Ex-vivo expansion of hematopoietic progenitor cells: preliminary results in breast cancer

Ex-vivo expanded progenitor cells have been proposed as a source of cells to support high-dose chemotherapy and to decrease or eliminate the period of neutropenia following transplantation. To date, no clinical studies using ex vivo expanded cells, have demonstrated any decrease in the time to neutrophil or platelet recovery, although a number of clinical studies have been performed using a variety of growth factor cocktails and culture conditions. Over the past 6 years we have developed a static culture system that results in optimal expansion of myeloid progenitor cells. We have initiated a clinical study to evaluate this culture system in breast cancer patients receiving peripheral blood progenitor cells (PBPC) to support high-dose chemotherapy. CD34 selected cells were cultured for 10 days in 800 ml of defined media (Amgen Inc.) containing 100 ng/ml each of rhSCF, rhG-CSF and rhMGDF in 1L teflon bags (American Fluoroseal) at 20,000 to 50,000 cells per ml. After culture the cells were washed with 3 volumes of PBS to remove all media and growth factors and reinfused on day 0 of transplant followed by daily administration of rhG-CSF. On day +1 the patients received an unexpanded PBPC product to ensure the durability of the graft. Patients transplanted with expanded PBPC cells recovered neutrophil counts (ANC > 500/microl) as early as day 4 post transplant with a median of 6 days (range 4 to 14 days). In comparison, our historical control group of patients (N=175) had a median time to neutrophil engraftment of 9 days (range 7 to 24 days). A second cohort of patients were transplanted with expanded cells alone and a similar rapid engraftment was obtained. The first patients are now over 70 days post transplant with durable engraftment. No effect on platelet recovery has been observed in any patients to date. These data demonstrate that PBPC expanded under the conditions defined can significantly shorten the time to engraftment of neutrophils.

Microvessel precursor smooth muscle cells express head-inserted smooth muscle myosin heavy chain (SM-B) isoform in hyperoxic pulmonary hypertension

The present study analyzes smooth muscle myosin heavy chain (SMMHC) expression as lung microvascular precursor smooth muscle cells (PSMCs), cells derived from fibroblasts and intermediate cells (immature SMCs), acquire a smooth muscle phenotype in an in vivo model of pulmonary hypertension (PH). Because of the unique contractile properties of the SMMHC isoform SM-B, we analyzed its expression in the microvessels (<100 micrometers diameter) and in larger vessels (100-700 micrometers) quantitatualy by the labeled [strept]avidin-biotin technique (day 1-28), and related this to cell phenotype by transmission microscopy and protein A-gold labeling (at day 28). Airway SMCs of the normal and hypertensive lung uniformly expressed SM-B whereas vascular SMC expression was heterogeneous. Thus, in some large arteries (and veins) SMCs contained cells expressing SM-B while in others all the cells were immunonegative. Microvascular cells expressing SM-B (arteries and veins) were rare in normal lung and numerous in PH, increasing as wall muscle developed in smaller segments with time. As in large vessels, some microvessels had immunopositive cells and others only negative ones. Ultrastructural analysis confirmed that the SMCs of bronchial vessels, and the septal SMCs adjoining alveolar ducts, contained dense filament arrays decorated with SM-B. While the PSMC processes of the normal lung contained sparse filaments decorated with SM-B, these cells expressed dense filament arrays in PH. Fibroblasts migrating to align around the microvessels also expressed SM-B but in the absence of a filament network. For the first time, we demonstrate in vivo that newly developed microvascular PSMCs express the SMMHC SM-B isoform in PH.

