Findings from aCGH in patients with congenital diaphragmatic hernia (CDH): a possible locus for Fryns syndrome

Congenital diaphragmatic hernia (CDH) is a common and often devastating birth defect that can occur in isolation or as part of a malformation complex. Considerable progress is being made in the identification of genetic causes of CDH. We applied array-based comparative genomic hybridization (aCGH) of approximately 1Mb resolution to 29 CDH patients with prior normal karyotypes who had been recruited into our multi-site study. One patient, clinically diagnosed with Fryns syndrome, demonstrated a de novo 5Mb deletion at chromosome region 1q41-q42.12 that was confirmed by FISH. Given prior reports of CDH in association with cytogenetic abnormalities in this region, we propose that this represents a locus for Fryns syndrome, a Fryns syndrome phenocopy, or CDH.

62 REPROGRAMMING EVENTS AND DEVELOPMENTAL COMPETENCE OF RHESUS MONKEY EMBRYOS PRODUCED BY SOMATIC CELL NUCLEAR TRANSFER

Successful reprogramming of somatic cell nuclei after nuclear transfer requires active remodeling by factors present in the nonactivated cytoplast. High levels of maturation promoting factor (MPF) activity are associated with this remodeling process which includes nuclear envelope breakdown (NEBD), premature chromosome condensation (PCC), and spindle formation. In this study, we examined the extent of nuclear remodeling in monkey somatic cell nuclear transfer (SCNT) embryos by monitoring the dynamics of lamin A/C appearance, as detected immunocytochemically, following fusion of donor cells with recipient cytoplasts. In the control, intracytoplasmic sperm injection (ICSI) fertilized embryos, lamin A/C was readily detected at the pronuclear stage but disappeared in early cleaving embryos only to reappear by the morula stage in association with the activation of the embryonic genome. We initially documented lack or incomplete NEBD and PCC in SCNT embryos in the form of retention of lamin A/C signal emanating from the donor nucleus. This observation was consistent with premature cytoplast activation due to the manipulation procedures. SCNT embryos produced by this approach typically arrested at the morula stage. Significant modifications in nuclear transfer protocols were then employed. Optimization of procedures resulted in robust NEBD and PCC, as indicated by loss of lamin A/C signal from the donor cell. Also, significant improvement of SCNT embryo development in vitro was observed, with a markedly improved blastocyst formation rate (21%). Several different fetal and adult somatic cell types screened as nuclear donors supported blastocyst development. SCNT blastocysts displayed a pattern of Oct-4 expression similar to that of sperm fertilized counterparts, indicative of efficient nuclear reprogramming. However, no pregnancies were established following a preliminary trial of 8 embryo transfers with 48 cloned embryos. Nevertheless, our results represent a breakthrough in efforts to produce cloned monkeys and should provide the resources required for the derivation of embryonic stem cells from SCNT blastocysts.

Current and future water issues in the Oldman River Basin of Alberta, Canada

Long-term trends in alpine and prairie snow pack accumulation and melt are affecting streamflow within the Oldman River Basin in southern Alberta, Canada. Unchecked rural and urban development also has contributed to changes in water quality, including enhanced microbial populations and increased waterborne pathogen occurrence. In this study we look at changing environment within the Oldman River Basin and its impact on water quality and quantity. The cumulative effects include a decline in net water supplies, and declining quality resulting in increased risk of disease. Our data indicates that decreases in the rate of flow of water can result in sedimentation of bacterial contaminants within the water column. Water for ecosystems, urban consumption, recreation and distribution through irrigation is often drawn from waterholding facilities such as dams and weirs, and concern must be expressed over the potential for contaminate build-up and disproportionate potential of these structures to pose a risk to human and animal health. With disruption of natural flow rates for water resulting from environmental change such as global warming and/or human intervention, increased attention needs to be paid to use of best management practices to protect source water supplies.

Use of in-stream reservoirs to reduce bacterial contamination of rural watersheds

An investigation into bacterial water quality problems was conducted on an interconnected stream and irrigation system within the Oldman River Basin of southern Alberta, Canada. Levels of indicator bacteria, including fecal coliforms, generic Escherichia coli and fecal streptococci, were repeatedly measured in streams and irrigation return canals of this river basin during the summer of 2001. Bacterial-loading segments of the irrigation/stream system were identified through a comparison of indicator bacteria levels in pairs of upstream and downstream sites. Mann-Whitney U-tests indicated that reservoirs significantly reduced bacterial counts. A temporal comparison of E. coli counts and river discharges suggested that these indicator bacteria do not originate from within in-stream sediments. Site-specific as well as cumulative inputs from a variety of non-point sources are likely to be responsible for the high downstream levels of indicator bacteria in this water system. The use of management practices such as in-stream reservoirs may significantly reduce contamination, and increase the quality of limited rural water supplies to allow their reuse and safe discharge into downstream water sources. The identification of bacteria-loading river/canal segments could also be used to prioritize restoration projects.

