Thoracic ventral dural defect: Idiopathic spinal cord herniation

Thoracic ventral dural defect, and resultant idiopathic spinal cord herniation, is a rare but increasingly recognized cause of a chronic progressive thoracic myelopathy, particularly in middle-aged women. A neurosurgically confirmed case is presented, together with a review of the pathogenesis, clinical presentation, imaging features, treatment options and progress of this entity post-treatment.

Development of a Biologically Relevant Dermal Sampler

There are currently no appropriate methods for measuring dermal exposure to volatile agents. To address this we have produced a prototype Institute of Occupational Medicine (IOM) dermal sampler consisting of an adsorbent sandwiched between a permeable membrane and an impervious backing. The concentration of solvent on the membrane surface may be estimated from the mass collected on the adsorbent and the known permeation rate through the membrane. We have developed the prototype IOM dermal sampler for measurement of toluene exposures. Evaluation of the prototype sampler was undertaken in two stages: laboratory performance in controlled exposure situations and two short-field evaluations, which included simultaneous measurement of inhalation exposure. In all cases we compared the prototype IOM dermal sampler with activated charcoal cloth (ACC). Laboratory trials were split into spray, pour and immersion tests. The data from these suggest that the sampler responds to concentration rather than the mass on the surface of the sampler. The field study showed that the prototype sampler was suitable for measuring dermal exposure. However, the mean permeation rate of the best membrane was 78 000 mug cm(-2) h(-1), which is higher than the permeation rate through skin. This high permeation rate created difficulties throughout the study, particularly as it allowed the adsorbent to become rapidly saturated. The prototype IOM dermal sampler is the first practical dermal exposure sampler to mimic uptake through the skin. The sampler gave reproducible results in the laboratory and field trials. Future work is required to identify a less permeable membrane, which has characteristics closer to that of human skin. Additionally, a higher capacity adsorbent would be desirable. We have demonstrated a major difference when calculating the total contribution to body burden via the dermal exposure pathway using the prototype IOM dermal sampler and ACC patches, 1.5% of the total body burden compared with 95%. The prototype IOM dermal sampler provides a more biologically relevant exposure metric than the alternatives.

A wet-primed extracorporeal membrane oxygenation circuit with hollow-fiber membrane oxygenator maintains adequate function for use during cardiopulmonary resuscitation after 2 weeks on standby*

OBJECTIVE

To assess the durability of wet-preprimed extracorporeal membrane oxygenation (ECMO) circuits for potential use in resuscitation after a 2-wk period of storage.

DESIGN

Experimental laboratory study.

SETTING

Tertiary care pediatric cardiac intensive care unit.

SUBJECTS

None.

INTERVENTIONS AND MEASUREMENTS

14 ECMO circuits (polyvinyl chloride and super-Tygon tubing with hollow-fiber oxygenator, Medos Hilite 800LT) were primed with crystalloid under sterile conditions and stored for 0 (control, n = 4), 7 (n = 5) and 14 (n = 5) days and maintained at 8 degrees C on pump at 10 rpm and gas flow at 0.2 L/min. Daily samples were inspected for plasticizers by means of high-performance liquid chromatography and for microorganisms by culture and polymerase chain reaction techniques. After storage, the oxygenators were primed with red blood cells (hemoglobin, 12 g/dL) and tested in vitro with a deoxygenator according to Association for Advancement of Medical Instrumentation standards. Oxygen and CO(2) transfer rates were calculated by standard formulae at maximum blood flow (800 mL/min) and maximum sweep gas flow (1.6 L/min).

MAIN RESULTS

Oxygen transfer was linearly related to venous oxygen saturation, increasing by 11 mL/min for each 10% decrease in venous oxygen saturation. Estimated oxygen transfer at venous oxygen saturation of 60% was 45.8 mL/min (95% confidence interval [CI], 43.5-48.1) for controls, 51.0 mL/min (95% CI, 48.9-53.2) for 7-day oxygenators, and 49.0 mL/min (95% CI, 47.8-50.1) for 14-day oxygenators. CO(2) transfer declined to 29.2 mL/min at 14 days of storage, a mean fall of 11.5 mL/min (95% CI, 4.2-18.7) in comparison with 7-day storage. All circuits were free from microbes/microbial DNA. Plasticizer levels fell below the lower limit of detection (0.003 microg/mL) at 7 and 14 days.

CONCLUSIONS

A wet-preprimed ECMO circuit with hollow-fiber membrane oxygenator can be stored for up to 2 wks with adequately preserved function if prepared appropriately. These data may improve safe access to rapid-response ECMO support.

Experimental Manipulation of Sexual Selection and the Evolution of Courtship Song in Drosophila pseudoobscura

Courtship song serves as a sexual signal and may contribute to reproductive isolation between closely related species. Using lines of Drosophila pseudoobscura experimentally selected under different sexual selection regimes, we tested whether increased promiscuity and enforced monogamy led to evolutionary changes in courtship song elements. In D. pseudoobscura, males produce both a low and high rate repetition song. We found that both song types diverged after selection and that the direction of changes was consistent with ordered hypotheses of predicted directions of change under the different mating system structures. In particular, latency to the initiation of song and duration of the interpulse interval (IPI) decreased in highly promiscuous lines and increased in monogamous lines. These results suggest that courtship song may rapidly evolve under different mating system structures, representing either functional evolution of more stimulatory song under conditions of strong sexual selection, or might result from increased courtship vigor, or represent correlated evolution. Some speciation theory predicts that increased sexual selection should result in increased variance of traits between allopatric populations, facilitating reproductive isolation. We also found that courtship song elements were not equally variable between replicate lines.