Tissue distribution of tramadol and metabolites in an overdose fatality

Tramadol (Ultram) is a centrally acting, synthetic analgesic agent. Although it has some affinity for the opiate receptors, tramadol is believed to exert its analgesic effect by inhibiting the re-uptake of norepinephrine and serotonin. There are several published cases of tramadol's involvement in drug-related deaths and impairment. Reports of deaths involving tramadol alone with associated tissue concentrations are rare. This report documents a case in which tramadol overdose was identified as the cause of death. The following tramadol concentrations were found in various tissues: blood, 20 mg/L; urine, 110.2 mg/L; liver, 68.9 mg/kg; and kidney, 37.5 mg/kg. Tissue distributions of the two primary metabolites, N-desmethyl and O-desmethyl tramadol, are also reported. In each tissue or fluid except urine, the tramadol concentration was greater than either metabolite, consistent with other reports of drug-impaired drivers and postmortem cases. The O-desmethyl metabolite concentration was greater than the N-desmethyl metabolite concentration in all tissues; this is in contrast to other postmortem reports, in which the majority of cases report concentrations of O-desmethyl as less than those of N-desmethyl. This may be useful as an indicator of time lapse between ingestion and death.

Stent design favorably influences the vascular response in normal porcine coronary arteries

OBJECTIVES

The purpose of this study was to compare the arterial response following implantation of a stainless-steel, balloon-expandable, tubular slotted stent with that of a novel computer-designed, multi-cellular stent in normal porcine coronary arteries.

BACKGROUND

Intracoronary stent placement has evolved into the primary strategy for percutaneous revascularization of symptomatic coronary arterial lesions. Presently there is intense interest in developing new stent designs to improve stent delivery and biocompatability.

METHODS

Computer-assisted design was utilized to develop a balloon-expandable stent with symmetric expansion properties, uniform arterial wall coverage, longitudinal flexibility and radial strength. Quantitative coronary angiography and histological assessment of the stented arteries was used to evaluate the acute and chronic vascular responses to a stainless-steel, balloon-expandable, tubular slotted stent as compared to the computer-designed BX stent in the normolipemic swine.

RESULTS

Forty stents (24 BX, 16 tubular slotted) were implanted in 19 miniature swine at a mean inflation pressure of 9 atm using identical delivery systems. Eight of the BX and none of the tubular slotted stents were post-dilated with a non-compliant balloon at 12-14 atm. The mean stent-to-artery ratio was similar for the BX (1.03 +/- 0.06) and tubular slotted (1.04 +/- 0.11; p = 0.59) designs. Protrusion or asymmetric radial flaring of a strut at the stent margin was present in 1 of 23 BX stents (4.3%) and 10 of 15 tubular slotted stents (66.7%; p < 0.0001). The mean arterial injury score was significantly less for the BX stent (0.2 +/- 0.2) as compared with the tubular slotted stents (0.4 +/- 0.4; p = 0.025). At 3 days, thrombus area was similar for the BX and tubular slotted designs (0.42 +/- 0.16 mm2 versus 0.44 +/- 0.18 mm2, respectively; p = 0.88). The mean neointimal area was significantly less for the BX at 2 months (1.09 +/- 0.25 mm2 versus 2.93 +/- 2.26 mm2 in the tubular slotted stent) and at 6 months (1.10 +/- 0.26 mm2 versus 2.07 +/- 0.65 mm2 in the tubular slotted stent; p = 0.01), resulting in approximately 50% less in-stent stenosis.

CONCLUSIONS

The arterial response to a balloon-expandable stent can be favorably influenced by computer-assisted modification of design in an experimental model. Further study is warranted to determine the impact of stent design upon clinical in-stent restenosis.

Low-dose lansoprazole provides greater relief of heartburn and epigastric pain than low-dose omeprazole in patients with acid-related dyspepsia

AIM

To compare the relative efficacies of lansoprazole 15 mg o.m. and omeprazole 10 mg o.m. in relieving heartburn and epigastric pain in patients with acid-related dyspepsia. In addition, the study compared the safety profiles of the two treatments.

METHODS

This double-blind, parallel group, randomised, multicentre study was conducted in 52 general practices in the UK. A total of 609 patients was recruited, 562 of whom were eligible for inclusion in the intention-to-treat analysis. All of the patients had experienced at least mild heartburn or mild epigastric pain persistently on at least 4 of the previous 7 days; patients with severe symptoms were excluded. 283 patients received lansoprazole 15 mg and 279 received omeprazole 10 mg, both for 4 weeks. The main efficacy measure was relief of symptoms, based on physician assessments.