Characterization of prolyl iminopeptidase-deficient Neisseria gonorrhoeae

Prolyl iminopeptidase (PIP) is an enzyme produced by Neisseria gonorrhoeae, the detection of which is incorporated into several commercial test panels. In this report we describe two distinct mutations in the pip gene which account for the loss of PIP activity.

Endovascular embolization of a traumatic arteriovenous fistula of the superficial temporal artery

Arteriovenous fistula of the superficial temporal artery is a rare condition most commonly caused by trauma. Traditional surgical treatment has been superseded by endovascular embolization. We present the case of a 40 year-old man with a traumatic arteriovenous fistula of the superficial temporal artery who was treated by endovascular embolization. The advantages of this approach are discussed, along with a brief history of the condition.

Determination of the Electron-Antineutrino Angular Correlation Coefficient a0 in Unpolarized Neutron β-Decay

The coefficient a 0 has been derived from a measurement of the integral spectrum of recoil protons stored in a quasi-Penning trap with inhomogeneous magnetic field and adiabatic focusing onto an electro-static mirror of potential variable in 10 V steps between 0 V and 850 V. Correction for incomplete transfer of energy from transverse to longitudinal degrees of freedom, and the violation of the adiabatic conditions on reflection at the mirror, is carried out by alternately measuring the spectrum at trapping times of 1 ms and 2 ms. The results a 0 = -0.1054 ± 0.0055 and |λ | = 1.271 ± 0.018 are comparable in precision with existing measurements of a 0.

Proposed Measurement of the Beta-Neutrino Correlation in Neutron Decay

Currently, the beta-neutrino asymmetry has the largest uncertainty (4 %) of the neutron decay angular correlations. Without requiring polarimetry this decay parameter can be used to measure λ (ga/gv ), test Cabibbo-Kobayashi-Maskawa (CKM) unitarity limit scalar and tensor currents, and search for Charged Vector Current (CVC) violation. We propose to measure the beta-neutrino asymmetry coeffcient, a, using time-of-flight for the recoil protons. We hope to achieve a systematic uncertainty of σa / a ≈ 1.0 %. After tests at Indiana University's Low Energy Neutron Source (LENS), the apparatus will be moved to the National Institute of Standards and Technology (NIST) where the measurement can achieve a statistical uncertainty of 1 % to 2 % in about 200 beam days.

Search for Radiative β-Decay of the Free Neutron

Results of the first experiment to search for the radiative decay mode of the free neutron are reported. The γ-spectrum was studied in the energy region from 35 keV to 100 keV in six Cs(Tl) scintillators, each set at an angle of 35° to, and shielded from, a central plastic scintillator electron detector. Triple coincidences were recorded with recoil protons detected in a micro-channel plate. A limit for the branching ratio BR < 6.9 × 10(-3) (90 % confidence level) was obtained, which is greater that the theoretical prediction by not more than a few tenths of a percent.

Detecting the Radiative Decay Mode of the Neutron

Beta decay of the neutron into a proton, electron, and electron antineutrino is occasionally accompanied by the emission of a photon. Despite decades of detailed experimental studies of neutron beta-decay, this rare branch of a fundamental weak decay has never been observed. An experiment to study the radiative beta-decay of the neutron is currently being developed for the NG-6 fundamental physics endstation at the National Institute of Standards and Technology (NIST) Center for Neutron Research (NCNR). The experiment will make use of the existing apparatus for the NIST proton-trap lifetime experiment, which can provide substantial background reduction by providing an electron-proton coincidence trigger. Tests and design of a detector for gamma-rays in the 10 keV to 200 keV range are under development. The need for a large solid-angle gamma-ray detector that can operate in a strong magnetic field and at low temperature has led us to consider scintillating crystals in conjunction with avalanche photodiodes. The motivation and experimental technique will be discussed.

Thoracofemoral bypass using spliced femoral vein with removal of an infected axillobifemoral bypass graft

A 63-year-old male underwent emergency repair of a ruptured juxtarenal aortic aneurysm via a transabdominal approach using an aorto-bi-iliac Dacron graft. This became infected. A right axillobifemoral bypass was placed and the infected graft was removed with oversewing of the aorta. The patient was re-admitted 8 months later with an infected axillobifemoral prosthesis. We harvested both femoral veins (FV) and spliced them to perform a left thoracobifemoral bypass with simultaneous explantation of the infected graft. The patient remains well with a patent graft 20 months post-operatively.