Plasticizer di(2-ethylhexyl)phthalate (DEHP) release in wet-primed extracorporeal membrane oxygenation (ECMO) circuits

A wet-primed ready-to-use extracorporeal membrane oxygenation (ECMO) circuit is used in some centres for rapid deployment of ECMO during cardiopulmonary resuscitation. Yet, the potential release of plasticizer di(2-ethylhexyl)phthalate (DEHP) from the polyvinyl chloride tubing in the circuit during storage is a concern. In this study, a high performance liquid chromatography method was used to determine the concentration of DEHP in the priming solution (Plasmalyte) from an ECMO circuit stored for up to 14 days at 8 degrees C. No accumulation of DEHP in the circulating fluid was detected. The results provide important information for centres where ECMO circuits are kept wet-primed prior to clinical use.

Breeding systems and continuing evolution in the endemic Sorbus taxa on Arran

The Arran whitebeams Sorbus arranensis and S. pseudofennica are two endemic woody plant taxa that have evolved on Arran through hybridisation. S. arranensis is a triploid hybrid between the widespread diploid S. aucuparia and the rare tetraploid S. rupicola. S. pseudofennica is a tetraploid formed by crossing between S. arranensis and S. aucuparia. In order to determine the mating systems of the two endemic species six maternal trees of each taxon together with 10-12 of their seed offspring were scored for their phenotype at three microsatellite loci and one nuclear intron locus. All seeds of S. arranensis were identical in phenotype to their maternal parents. In S. pseudofennica, 17.5% of all seeds differed in marker phenotype from their maternal parent. The proportion of seed with nonmaternal phenotypes varied significantly among maternal trees of S. pseudofennica. The results suggest that the triploid S. arranensis is an obligate apomict, whereas the tetraploid S. pseudofennica is a facultative apomict. Molecular marker analysis of three trees from Arran with an unusual leaf morphology indicates that they are the product of sexual reproduction by S. pseudofennica, and may originate from hybridisation with S. aucuparia. This research demonstrates that the Sorbus taxa on Arran are participants in an active evolutionary process generating novel biodiversity. Conservation programmes for these taxa should aim to preserve this evolutionary process rather than the individual taxonomic entities that it produces.

The hydroxyapatite-coated JRI-furlong hip. Outcome in patients under the age of 55 years

We present the clinical and radiographic outcome of 68 consecutive primary total hip replacements performed in 54 patients under the age of 55 years using a hydroxyapatite-coated femoral component and threaded cup with a modular ceramic head (JRI-Furlong). We reviewed 62 (91%) hips at a median follow-up of 8.8 years (5 to 13.8) after implantation; six (9%) were lost to follow-up. At review there had been four (6%) revisions but only one for aseptic loosening (acetabulum). Radiographic review of the remaining hips did not identify any evidence of femoral or acetabular loosening. The median Harris and Merle d'Aubigné and Postel hip scores were 95.9 (42.7 to 100) and 17 (3 to 18) respectively. The JRI-Furlong hip gives promising functional and radiographic results in young patients in the medium term.

The hydroxyapatite-coated JRI-Furlong hip

We present the clinical and radiographic outcome of 68 consecutive primary total hip replacements performed in 54 patients under the age of 55 years using a hydroxyapatite-coated femoral component and threaded cup with a modular ceramic head (JRI-Furlong). We reviewed 62 (91%) hips at a median follow-up of 8.8 years (5 to 13.8) after implantation; six (9%) were lost to follow-up. At review there had been four (6%) revisions but only one for aseptic loosening (acetabulum). Radiographic review of the remaining hips did not identify any evidence of femoral or acetabular loosening. The median Harris and Merle d’Aubigné and Postel hip scores were 95.9 (42.7 to 100) and 17 (3 to 18) respectively. The JRI-Furlong hip gives promising functional and radiographic results in young patients in the medium term.

[Traumatic lesion of the optic nerve head by flying fish: a case report]

BACKGROUND

Traumatic lesion to the optic nerve often leads to severe and persistent functional loss.

HISTORY AND SIGNS

A male patient was transferred to our hospital from the University Eye Clinic of Guadeloupe 5 days after ocular injury caused by a flying fish. Visual function was light perception. The anterior part of the eye and retina were unremarkable. A computer tomography disclosed a fracture of the sphenoid sinus, with a little bone fragment (DD: foreign body) located close to the optic nerve.

THERAPY AND OUTCOME

Therapy had been started with Aminopenicillin combined with clavulan acid (Augmentin) i. v., 500 ml methylprednisolone (Solumedrol) i. v., lysine-acetyl salicylate (Aspegic) and topical application of dexamethasone combined with neomycin/polymyxin B (Maxitrol). We continued this therapy and intensified it by adding nimodipine (Nimotop) 30 1-1-1 and acetazolamide retard (Diamox sustet) 1-0-1. Unfortunately visual function did not recover under therapy.

CONCLUSIONS

Traumatic lesions of the optic nerve head, especially when due to axial or tangential forces, can lead to severe and irreversible functional loss. Severe traumatic lesions, even bone fractures induced by flying fish are not a seldom encounter in the Caribbean Sea.

The effect of temperature, humidity and peak inspiratory nasal flow on olfactory thresholds

Temperature, humidity and nasal peak inspiratory flow rate (PIFR) are potential variables in the quantitative measurement of olfactory thresholds in the clinic. To date, these variables have not been properly evaluated with respect to olfactory perception, and therefore the aim of this study was to determine their effect on the thresholds. These variables were measured on 10 occasions in 10 subjects over a 10-week period. The results obtained were then subjected to statistical analysis using a linear mixed-effect model. This demonstrated that olfactory thresholds are sufficiently independent of room temperature, peak humidity and nasal PIFR in a routine outpatient clinic environment in normal subjects, with no evidence of any statistically significant influence by these variables.