RESULTS

In the intention-to-treat population, a complete relief of overall primary symptoms of dyspepsia was achieved after 2 weeks in 53% of patients receiving lansoprazole and in 41% of patients receiving omeprazole (P = 0.007). After 4 weeks, 59% of the lansoprazole group and 51% of the omeprazole group had achieved complete symptom relief (P = 0. 078). Antacids were taken for additional relief of symptoms in fewer patients given lansoprazole compared to the omeprazole group in the third and fourth weeks (P = 0.035) and also significantly fewer antacids were taken by patients in the lansoprazole group compared with patients in the omeprazole group (P = 0.033). The proportion of patients reporting adverse events was similar in both groups.

CONCLUSION

Low-dose lansoprazole is more effective than low-dose omeprazole in the treatment of patients with mild heartburn or epigastric pain in general practice.

Obstacles to timely neonatal screening in North Thames

OBJECTIVE

To assess the timeliness of neonatal (Guthrie card) screening in North Thames, and to identify the most effective ways of improving it.

DESIGN

Analysis of information routinely collected in the course of neonatal screening; reanalysis of published data on blood phenylalanine concentration in phenylketonuria (PKU) over the first two weeks; simulation studies on the impact of different interventions.

SUBJECTS

100,690 infants born over one year and screened at Great Ormond Street Hospital NHS Trust.

OUTCOME MEASURE

Interval between birth and reading PKU screen results.

RESULTS

Although 75% of samples (district range 55-91%) were collected by day 7, only 81% had arrived in the laboratory seven days later (range 57-96%). The average interval between birth and reading results was 14.5 days, with only 9.7% read by day 10. Samples could be collected from day 4 without significant impact on false negative rates for PKU. If samples were collected from day 4 and posted promptly (second class), the average interval between birth and reading results could be reduced to 9.3 days. If first class mail were used and the laboratory operated on Saturdays, and used assays that could be read the same day rather than bacterial inhibition assays, the average would be 7.8 days, with 96% read by day 10.

CONCLUSION

Timeliness of neonatal screening shows unacceptable variation between districts, and delays in dispatch of specimens to the laboratory. Same day, first class posting should be introduced, and samples could be collected between days 4 and 8.

Patient information systems that tailor to the individual

The potential of computers in patient education has been well described by Skinner et al. One of their recommendations was for more personalized systems. In this article we discuss how computer-based patient information systems can provide material that is tailored to the individual, giving a number of examples of systems developed in Scotland. We review some of the techniques used in developing tailored systems, and consider the evidence to date as to their efficacy.

Lipid diffusion in the plasma membrane of ram and boar spermatozoa during maturation in the epididymis measured by fluorescence recovery after photobleaching

Maturation of spermatozoa in the epididymis involves remodelling of many protein and lipid components of the plasma membrane. In this investigation we have examined whether (a) diffusion of lipid molecules in the surface membrane changes during epididymal maturation; (b) diffusion is spatially restricted; and (c) differences in lipid diffusion can be related to known changes in membrane composition. For this purpose we have used the technique of fluorescence recovery after photobleaching (FRAP) to measure diffusion of the lipid reporter probe ODAF (5-(octa-decanoyl)aminofluorescein) in spermatozoa from two species: ram, where substantial changes in membrane lipids occur during passage through the epididymis, and boar, where there are relatively few changes. Results on ram spermatozoa show that between the testis and cauda epididymidis, diffusion coefficients values (D) for ODAF increase significantly in all the surface domains. Percentage recovery values (%R) remain constant irrespective of maturational status. In boar spermatozoa, however, D and %R values do not change significantly between epididymal regions. Cholesterol, which has widespread effects on the behaviour of lipid molecules in cell membranes, was visualized by binding of filipin. In both species filipin was concentrated over the acrosomal domain and cytoplasmic droplet of testicular spermatozoa, but in the epididymis it had a heterogenous distribution over the whole head and tail. These results are discussed in relation to the establishment and maintenance of lipid domains in spermatozoa and their influence on development of fertilizing capacity.