52 NUCLEAR REMODELING AFTER SOMATIC CELL NUCLEAR TRANSFER (SCNT) IN THE RHESUS MONKEY

Successful reprogramming of somatic cell nuclei after nuclear transfer requires active remodeling by factors present in the nonactivated cytoplast. High levels of maturation promoting factor (MPF) activity are associated with this remodeling process which includes nuclear envelope breakdown (NEBD), premature chromosome condensation (PCC), and spindle formation. MPF degradation, caused by fertilization or artificial activation, is in turn required for pronuclear formation and subsequent embryonic cleavage, and involves cyclin B catalyzed proteolysis by the proteasome system. In the rhesus monkey, SCNT results in the production of cleaving embryos, but development arrests at the morula stage presumably because of abnormal or incomplete reprogramming. We undertook this pilot study to examine the timing and extent of nuclear remodeling events (NEBD, PCC) in monkey SCNT embryos. The proteasome inhibitor MG-132 was employed to avoid or delay premature MPF degradation (Zhou et al. 2003 Science 302, 1179). Monkey fetal fibroblasts employed as nuclear donor cells were fused with nonactivated cytoplasts and incubated in the presence (n = 20) or absence (control; n = 35) of MG-132. Embryos were fixed and co-labeled with DAPI (DNA) and monoclonal antibody against lamin A/C (nuclear envelope). In monkey germinal vesicle-stage oocytes (n = 5) and zygotes (n = 6), a lamin A/C signal was detected at the nuclear periphery while matured MI (n = 6) and MII (n = 12) oocytes were negative for lamin A/C staining, consistent with the absence of a nuclear membrane. Donor fetal fibroblasts arrested at the G1 stage of the cell cycle exhibited a lamin A/C signal. Minimal or no changes were observed in donor nuclei within 1 h after fusion. The majority of control SCNT embryos sampled 4 h after fusion exhibited only slight chromatin condensation; however, they failed to form metaphase chromosomes. Positive lamin A/C staining indicated the presence of intact nuclear membranes. Following activation these SCNT embryos cleaved, but arrested at the 8–16 cell stage. In initial experimentation we determined the minimal efficient concentration of MG-132 to be 5 μM, that is capable of inhibiting first polar body extrusion during the MI–MII transition. Subsequent in vitro development to the blastocyst stage (53%) of fertilized oocytes treated with 5 μM MG-132 for up to 4 h was similar to that of nontreated controls. Incubation of SCNT embryos (n = 20) for 4 h with MG-132 resulted in robust chromosome condensation, spindle formation, and weak or partial lamin A/C signal. Our observations suggest that incomplete nuclear remodeling events in monkey SCNT embryos may be due to premature MPF inactivation perhaps caused by the fusion pulse. Future studies will address the developmental potential of monkey SCNT embryos exposed to MG-132. This work was supported by NIH grant NS04330, Core Grant RR00163 and a product donation from Ares Advanced Technology, Inc.

Bacterial pathogens in rural water supplies in Southern Alberta, Canada

Raw river and irrigation water in the Oldman River Basin in southern Alberta was tested for the presence of two bacterial pathogens, Escherichia coli O157:H7 and Salmonella spp., over the last 2 yr (2000-2001). The number of E. coli O157:H7 and Salmonella spp. isolated from raw water peaked during the summer months. While E. coli O157:H7 was only isolated from 11/802 (1.35%) of raw water samples over the entire sampling season in 2000 and from 16/806 (2.05%) of the samples in 2001, the pathogen was isolated one or more times from 10/35 (28.55%) sampling sites in 2000 and from 13/40 (32.55%) sampling sites in 2001. Salmonella was isolated from 44/802 (5.55%) of raw water samples in 2000 and from 122/822 (14.95%) of the samples in 2001; the pathogen was isolated one or more times from 25/35 (71.45%) sampling sites in 2000 and from 29/40 (72.55%) sampling sites in 2001. Certain sites had multiple pathogen isolations in the same year and from year to year. Salmonella Rublislaw was the most common Salmonella serovar isolated in both years, accounting for 52.45% of isolates.

Clonal haemopoiesis may occur after conventional chemotherapy and is associated with accelerated telomere shortening and defects in the NQO1 pathway; possible mechanisms leading to an increased risk of t-AML/MDS