A prognostic index for operable, node-negative breast cancer

Clinical data and samples from patients diagnosed, more than 10 years previously, with operable node-negative breast cancer (participants in the Scottish Adjuvant Tamoxifen trial), were revisited. Cases with two distinct categories of outcome were selected; more than 10 years disease-free survival ('good outcome') or distant relapse within 6 years of diagnosis ('poor outcome'). An initial set of cases was analysed for a range of putative prognostic markers and a prognostic index, distinguishing the two outcome categories, was calculated. This index was then validated by testing its predictive power on a second, independent set of cases. A combination of histological grade plus immunochemical staining for BCL-2, p27 and Cyclin D1, generated a useful prognostic index for tamoxifen-treated patients but not for those treated by surgery alone. The value of the index was confirmed in a second set of tamoxifen-treated, early stage breast cancers. Overall, it correctly predicted good and poor outcome in 79 and 74% of cases, respectively (odds ratio 11.0). Other markers assessed added little to prediction of outcome. In the case of molecular assays, sensitivity and reliability were compromised by the age of the tissue specimens and the variability of fixation protocols. In selecting patients for adjuvant systemic chemotherapy, the proposed index improves considerably on current international guidelines and matches the performance reported for 'gene-expression signature' analysis.

The fabella: a forgotten source of knee pain?

We present a case of chondromalacia of the fabella, describe a provocative diagnostic test and review the literature on this unusual cause of knee pain.

Patients awaiting laparoscopic cholecystectomy--can preoperative complications be predicted?

AIMS

To determine the nature and incidence of gallstone-related complications arising in patients awaiting laparoscopic cholecystectomy and to formulate a strategy to detect those most in need of urgent intervention.

PATIENTS AND METHODS

A retrospective analysis of the case notes of 337 consecutive patients undergoing laparoscopic cholecystectomy under a single surgeon in a district general hospital between 1995 and 1999.

RESULTS

Of patients awaiting laparoscopic cholecystectomy, 65 (19.3%) were documented as suffering significant on-going symptoms, of whom 19 (5.6%) required hospital admission or urgent surgical review at median 8.9 weeks (range 0.1-32.3 weeks) after being placed on the waiting list. Factors predictive of symptom recurrence included: (i) initial acute presentation; (ii) diagnoses of jaundice, pancreatitis, or acute cholecystitis; (iii) elevation of amylase or liver function tests; and (iv) small stones on ultrasonography examination.

CONCLUSIONS

A significant proportion of patients awaiting laparoscopic cholecystectomy experience stone-related complications requiring hospital admission. We feel it is possible to reduce this number by selecting those most at risk on the basis of their history and pre-operative investigations for more urgent intervention.

Increased revascularization efficacy after administration of an adenovirus encoding VEGF(121)

Adenovirus-mediated VEGF gene delivery is being evaluated in clinical trials as a treatment for patients with vascular diseases that stem from ischemia, such as diffuse coronary artery disease and peripheral vascular disease. Although adenoviral vectors are one of the most widely utilized vectors to deliver therapeutic genes to cells, they also have a major limitation in that their inherent immunogenicity leads to the production of neutralizing antibodies that block effective repeat administration. Although this may be true of intravenous, intranasal, and other routes of administration, recent studies have indicated that it may be possible to effectively readminister adenovirus to skeletal muscle. The present study found improved efficacy after administration of AdVEGF(121.10), an E1/E3-deleted adenovirus encoding human VEGF(121) under the control of a CMV promoter in a rat hindlimb ischemia model. As expected, repeat administration of adenovirus resulted in a marked increase of circulating neutralizing antibody, yet nanogram quantities of VEGF protein were still detectable within the hindlimb skeletal muscle after a second administration of vector. The amount of VEGF protein produced after repeat administration translated into improved efficacy as evidenced by increased blood flow as measured by laser Doppler, increased vessel number upon post-mortem angiography, and an increased number of CD31-positive vessels. These findings have important implications for increasing the efficacy of adenovirus-mediated gene therapy in the treatment of peripheral vascular disease and coronary artery disease.

Posterolateral intertransverse lumbar arthrodesis in the New Zealand White rabbit model: I. Surgical anatomy

BACKGROUND CONTEXT

The New Zealand White rabbit model for posterolateral lumbar fusion is commonly used for spinal fusion research. However, the high rate of animal morbidity and mortality associated with the model makes experimentation inefficient and can lead to faulty data analysis. Operative complications are in part the result of inadequate knowledge of normal rabbit lumbar spine anatomy.

PURPOSE

To describe the lumbar spine anatomy of the New Zealand White rabbit as it pertains to the surgical technique of posterolateral intertransverse arthrodesis.

STUDY DESIGN/SETTING

This is a descriptive anatomical study of the lumbar spine (and related structures) of the New Zealand White rabbit spinal fusion model. The study was performed at a university research facility.

METHODS

The lumbar spine and associated soft tissue structures of 16 previously sacrificed, skeletally mature New Zealand White rabbits were dissected and examined.

RESULTS

The musculoskeletal and neurologic structures relevant to posterolateral lumbar fusion in the New Zealand White rabbit are described.

CONCLUSIONS

Specific knowledge of rabbit lumbar spine anatomy allows the researcher to more rapidly acquire expertise in the surgical technique of posterolateral arthrodesis. Improved technical execution of the procedure should lower the complication rate, reduce the costs of experimentation and lead to more reliable and reproducible results.

Effects of leg massage on recovery from high intensity cycling exercise

BACKGROUND

The effect of massage on recovery from high intensity exercise is debatable. Many studies on massage suffer from methodological flaws such as poor standardisation of previous exercise, lack of dietary control, and inappropriate massage duration.

OBJECTIVE

To examine the effects of leg massage compared with passive recovery on lactate clearance, muscular power output, and fatigue characteristics after repeated high intensity cycling exercise, with the conditions before the intervention controlled and standardised.

METHODS

Nine male games players participated. They attended the laboratory on two occasions one week apart and at the same time of day. Dietary intake and activity were replicated for the two preceding days on each occasion. After baseline measurement of heart rate and blood lactate concentration, subjects performed a standardised warm up on the cycle ergometer. This was followed by six standardised 30 second high intensity exercise bouts, interspersed with 30 seconds of active recovery. After five minutes of active recovery and either 20 minutes of leg massage or supine passive rest, subjects performed a second standardised warm up and a 30 second Wingate test. Capillary blood samples were drawn at intervals, and heart rate, peak power, mean power, and fatigue index were recorded.