Structural elucidation studies of erythromycins by electrospray tandem mass spectrometry

Erythromycin A (EryA) was studied by electrospray ionisation tandem mass spectrometry (ESI-MS/MS) with the aim of developing a methodology for the structural elucidation of novel erythromycins developed by biological synthetic methods. Skimmer dissociation along with sequential mass spectrometry studies (up to MS5) have been employed in this study. In the low-resolution MS/MS analysis of the polyketides, there are several fragment ions that are easily assigned to various neutral losses. These have all been confirmed by accurate-mass measurements. There is also a series of peaks due to ring opening and fragmentation that can only be assigned by high-resolution MSn analysis. Further experiments were performed in deuterated media (D2O/CD3OD 50%) which, along with the high-resolution MSn of erythromycin analogues, has enabled us to identify some of the steps in the ring fragmentation, particularly the loss of the polyketide starter acid. This is an essential step for determining structural alterations in the novel polyketides, but further labelling experiments and studies on more erythromycin analogues are required before the complete fragmentation pathway can be confirmed.

Does teaching during a general practice consultation affect patient care?

BACKGROUND

General practice differs from hospital medicine in the personal nature of the doctor-patient relationship and in the need to address social and psychological issues as well as physical problems. Recent changes in undergraduate medical education have resulted in more teaching and learning taking place in general practitioner (GP) surgeries.

AIM

To explore patients' experiences of attending a surgery with a medical student present.

METHOD

A questionnaire was designed, based on semi-structured interviews. Questionnaires were posted to patients who had attended teaching surgeries in London and Newcastle-upon-Tyne.

RESULTS

Four hundred and eighty questionnaires were sent; of these, 335 suitable for analysis were returned. The response rate in Newcastle was 79%, and in London 60%. Ninety-five per cent of responders agreed that patients have an important role in teaching medical students. Patients reported learning more and having more time to talk, however, up to 10% of responders left the consultation without saying what they wanted to say and 30% found it more difficult to talk about personal matters.

CONCLUSION

The presence of a student has a complex effect on the general practice consultation. Future developments in medical education need to be evaluated in terms of how patient care is affected as well as meeting educational aims.

Structural elucidation studies of erythromycins by electrospray tandem mass spectrometry II

Erythromycin A (EryA), sec-butyl erythromycin B (SEryB), oleandomycin (Olean) and a synthetic derivative, roxithromycin (Rox), were used to investigate the fragmentation of polyketide macrolide antibiotics by collision induced dissociation (CID) tandem mass spectrometry (MS/MS). Analyses were performed with two commercially available mass spectrometers: a Q-TOF hybrid quadrupole time-of-flight instrument and a BioApex II (4.7 Tesla) Fourier transform ion cyclotron resonance (FTICR) instrument both equipped with electrospray ionisation (ESI) sources. One of the first fragmentation processes is the loss of an H(2)O molecule from the [M+H](+) ion. EryA has three hydroxyl groups on the polyketide ring and loses three H(2)O molecules during CID. This study indicates that these facts are not necessarily related. Deuterium exchange experiments were carried out in order to isotopically label free hydroxyl groups. (18)O-exchange experiments were also carried out in order to label the carbonyl group at the 9-position. In EryA and its analogue the first H(2)O loss shifts in mass from loss of 18 Da to loss of 20 Da in deuterated solvents. For both molecules the loss also shifts in mass from loss of 18 Da to loss of 20 Da during the (18)O-exchange experiments. This suggests that the first loss of H(2)O is from the 9-position carbonyl group, indicating that this, and not the nitrogen of the amino sugar, is the site of protonation of the activated MH(+) ions. For Rox the initial loss of H(2)O is replaced by loss of the 9-position oxime group, the rest of the fragmentation sequence being the same as for EryA. For Olean, there is no H(2)O loss from the parent ion. The results have allowed the proposal of a mechanism for the first loss of H(2)O in the EryA MS/MS fragmentation.