The molecular pathogenesis of therapy-related acute myeloid leukaemia/myelodysplastic syndrome (t-AML/MDS) remains uncertain. However, clonal haemopoiesis may develop following stem cell transplantation and precede the development of t-AML/MDS. Moreover, accelerated telomere shortening may be induced by replicative stress or oxidative damage, leading to genomic instability, and inactivating polymorphisms of the gene encoding NADPH-quinone oxidoreductase (NQO1) are more frequently observed in patients with t-AML. We studied clonal haemopoiesis, telomere length and NQO1 status in 146 patients receiving conventional chemotherapy for non-myeloid malignancies. Clonal haemopoiesis was demonstrated in eight of 98 (8%) patients. Telomere length was reduced in patients following chemotherapy (n = 52) compared with controls (n = 42) (P < 0.001), particularly in those with clonal haemopoiesis (P < 0.002). Whilst there was a trend towards telomere shortening in control subjects polymorphic for NQO1-187Ser (n = 12), chemotherapy-exposed patients polymorphic for the NQO1-187Ser allele (n = 29) had significantly shorter telomeres (P < 0.001). Furthermore, chemotherapy-treated patients with the NQO1-187Ser, polymorphism were more likely to develop clonal haemopoiesis than patients with wild type NQO1 (odds ratio = 7; 1.16-42.6). We conclude that a switch to clonal haemopoiesis may occur after conventional chemotherapy and lead to accelerated telomere shortening. Patients with the NQO1-187Ser polymorphism have an increased risk of developing both clonal haemopoiesis and telomere shortening, which may partly explain the predisposition to t-AML in NQO1-187Ser null individuals.

A generalized extension to the Hounsell–Wilkinson head scatter model

Hounsell and Wilkinson (1997 Phys. Med. Biol. 42 1737-49) have demonstrated that the concept of a scatter-plane source can accurately describe head scatter in irregularly shaped fields produced by the MLC of an Elekta linear accelerator. In these linacs, the solid jaw is below the MLC set and plays no part on defining the view of the main source of head scatter, the flattening filter. A more complicated situation arises for linear accelerator head designs which incorporate a solid upper jaw pair with the MLC jaws further from the source. Application of the Hounsell and Wilkinson technique to these accelerator designs does not achieve the accuracy in the Elekta application. We present a generalized extension to Hounsell and Wilkinson's model and present results for typical treatment field shapes on a Siemens Primus linear accelerator.

Folic acid knowledge and use among relatives in Irish families with neural tube defects: an intervention study

BACKGROUND

Relatives in families where a child has a neural tube defect (NTD) may be at higher risk of having an affected child. Little is known of their level of knowledge and use of folic acid.

AIM

To carry out an intervention study intended to increase knowledge and use of folic acid among relatives.

METHODS

One hundred aunts and female first cousins (relatives of the proband) were interviewed by telephone before and after receiving an information pack.

RESULTS

At baseline, although knowledge of the benefits of folic acid was high (73%), use of folic acid was low (8.8%). After the intervention, knowledge increased and use went up to 19% (p < 0.05).

CONCLUSIONS

This study suggests that relatives in Irish NTD families have a high level of information about folic acid benefits. This awareness may not translate into action since the intervention produced only a modest increase in folic acid use overall. Future studies focussing on women who are planning a pregnancy may show larger benefits from intervention.

Delirium

Delirium is a common cause of mortality and morbidity in older people in hospital, and indicates severe illness in younger patients. Identification of risk factors, education of professional carers, and a systematic approach to management can improve the outcome of the syndrome. Physicians should be aware that delirium sufferers often have an awareness of their experience, which may be belied by their varying grasp of reality.

Response to imatinib in patients who relapse after allogeneic stem cell transplantation for chronic myeloid leukemia

We studied 128 patients with chronic myeloid leukemia (CML) relapsing after allogeneic stem cell transplantation (SCT). Disease at the time of treatment with Imatinib was in chronic phase (CP) in 51 patients, accelerated phase (AP) in 31 and blastic crisis (BC) in 46. Of the 51 patients in CP, 14 were in cytogenetic and two in molecular relapses. The median interval between relapse and Imatinib therapy was 5 months (0-65). A total of 50 patients had failed treatment with donor lymphocyte infusions prior to Imatinib. The overall hemato-logical response rate was 84% (98% for patients relapsing in CP). The complete cytogenetic response (CCR) was 58% for patients in CP, 48% for AP and 22% for patients in BC. Complete molecular responses were obtained in 25 patients (26%), of whom 21 were in CP or AP. With a median follow-up of 9 months, the estimated 2-year survival for CP, AP and BC patients was 100, 86 and 12%, respectively. Out of 79 evaluable patients, 45 (57%) achieved full donor and 11 (14%) mixed chimerism after Imatinib. We conclude that Imatinib has significant activity against CML in relapse after allogeneic SCT. Durable cytogenetic and molecular remissions are obtainable in patients in CP.