RESULTS

There were no significant differences in mean power during the initial high intensity exercise bouts (p = 0.92). No main effect of massage was observed on blood lactate concentration between trials (p = 0.82) or heart rate (p = 0.81). There was no difference in the maximum power (p = 0.75) or mean power (p = 0.66) in the subsequent Wingate test, but a significantly lower fatigue index was observed in the massage trial (p = 0.04; mean (SD) fatigue index 30.2 (4.1)% v 34.2 (3.3)%).

CONCLUSIONS

No measurable physiological effects of leg massage compared with passive recovery were observed on recovery from high intensity exercise, but the subsequent effect on fatigue index warrants further investigation.

What effect does isoflurane have upon ciliary beat pattern: an in vivo study

The effect of anaesthetic gases given via laryngeal mask on nasal ciliary beat pattern and frequency has not been studied. Anaesthetic gases such as isoflurane, halothane and enflurane are known to reduce ciliary beat frequency, but it is unknown whether they also cause cilia to beat in a dyskinetic fashion. Brush biopsies of nasal mucosa were taken pre- and post-anaesthesia with isoflurane, given via a laryngeal mask, from patients undergoing nasal surgery. The samples were observed by light microscopy, and high-speed digital video recordings were made to determine ciliary beat frequency. Using slow-motion playback, the ciliary beat pattern was scored for dysmotility, and the proportion of immotile cilia in the sample was determined. We found that ciliary beat frequency decreased significantly (P < 0.01) after exposure to isoflurane (10.24 Hz compared to 9.20 Hz). However, isoflurane did not alter the ciliary beat pattern or the proportion of immotile cilia.

Comparison of the Micro-Nutrica Nutritional Analysis program and the Russian Food Composition Database using data from the Baltic Nutrition Surveys

OBJECTIVE

The objective of this study was to compare the nutrient content of foods and diets based on data from two food composition databases used in the Baltic Nutrition Surveys (conducted in Estonia, Latvia and Lithuania in 1997): an adapted version of the Finnish Micro-Nutrica Nutritional Analysis program (used in Estonia) and the Russian Institute of Nutrition Food Composition Database (used in Latvia and Lithuania).

DESIGN

The adapted Micro-Nutrica and Russian databases were used to estimate the energy and nutrient (protein, fat, carbohydrate, vitamin C, calcium and iron) content of 15 common foodstuffs in the region and the nutrient intakes of 32 Latvian respondents (based on 24-h recalls). Differences between databases were estimated.

RESULTS

There were discrepancies in the energy and nutrient content of the 15 selected foods using the two databases. The adapted Micro-Nutrica database generally gave a lower energy content than the Russian database (median: -6%), and a lower fat content for typically fat-rich foods. Intakes of energy, fat, carbohydrate and calcium by the 32 selected respondents were significantly lower when the Micro-Nutrica database was used. Differences were particularly high for fat (difference=-23.5%, 95% confidence interval=-31.1 to -15.8%, P<0.0001).

CONCLUSIONS

The results suggest that reported comparisons of nutrient intakes in the Baltic countries should be treated with caution and that more research is needed for the development of comparable national databases in the region. Potential differences between databases should be investigated early when international surveys of dietary intake are being planned.

A double-blind, randomised, controlled Phase II trial of Heliox28 gas mixture in lung cancer patients with dyspnoea on exertion

Helium has a low density and the potential of reducing the work of breathing and improving alveolar ventilation when replacing nitrogen in air. A Phase II, double-blind, randomised, prospective, controlled trial was undertaken to assess whether Heliox28 (72% He/28% O₂) compared with oxygen-enriched air (72% N₂/28% O₂) or medical air (78.9% N₂/21.1% O₂) could reduce dyspnoea and improve the exercise capability of patients with primary lung cancer and dyspnoea on exertion (Borg >3). A total of 12 patients (seven male, five female patients, age 53–78) breathed the test gases in randomised order via a facemask and inspiratory demand valve at rest and while performing 6-min walk tests. Pulse oximetry (SaO₂) was recorded continuously. Respiratory rate and dyspnoea ratings (Borg and VAS) were taken before and immediately post-walk. Breathing Heliox28 at rest significantly increased SaO₂ compared to oxygen-enriched air (96±2 cf. 94±2, P<0.01). When compared to medical air, breathing Heliox28 but not oxygen-enriched air gave a significant improvement in the exercise capability (P<0.0001), SaO₂ (P<0.05) and dyspnoea scores (VAS, P<0.05) of lung cancer patients.

Multiple hybrid origins, genetic diversity and population genetic structure of two endemic Sorbus taxa on the Isle of Arran, Scotland

Understanding the processes that have given rise to polyploid hybrid taxa is central to our understanding of plant evolution. In this study, we use an array of genetic markers in a population analysis to elucidate the hybrid origins of the Arran whitebeams Sorbus arranensis and S. pseudofennica, two woody plant taxa endemic to the Isle of Arran, Scotland. It has been proposed that S. arranensis was derived by hybridization between S. aucuparia and S. rupicola, and that subsequent hybridization between S. arranensis and S. aucuparia gave rise to S. pseudofennica. Analyses of species-specific isozyme, nuclear intron and chloroplast DNA markers confirm the proposed origin of S. arranensis, and indicate that S. aucuparia was the female parent in the hybridization. Analysis of microsatellite markers suggests that there have been at least three origins of S. arranensis on Arran. Microsatellite markers also support the proposed hypothesis for the origin of S. pseudofennica, and indicate at least five hybrid origins of this taxon. In total, three multilocus genotypes of S. arranensis and eight of S. pseudofennica were detected on Arran and multilocus genotypic diversity levels Hg were 0.09 and 0.63, respectively. Genetic differentiation (thetaST) values based on multilocus genotypes are substantial (0.344 and 0.470 for S. arranensis and S. pseudofennica, respectively) implying limited seed flow among populations. These results indicate that the endemic Sorbus taxa on Arran are the products of multiple and ongoing evolutionary events. This information must be incorporated into management policies for their future conservation.

