulation of ribosomal protein (RP) genes. Rrb1p is located in the nucleus and is concentrated in the nucleolus. Its presence is required to maintain normal cellular levels of 60S subunits, 80S ribosomes, and polyribosomes. The function of Rrb1p in ribosome biogenesis appears to be linked to its association with the ribosomal protein rpL3. Immunoprecipitation of Rrb1p from nuclear extracts revealed that it physically interacts with rpL3. Moreover, the overproduction of Rrb1p led to increases in cellular levels of free rpL3 that accumulated in the nucleus together with Rrb1p. The concentration of these proteins within the nucleus was dependent on ongoing protein translation. We also showed that overexpression of RRB1 led to an increase in the expression of RPL3 while all other examined RP genes were unaffected. In contrast, depletion of RRB1 caused an increase in the expression of all RP genes examined except RPL3. These results suggest that Rrb1p regulates RPL3 expression and uncouples it from the coordinated expression of other RP genes.

Adult human olfactory stem cells

The location of stem cells within the adult CNS makes them impractical for surgical removal and autologous transplantation. Their limited availability and histocompatibility issues further restrict their use. In contrast, olfactory neuroepithelium (ONe) located in the nasal passageways has a continuous regenerative capability and can be biopsied readily. To investigate the potential of human ONe to provide viable populations of pluripotent cells, ONe was harvested from cadavers 6-18 h postmortem, dissociated, plated and fed every 3-4 days. Heterogeneous populations of neurons, glia, and epithelia were identified with lineage-specific markers. After several weeks, 5-10% of the cultures produced a population of rapidly dividing cells, which in turn, produced neurospheres containing at least two subpopulations based on neuronal and glial specific antigens. Most contained one or more neuronal markers; a few were positive for A2B5 and/or GFAP. To determine if growth modulators would affect the neurosphere forming cells, they were exposed to dibutyryl-cAMP. The nucleotide reduced cell division and increased process formation. Although the cells had been passaged more than 70 times, their viability remained constant as shown by the MTT viability index. Donor age or sex were not limiting factors, because neurospheres have been established from cadavers of both sexes from 50 to 95 years old at time of death. The ex vivo expansion of these cells will provide a patient-specific population of cells for immunological, genetic and pharmacological evaluation. Our long-term goal is to determine the utility of these cells to facilitate CNS repair.

Vasoconstriction to endogenous endothelin-1 is impaired in patients with type II diabetes mellitus

Endothelin-1 has potent vasoconstrictor and vasopressor actions contributing to basal vascular tone and maintenance of blood pressure acting predominantly through endothelin-A receptors. Endothelin antagonists may be of value in the treatment of hypertension and heart failure. However, the role of endothelin-1 in the regulation of vascular tone and the potential benefits of endothelin antagonists in non-insulin-dependent diabetes mellitus (Type II diabetes) are less clear. Vasoconstriction to exogenous endothelin-1 is impaired in Type II diabetes. The purpose of this study was to determine whether vasoconstriction to endogenous endothelin-1 acting through the endothelin-A receptor is impaired in Type II diabetes. In ten patients with Type II diabetes and nine controls the endothelin-A receptor antagonist BQ123 was infused intra-arterially at 100 nmol/min for 60 min followed by normal saline for 30 min. Forearm blood flow was measured using venous occlusion plethysmography. Control subjects showed gradual onset of vasodilation in response to BQ123 (P < 0.001). Diabetic subjects, however, showed no significant response (P > 0.05). There was a significant difference between the diabetic and control groups (P < 0.05). Blockade of the endothelin-A receptor is associated with impaired vasodilation in Type II diabetes indicating vasoconstriction to endogenous endothelin-1 mediated by the endothelin-A receptor is impaired.