Prevalence of Escherichia coli O157:H7 and Salmonella spp. in surface waters of southern Alberta and its relation to manure sources

The Oldman River watershed in southern Alberta, Canada, is an extensively irrigated region in which intensive agricultural practices have flourished. Concern over water quality in the basin has been expressed because of high levels of enteric disease indigenous to the region. To address these concerns, we conducted a 2-year study to estimate the prevalence of Escherichia coli O157:H7 and Salmonella spp. in surface water within the basin. This study is the first of its kind to identify E. coli O157:H7 repeatedly in surface water collected from a Canadian watershed. Prevalence of E. coli O157:H7 and Salmonella spp. in water samples was 0.9% (n = 1,483) and 6.2% (n = 1,429), respectively. While data examined at a regional level show a relationship between high livestock density and high pathogen levels in southern Alberta, statistical analysis of point source data indicates that predicted manure output from bovine, swine, and poultry feeding operations was not directly associated with either Salmonella spp. or E. coli O157:H7 prevalence. However, geography and weather variables, which are likely to influence bacterial runoff, were not considered in this model. We also postulate that variations in time, amount, and frequency of manure application onto agricultural lands may have influenced levels of surface-water contamination with these bacterial pathogens.

Outcome of 112 consecutive patients with an abdominal aortic aneurysm greater than 5·5 cm turned down for elective repair at a university hospital

Background

The UK Small Aneurysm study has demonstrated the low risk of rupture in aneurysms less than 5·5 cm in diameter. However, the natural history of aneurysms greater than 5·5 cm remains unresolved. Questions of equipoise probably preclude another trial in patients with an AAA over 5·5 cm. In this centre, the authors prospectively maintain records of all patients refused elective aneurysm surgery. This study aimed to document the outcome of all patients referred with an AAA greater than 5·5 cm in diameter, and to determine the cause of death and risk of rupture in all patients.

Methods

Details of all patients presenting with an AAA from 1989 to 1999 were recorded and demographic details on all patients with an AAA greater than 5·5 cm were collected. The endpoint was 1 May 1999. Copies of death certificates for deceased patients were obtained from the Office of National Statistics, local in-hospital patient records and general practitioner records. Results of post-mortem examinations were also retrieved. Aneurysms were stratified according to size at presentation (5·5–5·9, 6·0–7·0, more than 7·0 cm) and reasons for non-intervention were documented.

Results

Some 112 patients were turned down over 10 years (11·4 per year). The mean(s.d.) age of this patient group was 77·7(7·7) years; there were 74 men and 38 women. Crude mortality data are shown in the Fig. below (Kaplan–Meier curve). At the end of the study period, 87 patients (76 per cent) were dead, 26 (30 per cent) from a ruptured AAA. Mean survival times were: 23 months (5·5–5·9 cm), 20 months (6·0–7·0 cm) and 15 months (greater than 7·0 cm).

Conclusion

While recognizing the problems with death certification, rupture still seems to be a significant cause of death in patients with untreated AAAs greater than 5·5 cm. While little difference is observed in 5·5–7·0-cm range, patients with an AAA greater than 7·0 cm seem to have a much poorer prognosis.

Allogeneic stem-cell transplantation for lymphoproliferative disorders using BEAM-CAMPATH (+/- fludarabine) conditioning combined with post-transplant donor-lymphocyte infusion

BACKGROUND

We report our updated experience of allogeneic transplantation in lympho-proliferative disorders using a reduced-intensity conditioning regimen combining BEAM (plus fludarabine in three cases) with pre-transplant CAMPATH. Post-transplant donor lymphocytes have been infused for persisting disease or relapse, and both chimerism and minimal residual disease have been monitored utilizing molecular techniques.

METHODS

Thirty patients with median age 47.6 years underwent allogeneic transplantation for relapsed or high-risk lymphoproliferative disease using HLA-identical (sibling n = 25, unrelated n = 2) or one antigen mismatched sibling donors (n = 3). Twenty-one had NHL, three had HD and six had CLL/PLL. Stem-cell source was PBSC (n = 24), BM (n = 5) or both (n = 1) with a median CD34 dose of 4.5 x 10(6)/kg. GvHD prophylaxis was with CYA and MTX.

RESULTS

Engraftment was prompt in the majority of patients, with a median of 15 days to both ANC > 0.5 and platelets > 20. There have been three transplant-related deaths secondary to viral pneumonitis or bacterial pneumonia. Seven patients developed Grade I-II acute GvHD post-transplant. Of 28 evaluable patients, 18 achieved a CR at assessment 2-3 months post-transplant and a further patient converted from PR to CR following DLI, to give an overall CR rate of 68%. Three patients had early progressive disease and six have relapsed from CR or progressed from PR (two of whom have achieved CR following DLI therapy). Overall survival is 67% and event-free survival 48% at 3 years. With a median follow-up of 1.3 years 57% of patients are currently alive and lymphoma-free. A molecular remission has been achieved in nine of 12 informative patients.

DISCUSSION

These encouraging results show that this reduced-intensity conditioning regimen is effective, with a low-toxicity profile compared with conventional TBI-based conditioning, and certainly merits further evaluation in this setting.