Creation of EcR isoform-specific mutations in Drosophila melanogaster via local P element transposition, imprecise P element excision, and male recombination

Collections of single P transposable-element insertion strains that currently inactivate more than 25% of essential Drosophila genes have proven to be a valuable tool for genome research in Drosophila melanogaster. For genes unrepresented in these collections, strategies including local P element transposition and transposase-induced imprecise excision can be used to inactivate or delete the gene of interest. Here we report our use of local P element transposition followed by imprecise P element excision and transposase-induced male recombination to generate two deficiencies specific for the EcR-A isoform of the ecdysone receptor ( EcR) gene, and four larger deficiencies likely to affect multiple EcR functions. We also report here the determination of sequences flanking six EcR-B deficiencies generated in a previous imprecise excision screen. EcR-A encodes one of a family of three related nuclear receptor proteins that, together with the heterodimer partner USP, mediate ecdysone signaling during Drosophila development. Our results delineate sequences required in vivo for EcR-A function, as well as identifying EcR-A intron 1 sequences that are not essential for EcR function.

Torsion of an intra-articular lipoma as a cause of pseudo locking of the knee

We describe a case of a painful locked knee caused by the torsion of an intra-articular lipoma and review the literature on this unusual condition. There are many cases of locked knee and of intra-articular lipoma but to our knowledge there are no previous documented cases of a torted lipoma being identified as a cause of locking.

Karyotypic aberrations of chromosomes 16 and 17 are related to survival in patients with breast cancer

BACKGROUND

Breast cancer has a high incidence and associated mortality rate, yet little is known of the sequence of genetic events that underlie the clinical course.

METHODS

The study was a comparative genomic hybridization analysis of 40 primary breast cancers with survival data at a mean of 8.4 years.

RESULTS

The mean number of aberrations was 9.0, with a mean of 5.5 gains and 3.5 deletions per tumour. The most common aberrations were: gain of 1q (27 of 40), 8q (19 of 40) and 17q (13 of 40), and deletion of 17p (12 of 40) and 8p (11 of 40). These results are consistent with a distinctive pattern of large-scale (karyotypic) genetic change in primary breast cancer.

CONCLUSION

The novel findings of this study were that only women who were disease-free had loss of 16q (E-cadherin) in association with a gain of 16p, and 17p13 (p53) loss combined with 17q12 (HER2) amplification was found only in the cancers of women who developed recurrent disease. The karyotypic changes seen in primary breast cancer seem to be associated with outcome and point to the underlying genetic events.

Post-mortem analysis of samples from a human victim of a fatal poisoning caused by the xanthid crab, Zosimus aeneus

After ingestion of a specimen of the crab Zosimus aeneus (Xanthidae), an East Timorese adult male died within several hours. Xanthid crabs are known to harbour paralytic shellfish toxins (PSTs), tetrodotoxin and palytoxin. A post-mortem examination did not find any obvious pathological abnormalities. This absence of pathologies is more often associated with PSTs and tetrodotoxin intoxication. A second, yet uneaten specimen of Z. aeneus from the same meal, contained a significant amount of PSTs and these same toxins were identified in the gut contents, blood, liver and urine of the victim. Metabolism of the PSTs occurred with the ingested crab harbouring gonyautoxin 2, gonyautoxin 3 and saxitoxin (STX) whereas neoSTX, decarbamoylSTX and STX dominated the PSTs in the victim's urine. The PST composition in the gut contents, in both their identity and proportion, was intermediate between the eaten crab and the urine suggesting that toxin conversion commenced in the victim's gut. The dose consumed by the victim was calculated to be between 1 and 2 microg STX equivalents/kg based upon the concentration in the remains of the cooked crab. The victim's meal did not consist solely of the toxic crab eaten and the possibility of other food items acting in a synergistic manner with the consumed PSTs cannot be discounted.

Interpretation of occupational peak flow records: level of agreement between expert clinicians and Oasys-2

BACKGROUND

Oasys-2 is a validated diagnostic aid for occupational asthma that interprets peak expiratory flow (PEF) records as well as generating summary plots. The system removes inconsistency in interpretation, which is important if there is limited agreement between experts. A study was undertaken to assess the level of agreement between expert clinicians interpreting serial PEF measurements in relation to work exposure and to compare the responses given by Oasys-2.

METHOD

35 PEF records from workers under investigation for suspected occupational asthma were available for review. Records included details of nature of work, intercurrent illness, drug therapy, predicted PEF, rest periods, and holidays. Simple plots of PEF and the Oasys-2 generated plots were available. Experts were advised that approximately 1 hour was available to review the records. They were asked to score each work-rest-work (WRW) period and each rest-work-rest (RWR) period for evidence of occupational effect. At the end of each record scores of 0-100% were given for evidence of "asthma" and "occupational effect" for the whole record. Kappa values were calculated for each scored period and for the opinions on the whole record. The scores were converted into four groups (0-25%, 26-50%, 51-75%, 76-100%) and two groups (0-50% and 51-100%) for analysis. This is relevant to scores produced by Oasys-2. Agreement between Oasys-2 scores and each expert was calculated.