Accuracy relationship of blood pressure devices between the AAMI SP 10 standard and the British Hypertension Society protocols

This article analyzes and compares the accuracy requirements for the AAMI SP10 standard and the British Hypertension Society (BHS) protocol for evaluation of blood pressure devices. It generates a theoretical mapping relationship between the AAMI accuracy criteria and the BHS grading system, using these requirements. It locates within that relationship the analyses of blood pressure devices in the literature that have used both of these standards from 1990, when the original BHS protocol was published and the original AAMI SP10 standard was available, through the end of 1997. Comparison of 67 paired entries thus provides a framework for consideration of the concept of accuracy implicit in both systems against empirical testing of devices. Results of accuracy testing with each of the two systems should be consistent and convertible to the other system. The discrepancies between the theoretic combination of accuracy standards and empirical testing for each standard separately suggest a variety of difficulties in determining accuracy, such as statistical variability and test procedure variations. Using a chi-square test for matched samples, the discrepancies are found statistically significantly different (chi-square = 28.96, p < 0.001). Although there are fewer literature reports using the revised BHS protocol, the differences in the two systems suggest a potential need for an international agreement on accuracy determinations of blood pressure devices.

The accessibility of information systems for patients: use of touchscreen information systems by 345 patients with cancer in Scotland

AIM

To examine cancer patients' use, and satisfaction with touchscreen information systems. By examining the experience of subgroups, to address issues of equality of access.

PATIENTS

345 patients starting radiotherapy at the Beatson Oncology Centre (BOC), Glasgow.

METHODS

Patients were invited to use a touchscreen computer at the start of treatment. They were sent a printout of what they saw on screen. Patients had open access to the system. Data were collected at recruitment, intervention, 3 weeks and 3 months. Predictor variables included: patients' demographics, information preferences, technology use, and psychological state. Outcome variables included: use and views of the computer and printout.

RESULTS

Younger, broadsheet readers with previous computer use were more likely to find the system easy to use. Older, tabloid readers were more likely to find the content new and relevant.

DISCUSSION

We need to make systems adapt to users' different needs. More effort should be made to provide affordable information for older, generally less literate and technologically less literate groups in suitable locations.

Evaluations of aggressive women: the effects of gender, socioeconomic status, and level of aggression

Research finds gender differences in aggression and suggests that female violence is viewed differently from male violence. Participants were 94 female and 38 male students from a mid-size public university in the Southeast. Participants read a mock trial and answered questions about their attitudes concerning an aggressor in the scenario. The study was a 2 (male or female) by 2 (high socioeconomic status or low socioeconomic status) by 2 (verbal aggression or physical aggression) between-subjects factorial design. The participants responded to a revised version of the Attitudes Toward Women Scale (Nelson, 1988). As hypothesized aggressive women were evaluated more negatively than aggressive men and participants evaluated the female aggressor who used physical aggression more negatively than the female who used verbal aggression. The hypothesis that the female aggressor would be perceived as more in need of counseling than the male aggressor was not supported. Contrary to another hypothesis, respondents did not evaluate higher socioeconomic status aggressors more negatively than those of lower status. As hypothesized people with traditional views of women evaluated the female aggressor more negatively than people with more liberal views of women, and liberal participants evaluated the male and female aggressors similarly. The more negative evaluation of female aggressors and, in particular, females who use physical aggression, may result in unfair treatment of such females. These social biases may cloud perceptions of aggressive females, suggesting that their actions are more inappropriate than those of a male who committed the same act.

Management of gastroesophageal reflux disease: the primary care strategy

Gastroesophageal reflux disease (GERD) is a common problem in the community and in general practice. General practitioners and family physicians need to understand patients' reasons for consultation and also be aware of alarm symptoms suggestive of serious disease. A primary care management strategy for GERD is proposed, in which the place of endoscopic and other investigations is defined, the role of lifestyle modification discussed, and recommendations for longer-term therapy and management are made.