A comparison of physiological responses and rating of perceived exertion in two modes of aerobic exercise in men and women over 50 years of age

OBJECTIVES

To compare the physiological responses and ratings of perceived exertion to aerobic dance and walking sessions completed at a self selected pace.

METHODS

Six women and six men with a sample mean (SD) age of 68 (7) years completed aerobic dance and walking sessions in random order. A treadmill test was performed by each subject from which peak oxygen uptake (.VO(2)) and maximum heart rates (HRmax) were determined. During the aerobic dance and walking sessions, heart rate and .VO(2) were measured continuously throughout. Rate of perceived exertion (RPE) was measured every three minutes throughout the session.

RESULTS

The sample means (SD) for %peak .VO(2) were 67 (17)% for the aerobic dance sessions and 52 (10)% for the walking sessions, and the %HRmax sample means (SD) were 74 (12)% for the aerobic dance sessions and 60(8)% for walking sessions. The sample mean (SD) RPE for the aerobic dance sessions was 11(2), and for the walking sessions it was 10(2).

CONCLUSIONS

%peak .VO(2), %HRmax, and RPE were significantly higher for aerobic dance than for walking. However, both the aerobic dance and walking sessions were of adequate intensity to improve aerobic fitness in most subjects. Further investigation into the relation between RPE and %peak .VO(2) in a field setting over representative exercise time periods would be useful.

The LIM domain protein LMO4 interacts with the cofactor CtIP and the tumor suppressor BRCA1 and inhibits BRCA1 activity

LMO4 belongs to the LIM-only (LMO) group of transcriptional regulators that appear to function as molecular adaptors for protein-protein interactions. Expression of the LMO4 gene is developmentally regulated in the mammary gland and is up-regulated in primary breast cancers. Using LMO4 in a yeast two-hybrid screen, we have identified the cofactor CtIP as an LMO4-binding protein. Interaction with CtIP appeared to be specific for the LMO subclass of LIM domain proteins and could be mediated by a single LIM motif of LMO4. We further identified the breast tumor suppressor BRCA1 as an LMO4-associated protein. The C-terminal BRCT domains of BRCA1, previously shown to bind CtIP, also mediated interaction with LMO4. Tumor-associated mutations within the BRCT repeats that abolish interaction between BRCA1 and CtIP had no effect on the association of BRCA1 with LMO4. A stable complex comprising LMO4, BRCA1, and CtIP was demonstrated in vivo. The LIM domain binding-protein Ldb1 also participated in this multiprotein complex. In functional assays, LMO4 was shown to repress BRCA1-mediated transcriptional activation in both yeast and mammalian cells. These findings reveal a novel complex between BRCA1, LMO4, and CtIP and indicate a role for LMO4 as a repressor of BRCA1 activity in breast tissue.

An audit of activity and outcome from a daily and a weekly "one stop" rapid assessment chest pain clinic

OBJECTIVES

The recent National Service Framework for coronary heart disease advocates the establishment of rapid assessment clinics for chest pain. But how should these clinics be organised and do they fulfil their objectives? The aim of this study was to compare referral patterns to a daily and a weekly "one stop" rapid access chest pain clinic (RACPC), and to examine clinical outcome in patients attending these clinics.

DESIGN

Patients were prospectively categorised into one of the following subgroups: "acute coronary syndrome", "stable coronary heart disease", or "low risk/non-coronary chest pain". Fatal and non-fatal outcomes were audited over eight months.

SETTING

Both RACPCs were situated within the cardiology departments of two large Glasgow teaching hospitals. Patients were seen by a cardiologist, and underwent non-invasive testing.

PARTICIPANTS

A total of 633 patients with chest pain who were referred by their general practitioner; 500 came to the daily and 133 to the weekly clinic. Forty four (7%) were categorised as having an acute coronary syndrome, 267 (42%) as stable coronary artery disease, and 322 (51%) as low risk/non-coronary chest pain.

RESULTS

Referral patterns to the two clinics differed significantly. Compared with the weekly clinic, more patients with an acute coronary syndrome (7.8 v. 3.8%) and low risk/non-coronary chest pain (55.2 v. 35.6%), but fewer patients with stable coronary disease (37.0 v. 61.6%) were referred to the daily clinic (p<0.00001). During follow up eight (1.3%) patients died from a cardiac cause, and eight (1.3%) patients suffered a myocardial infarction. None of these patients were classified as low risk/non-coronary chest pain.

CONCLUSIONS

(1) RACPCs do provide an effective tool for the early assessment of patients with possible angina. (2) The frequency with which clinics are scheduled may be an important factor in determining how the service is utilised in practice.