RESULTS

24 of 35 records were analysed by seven experts in the allotted time. For whole record occupational effect, median kappa values were 0.83 (range 0.56-0.94) for two groups and 0.62 (0.11-0.83) for four groups. For asthma, median kappa values were 0.58 (0-0.67) and 0.42 (0.15-0.70) for two and four groups respectively. For all WRW and RWR periods kappa values were 0.84 (0.42-0.94) and 0.70 (0.46-0.87) respectively. Agreement between Oasys-2 and individual experts showed a median kappa value of 0.75 (0.50-0.92) for two groups and 0.50 (0.39-0.70) for four groups. Kappa values for the median expert score v Oasys-2 were 0.75 for two groups and 0.67 for four groups. Agreement was poor for records with intermediate probability, as defined by Oasys-2.

CONCLUSION

Considerable variation in agreement was seen in expert interpretation of occupational PEF records which may lead to inconsistencies in diagnosis of occupational asthma. There is a need for an objective scoring system which removes human variability, such as that provided by Oasys-2.

Paroxysmal finger haematomas (Achenbach's syndrome) with angiographic abnormalities

We present two cases of women with Achenbach's syndrome (paroxysmal finger haematomas) with abnormal angiograms.

250 mW of coherent blue 460-nm light generated by single-pass frequency doubling of the output of a mode-locked high-power diode laser in periodically poled KTP

We report on the generation of 250mW of coherent 460-nm light by single-pass frequency doubling of the mode-locked picosecond pulses emitted by an InGaAs diode master oscillator power amplifier in periodically poled KTP.

Laparoscopic cholecystectomy without routine operative cholangiography does not result in significant problems related to retained stones

BACKGROUND

This study investigated whether failure to identify common bile duct stones at laparoscopic cholecystectomy results in significant postoperative complications related to retained stones.

METHODS

We performed a retrospective analysis of the case notes of 377 consecutive patients undergoing laparoscopic cholecystectomy without routine operative cholangiography under a single surgeon in a district general hospital between 1995 and 1999. Highly selective preoperative endoscopic retrograde cholangiopancreatography (ERCP) was employed to identify and manage suspected bile duct stones in pancreatitis, jaundice, persistently elevated liver function tests, or a dilated common bile duct.

RESULTS

Eighteen (4.8%) of 377 patients presented postoperatively with symptoms/signs suggesting biliary pathology. Two (0.5%) were confirmed to have retained duct stones/debris (ultrasound/ERCP); both recovered with conservative treatment. Only 1 patient of 274 (0.4%) without preoperative ERCP subsequently presented with a symptomatic retained stone, the other having been stented preoperatively.

CONCLUSIONS

Highly selective preoperative ERCP without routine operative cholangiography is not associated with a significant increase in morbidity/mortality related to retained stones following laparoscopic cholecystectomy.

Improved transcutaneous bilirubinometry: comparison of SpectR(X) BiliCheck and Minolta Jaundice Meter JM-102 for estimating total serum bilirubin in a normal newborn population

OBJECTIVE

To compare a new transcutaneous bilirubinometer, which uses multiple wavelength analysis of reflectance data (BiliCheck system), and the commonly used two-wavelength bilirubinometer (Jaundice Meter JM-102) to estimate serum bilirubin.

STUDY DESIGN

Jaundiced newborn term infants (101 babies) had transcutaneous bilirubinometry (TCB) using each bilirubinometer, a determination of skin color using a skin color chart, and a total serum bilirubin determination.

RESULTS

The variability of the BiliCheck system was less than the variability of the Jaundice Meter JM-102. The accuracy of the BiliCheck system was not affected by skin color, whereas the Jaundice Meter JM-102 was affected.

CONCLUSION

Multiple wavelength analysis, as used in the BiliCheck system, is a significant improvement in TCB.

Social inequalities and the burden of food-related ill-health

Increased health inequalities are a result of poverty and social inequalities. Examples of how food intake is affected by poverty exist throughout the European Region. The diets of low-income groups are likely to be inadequate. Low-income groups and specific groups such as children, adolescents, pregnant and lactating women, and older people often face problems gaining access to a healthy variety of safe foods. Safe healthy food may not be accessible to those most in need. Yet access to a safe and varied healthy diet is a fundamental human right and policies are needed to address this.

Time course and nerve growth factor dependence of inflammation-induced alterations in electrophysiological membrane properties in nociceptive primary afferent neurons

Novel findings of changes in nociceptive dorsal root ganglion (DRG) neurons during hindlimb inflammation induced by complete Freund's adjuvant (CFA) injections in the hindpaw and hindleg are reported. These include increased maximum fiber following frequency in nociceptive C- and Adelta-fiber units by 2.7 and 3 times, respectively, and increased incidence of ongoing (spontaneous) activity by 3.3 times (to 54%) and 2.4 times (to 27%), respectively. These changes and the CFA-induced changes in somatic action potential (AP) configuration in nociceptive neurons (Djouhri and Lawson, 1999) were incomplete 24 hr after CFA. The nerve growth factor (NGF) dependence of the inflammation-induced changes was examined by injecting a synthetic NGF sequestering protein [tyrosine receptor kinase A Ig2 (trkA Ig2)] with CFA and subsequently into the CFA injection sites. NGF sequestration prevented some CFA-induced changes in nociceptive neurons including: the increased fiber following frequency (C and Adelta), the increased proportions of units with ongoing activity (C and Adelta), the decreased AP duration (C and Adelta), but not the decreased afterhyperpolarization (AHP) durations (C, Adelta, and Aalpha/beta) (Djouhri and Lawson, 1999). AP variables of nociceptive units with spontaneous activity were examined. The time course of electrophysiological changes in nociceptive units is consistent with processes involving altered protein expression and/or retrograde transport of factors. These results (1) implicate NGF in regulating inflammation-induced decreases in AP duration and in increases in firing rate and spontaneous activity but not in decreases in AHP duration and (2) suggest clinical advantages of reducing NGF in some inflammatory pain states.