Primary squamous cell carcinoma of the parotid gland: the importance of correct histological diagnosis

BACKGROUND

Primary squamous cell carcinoma of the parotid is an uncommon, aggressive malignancy with a poor prognosis. The diagnosis is made after excluding metastasis from other sites in the head and neck or other primary malignancies of the parotid.

METHODS

Tumor registry data from 1974 to 1994 were reviewed at three University of Louisville-affiliated hospitals. Of 370 parotid tumors, 40 (11%) were initially classified as squamous cell carcinoma of the parotid. Chart review and histological specimen re-examination were conducted to confirm diagnosis.

RESULTS

Only 8 (2%) of the 370 cases, were considered true primary squamous cell carcinoma of the parotid. Patients with metastases to the parotid from primary sites within the upper aerodigestive tract or skin of the head and neck region and high-grade mucoepidermoid carcinoma of the parotid were excluded. Facial nerve dysfunction was a presenting complaint in three patients. Two patients presented with American Joint Committee on Cancer (AJC) clinical stage III disease and six with AJC stage IV disease. All patients were treated with total parotidectomy and radiotherapy. One patient (12%) is alive and free of disease. Median survival was 13 months (range, 11 months-7 years).

CONCLUSIONS

Primary squamous cell carcinoma of the parotid is uncommon, occurring in 2% of parotid neoplasms at our institution. This is an aggressive malignancy, usually presenting in advanced stage and with facial nerve involvement or cervical metastases. Prognosis is poor even with radical surgery and adjunctive radiotherapy. Careful clinical and histological review is necessary to differentiate primary squamous cancer of the parotid from metastases or other primary parotid malignancy.

Combining serial analysis of gene expression and array technologies to identify genes differentially expressed in breast cancer

Several methods have been used recently to determine gene expression profiles of cell populations. Here we demonstrate the strength of combining two approaches, serial analysis of gene expression (SAGE) and DNA arrays, to help elucidate pathways in breast cancer progression by finding genes consistently expressed at different levels in primary breast cancers, metastatic breast cancers, and normal mammary epithelial cells. SAGE profiles of 21PT and 21MT, two well-characterized breast tumor cell lines, were compared with SAGE profiles of normal breast epithelial cells to identify differentially expressed genes. A subset of these candidates was then placed on an array and screened with clinical breast tumor samples to find genes and expressed sequence tags that are consistently expressed at different levels in diseased and normal tissues. In addition to finding the predicted overexpression of known breast cancer markers HER-2/neu and MUC-1, the powerful coupling of SAGE and DNA arrays resulted in the identification of genes and potential pathways not implicated previously in breast cancer. Moreover, these techniques also generated information about the differences and similarities of expression profiles in primary and metastatic breast tumors. Thus, combining SAGE and custom array technology allowed for the rapid identification and validation of the clinical relevance of many genes potentially involved in breast cancer progression. These differentially expressed genes may be useful as tumor markers and prognostic indicators and may be suitable targets for various forms of therapeutic intervention.

Forearm reactive hyperaemia is not mediated by nitric oxide in healthy volunteers

AIMS

To determine the role of nitric oxide (NO) in forearm reactive hyperaemia in healthy human subjects.

METHODS

Ten healthy subjects aged 19-34 years underwent brachial artery cannulation. Forearm circulatory arrest was achieved by means of an upper arm cuff inflated to 200 mmHg for 5 min. The blood flow responses during reactive hyperaemia were measured using venous occlusion plethysmography following a 10 min intra-arterial infusion of 8 micromol min-1 N-monomethyl L-arginine (L-NMMA) and following matching placebo administered in random order. Results were analysed by repeated measures anova and t-tests.

RESULTS

L-NMMA resulted in a significant reduction of basal forearm blood flow indicating inhibition of basal NO release (P=0.005). There was no significant difference between the blood flow responses during reactive hyperaemia following L-NMMA and placebo (P=0.97).

CONCLUSIONS

Nitric oxide production does not make a significant contribution to the vasodilatation associated with reactive hyperaemia in the human forearm.