Trends in periconceptional folic acid use by relatives in Irish families with neural tube defects

Close relatives in families who have a child with a neural tube defect (NTD) are at greatly increased risk of having an affected child. Periconceptional folic acid reduces the risk of both occurrence and recurrence of NTDs substantially. Public health authorities currently recommend that the diets of all women between the ages of 15 and 44 who are capable of becoming pregnant be supplemented with folic acid tablets daily. We wondered if relatives in NTD families were more likely to use folic acid. From data obtained by interview with uncles and aunts in Irish NTD families we evaluated folic acid use in 144 of their pregnancies occurring between 1990 and 2000. There was a significant trend towards increasing use of folic acid both before and during pregnancy over the 10 years covered by the study. During the most recent years, 1998-2000, 57.9% of pregnancies reported by aunts were supplemented beforehand and 89.5% during the pregnancy. Pregnancies to smokers were significantly less likely to be supplemented with folic acid. In this study close relatives of an NTD child were more likely to report periconceptional folic acid use than the general public. While these results are encouraging, more remains to be done to ensure in this high risk group to ensure that the full prevention potential of folic acid is realised.

Prognostic factors and secondary malignancies in childhood medulloblastoma

PURPOSE

Little is known of the outcome of long-term survivors of childhood medulloblastoma, one of the most common pediatric malignancies. To determine the potential for secondary malignancies, a retrospective outcome evaluation in 88 consecutive cases of childhood medulloblastoma was performed.

PATIENTS AND METHODS

The records of all patients with childhood medulloblastoma diagnosed at Children's National Medical Center in Washington, DC from 1969 through 1997 were reviewed.

RESULTS

The median follow-up time was 92 months (range 6-257 months). Overall survival was 59% at 5 years and 52% at 10 years. Univariate analysis showed that age at diagnosis, extent of surgical resection, presence of metastatic disease (M stage), ventriculoperitoneal shunt placement within 30 days from diagnosis, posterior fossa radiation therapy dose, and adjuvant chemotherapy significantly affected survival. Although based on small numbers, the risk of second neoplasms was significantly increased in this cohort. Multiple basal cell carcinomas developed in the areas of radiation therapy in two patients; these patients also had nevoid basal cell carcinoma syndrome (NBCCS) diagnosed. One other patient died of glioblastoma multiforme 8 years after treatment of medulloblastoma. A meningioma developed in another patient 10 years after radiation therapy.

CONCLUSION

As survival of medulloblastoma patients improves, increased surveillance regarding secondary malignancies is required, especially because radiation-induced tumors may occur many years after treatment. These two cases of NBCCS also illustrate the importance of considering the concomitant diagnosis of NBCCS in young patients with medulloblastoma. In those patients, alternative therapy should be considered to minimize radiation therapy-related sequelae.

The reliability of a breastfeeding questionnaire

This research project tests the reliability of a correctly constructed breastfeeding questionnaire. The questionnaire is designed to evaluate the impact of breastfeeding support services on breastfeeding initiation and duration and identify groups of women most at risk of premature weaning. The development of the questionnaire followed a seven-step plan to determine the accuracy of the data and the overall integrity of the questionnaire. Reliability was assessed using the test-retest method on twenty-one women with children between the age of one and three years. The statistic kappa was used to assess nominal data, while ordinal and ratio data were assessed using the correlation coefficient, Pearson's r. This study served as a preliminary analysis of the assertion that the correctly constructed breastfeeding questionnaire is an effective and efficient tool.

Treatment of intractable angina in a nonagenarian patient by direct coronary stenting

BACKGROUND

A 91-year-old man presented with a 6-month history of exertional angina. As he was already on maximally tolerated medical therapy, we decided to perform coronary angiography, which revealed severe stenosis of the distal main stem coronary artery,

OUTCOME

The lesion was crossed with an intra-coronary wire, and a stent placed to cover the distal main stem lesion, without prior balloon dilatation. The result was satisfactory and he remains symptom-free at 6-month follow-up.

CONCLUSION

Treatment of left main stem lesions with percutaneous intervention may be an acceptable alternative to surgery in high-risk elderly patients. Since percutaneous coronary angioplasty can be performed on very elderly patients with a high degree of success, the decision to investigate and treat should not be based solely on biological age.

Aneurysmal SAH: cognitive outcome and structural damage after clipping or coiling

BACKGROUND

Aneurysmal subarachnoid hemorrhage (SAH) and surgical clipping of intracranial aneurysms are associated with substantial morbidity and mortality.

OBJECTIVE

To compare cognitive outcome and structural damage in patients with aneurysmal SAH treated with surgical clipping or endovascular coiling.