Conrad Hal Waddington, 8 November 1905--26 September 1975

Conrad Hal Waddington was born in Evesham on 8 November 1905. His parents, Hal and Mary Ellen (Warner) Waddington, were of long-established Quaker families and were first cousins, as were Mary Ellen’s parents. His surname traces to the Lancashire village of Waddington. He had one sister— Mrs Doris Christie. His father was a tea planter in South India and he spent his first 2 1/2-3 years on a tea estate in the Wynaad district of the Western Ghats and then nearly two years in Coimbatore, both being in the Madras Presidency (now Tamil Nadu). In a brief autobiographical fragment he describes one of his few memories of India: ‘One morning in the road outside our house I was scuffling my feet in the thick dust; as I remember it, it must have been at least six inches deep. I looked over my shoulder and there was a herd of young domesticated buffaloes coming fast towards me. I was terrified. I fled through the gate into the wide open garden, where the only cover was a rather straggly hedge in which I hid. It was made of some thick juicy plant, whose fleshy leaves were almost indistinguishable from the stem and when I broke one off and, without thinking, put it in my mouth as I watched with relief how the buffaloes went by without noticing me, the white acrid sap stung my tongue sharply, and I felt a renewal of terror that I was now poisoned and would surely die.’ He returned to England at the age of four (though his parents did not return permanently until 1928) to live with an aunt and uncle who had a son of his own age, on a farm in Sedgeberrow in the shadow of Bredon Hill. His uncle was farm manager for a bachelor gentleman farmer, always known as ‘Squire Bowly’, and the family lived with the squire in the farmhouse. His grandmother, who brought up his sister, lived in a house on the outskirts of Evesham where he went on school holidays.

Molecular modelling and experimental studies of mutation and cell-adhesion sites in the fibronectin type III and whey acidic protein domains of human anosmin-1

Anosmin-1, the gene product of the KAL gene, is implicated in the pathogenesis of X-linked Kallmann's syndrome. Anosmin-1 protein expression is restricted to the basement membrane and interstitial matrix of tissues affected in this syndrome during development. The anosmin-1 sequence indicates an N-terminal cysteine-rich domain, a whey acidic protein (WAP) domain, four fibronectin type III (FnIII) domains and a C-terminal histidine-rich region, and shows similarity with cell-adhesion molecules, such as neural cell-adhesion molecule, TAG-1 and L1. We investigated the structural and functional significance of three loss-of-function missense mutations of anosmin-1 using comparative modelling of the four FnIII and the WAP domains based on known NMR and crystal structures. Three missense mutation-encoded amino acid substitutions, N267K, E514K and F517L, were mapped to structurally defined positions on the GFCC' beta-sheet face of the first and third FnIII domains. Electrostatic maps demonstrated large basic surfaces containing clusters of conserved predicted heparan sulphate-binding residues adjacent to these mutation sites. To examine these modelling results anosmin-1 was expressed in insect cells. The incorporation of the three mutations into recombinant anosmin-1 had no effect on its secretion. The removal of two dibasic motifs that may constitute potential physiological cleavage sites for anosmin-1 had no effect on cleavage. Peptides based on the anosmin-1 sequences R254--K285 and P504--K527 were then synthesized in order to assess the effect of the three mutations on cellular adhesion, using cell lines that represented potential functional targets of anosmin-1. Peptides (10 microg/ml) incorporating the N267K and E514K substitutions promoted enhanced adhesion to 13.S.1.24 rat olfactory epithelial cells and canine MDCK1 kidney epithelial cells (P<0.01) compared with the wild-type peptides. This result was attributed to the introduction of a lysine residue adjacent to the large basic surfaces. We predict that two of the three missense mutants increase the binding of anosmin-1 to an extracellular target, possibly by enhancing heparan sulphate binding, and that this critically affects the function of anosmin-1.

The potential contribution of increased vegetable and fruit consumption to health gain in the European Union

BACKGROUND

The risk of many important diseases can be reduced by consuming a diet rich in vegetables and fruit. For this reason the World Health Organization (WHO) recommends a daily intake of more than 400 g person(-1). The pattern of both the supply and intake of vegetables and fruit and the potential health gain achieved by increasing intake in the European Union (EU) and three accession countries are presented in this paper.

METHODS

Patterns of supply and dietary intake were assessed using (1) FAO food balance sheets, which allow comparison between the levels of supply in countries but do not reflect actual intake; and (2) survey data reflecting dietary intake. Using WHO mortality data for coronary heart and cerebrovascular disease and major cancers up to age 65 years, the number of preventable deaths is estimated, assuming vegetable and fruit consumption were levelled up to that of the highest consuming group, and assuming relative risks of 0.5, 0.7 or 0.9.

RESULTS

Vegetable and fruit consumption varies considerably between EU Member States. The populations of about half (seven) of the EU Member States have a mean daily intake of less than 275 g. Using the best current estimates of relative risk, over 26,000 deaths before the age of 65 years would be prevented annually in the EU if intake was levelled up to the highest consumption levels (and about double this number of deaths before the age of 75 years).

CONCLUSION

Increasing the intake of vegetables and fruit is feasible and could result in considerable improvements in public health within the EU. Priority should be given to developing methods that demonstrate the burden of disease caused by too low intakes of vegetables and fruit. This would enable the appropriate social, cultural and economic policies to be developed within the EU.

Idiopathic gonadotrophin deficiency: genetic questions addressed through phenotypic characterization

OBJECTIVE

The association of idiopathic hypogonadotrophic hypogonadism (IHH) with congenital olfactory deficit defines Kallmann's syndrome (KS). Although a small proportion of IHH patients have been found to harbour defined genetic lesions, the genetic basis of most IHH cases remains to be elucidated. Genes currently recognized to be involved comprise KAL (associated with X-linked-KS), the GnRH receptor (associated with resistance to GnRH therapy), DAX 1 (associated with adrenohypoplasia congenita) and three loci also associated with obesity, leptin (OB), leptin receptor (DB) and prohormone convertase (PC1). Because of the rarity of the condition and the observation that patients are almost universally infertile without assistance, familial transmission of IHH is encountered infrequently and pedigrees tend to be small. This has constrained the ability of conventional linkage studies to identify other candidate loci for genetic IHH. We hypothesized that a systematic clinical evaluation of a large patient sample might provide new insights into the genetics of this rare disorder. Specifically, we wished to examine the following propositions. First, whether normosmic (nIHH) and anosmic (KS) forms of IHH were likely to be genetically discrete entities, on the basis of quantitative olfactory testing, analysis of autosomal pedigrees and the prevalence of developmental defects such as cryptorchidism and cleft palate. Second, whether mirror movements and/or unilateral renal agenesis were specific phenotypic markers for X-linked-KS.