METHODS

Forty case-matched pairs of patients with aneurysmal SAH treated by surgical clipping or endovascular coiling were prospectively assessed by use of a battery of cognitive tests. Twenty-three case-matched pairs underwent MRI 1 year after the procedure. Matching was based on grade of SAH on admission, location of aneurysm, age, and premorbid IQ.

RESULTS

Both groups were impaired in all cognitive domains when compared with age-matched healthy control subjects. Comparison of cognitive outcome between the two groups indicated an overall trend toward a poorer cognitive outcome in the surgical group, which achieved significance in four tests. MRI showed focal encephalomalacia exclusively in the surgical group. This group also had a significantly higher incidence of single or multiple small infarcts within the vascular territory of the aneurysm, but both groups had similar incidence of large infarcts and global ischemic damage.

CONCLUSION

Endovascular treatment may cause less structural brain damage than surgery and have a more favorable cognitive outcome. However, cognitive outcome appears to be dictated primarily by the complications of SAH.

Prognosis of patients turned down for conventional abdominal aortic aneurysm repair in the endovascular and sonographic era: Szilagyi revisited?

PURPOSE

The United Kingdom Small Aneurysm study has demonstrated the low risk of rupture in aneurysms less than 5.5 cm in diameter. With the advent of endoluminal techniques, patients considered unfit to undergo laparotomy are now considered for endovascular repair. However, the natural history of aneurysms larger than 5.5 cm remains uncertain, especially when severe comorbidity is present. In our center, we prospectively maintain records of all patients for whom elective aneurysm surgery was refused. This study documented the outcome of all patients referred with abdominal aortic aneurysms (AAAs) larger than 5.5 cm in diameter who were turned down for elective open repair and determined the cause of death and risk of rupture in all patients.

METHODS

Details of all patients with AAAs from January 5, 1989, to January 5, 1999, were recorded, and demographic details on all patients with AAAs larger than 5.5 cm were collected. Copies of death certificates were obtained from the Office of National Statistics, local in-hospital patient records, and general practitioner records. Results of postmortem examinations were also obtained. Aneurysms were stratified according to their size at presentation (5.5-5.9 cm, 6.0-7.0 cm, and > 7.0 cm), and the reasons no intervention was made were documented.

RESULTS

A total of 106 patients were turned down for elective aneurysm surgery in the 10-year period (10.6 per year). The mean age of the patients was 78.4 years (SD, 7.4), and 70 were men and 36 were women. At the end of the study, 76 patients (71.7%) had died. Overall, the 3-year survival rate was 17%. Patients with AAAs larger than 7.0 cm lived a median of 9 months. A ruptured aneurysm was certified as a cause of death in 36% of the patients with an AAA of 5.5 to 5.9 cm, in 50% of the patients with an AAA of 6 to 7.0 cm, and 55% of the patients with an AAA larger than 7.0 cm. Reasons given for not intervening were patient refusal (31 cases), the patient being "unfit for surgery" (18 cases), the "advanced age" of the patient (18 cases), cardiac disease (9 cases), cancer (9 cases), respiratory disease (6 cases), and other (15 cases).

CONCLUSION

Although we recognize the problems with death certification, we found that rupture was a significant cause of death in patients with an untreated AAA that was larger than 5.5 cm. Although little difference in outcome was observed in aneurysms in the 5.5 to 7.0 cm size range, patients with an AAA that was larger than 7.0 cm seemed to have a much poorer prognosis.

Harm reduction - a historical view from the left

The harm reduction movement formed during a period in which social movements of the working class and the excluded were weak, neo-liberalism ideologically triumphant, and potential opposition movements were viewed as offering "tinkering" with the system rather than a total social alternative. This climate shaped and limited the perspectives, strategies, and tactics of harm reductionists almost everywhere. In many countries, this period was also marked by a "political economy of scapegoating" that often targeted drug users as the cause of social woes. This scapegoating took the form of "divide and rule" political initiatives by business and political leaderships to prevent social unrest in a long period of worldwide economic trends toward lowered profit rates and toward increasing income inequality. However, times have changed. Mass strikes and other labor struggles, opposition to the World Trade Organisation and other agencies of neo-liberalism, community-based protests against belt-tightening, and other forms of social unrest have been increasing in many countries. This opens up the possibility of new allies for the harm reduction movement, but also poses difficult problems for which we need to develop answers. On-the-ground experience in alliance formation needs to be combined with careful discussion of and research about what approaches work to convince other movements to work for and with harm reduction, and which approaches do not. Class differences within the harm reduction movement are likely to become more salient in terms of (a) creating internal tensions, (b) increasingly, opening up new ways in which working class harm reductionists can organize within their own communities and workplaces, and (c) producing different strategic orientations that will need to be discussed and debated. As a movement, we will need to find ways to accommodate and discuss differing perspectives, needs, and assessments of opportunities and threats without paralyzing harm reduction activities.