DESIGN AND PATIENTS

We conducted a clinical study of 170 male and 45 female IHH patients attending the endocrinology departments of three London University teaching hospitals. Approximately 80% of data were obtained from case records and 20% collected prospectively. Parameters assessed included olfaction, testicular volume, family history of hypogonadism, anosmia or pubertal delay, and history or presence of testicular maldescent, neurological, renal or craniofacial anomalies. Where possible, the clinical information was correlated with published data on genetic analysis of the KAL locus.

RESULTS

Olfactory acuity was bimodally distributed with no evidence for a spectrum of olfactory deficit. Testicular volume, a marker of integrated gonadotrophin secretion, did not differ significantly between anosmic and normosmic patients, at 2.0 ml and 2.2 ml, respectively. Nevertheless, the prevalence of cryptorchidism was nearly three times greater in anosmic (70.3%, of which 75.0% bilateral) than in normosmic (23.2%, of which 43.8% bilateral) patients. Individuals with nIHH, eugonadal isolated anosmia and/or KS were observed to coexist within 6/13 autosomal IHH pedigrees. On three occasions, fertility treatment given to an IHH patient had resulted in the condition being transmitted to the resulting offspring. Mirror movements and unilateral renal agenesis were observed in 24/98 and 9/87 IHH patients, respectively, all of whom were identifiable as X-KS males on the basis of pedigree analysis and/or defective KAL coding sequence. Abnormalities of eye movement and unilateral sensorineural deafness were observed in 10/21 and 6/111 KS patients, respectively, but not in nIHH patients.

DISCUSSION

Patients with IHH are almost invariably either anosmic (KS) or normosmic (nIHH), rather than exhibiting intermediate degrees of olfactory deficit. Moreover, the prevalence of cryptorchidism is nearly three times greater in KS than in nIHH despite comparable testicular volumes, suggesting a primary defect of testicular descent in KS independent of gonadotrophin deficiency. Disorders of eye movement and hearing appear only to occur in association with KS. Taken together, these findings indicate a clear phenotypic separation between KS and nIHH. However, pedigree studies suggest that autosomal KS is an heterogeneous condition, with incomplete phenotypic penetrance within pedigrees, and that some cases of autosomal KS, nIHH and even isolated anosmia are likely to have a common genetic basis. The prevalences of anosmia, mirror movements and unilateral renal agenesis among X-KS men are estimated to be 100, 85 and 31%, respectively. In sporadic IHH, mirror movements and unilateral renal agenesis are 100% specific phenotypic markers of de novo X-KS. By comparison, only 7/10 X-KS families harboured KAL coding defects. Clinical ascertainment, using mirror movements, renal agenesis and ichthyosis as X-KS-specific phenotypic markers, suggested that de novo X-KS was unlikely to comprise more than 11% of sporadic cases. The majority of sporadic KS cases are therefore presumed to have an autosomal basis and, hence, the preponderance of affected KS males over females remains unexplained, though reduced penetrance in women would be a possibility.

Multicystic dysplastic kidney and Kallmann's syndrome: a new association?

BACKGROUND

Kallmann's syndrome is characterized by anosmia and hypogonadotrophic hypogonadism. Radiographic studies of teenagers and older subjects with the X-linked form of the syndrome have shown that up to 40% have an absent kidney unilaterally. Although this has been attributed to renal "agenesis", a condition in which the kidney fails to form, little is known about the appearance of the developing urinary tract either pre- or post-natally in individuals with Kallmann's syndrome.

METHODS

We describe two brothers who had features of Kallmann's syndrome, most probably of the X-linked variety, who both had a major urinary-tract malformation detected before birth.

RESULTS

The brothers were found to have unilateral multicystic dysplastic kidneys on routine antenatal ultrasound scanning and both underwent surgical nephrectomy of these organs post-natally. Immunohistochemical studies on the younger sibling revealed hyperproliferative dysplastic kidney tubules which overexpressed PAX2, a potentially oncogenic transcription factor, and BCL2, a cell-survival factor, surrounded by metaplastic, alpha smooth-muscle actin-positive stroma: similar patterns have been observed in patients with non-syndromic multicystic dysplastic kidneys.

CONCLUSIONS

Our results describe a new type of urinary-tract malformation associated with Kallmann's syndrome. However, since multicystic kidneys tend to involute, only when more Kallmann's syndrome patients are screened in utero or in early childhood using structural renal scans, will it be possible to establish whether multicystic kidney disease is a bona-fide part of the syndrome.

Transmission loss of sound into incubators: implications for voice perception by infants

OBJECTIVE

To assess the transmission of sound into incubators as a function of talker position (i.e., standing or sitting), incubator port position (i.e., opened or closed), and center frequency (i.e., 125 to 10,000 Hz in one-third octave steps). The second objective was to estimate the audibility of the human voice inside the incubator.

STUDY DESIGN

L(eq) measures of signal transmission loss and motor noise were obtained from two incubators.

RESULTS

In general, signal transmission loss was greater for the standing-talker position, with front portholes closed, and for high-frequency spectra. Motor noise was greater with both front portholes closed and for lower-frequency spectra. The greatest signal delivery to an infant would be obtained when the speaker is sitting using a raised vocal effort while the incubator ports are opened.

CONCLUSION

Measured signal transmission loss and motor noise characteristics of two incubators suggest that only mid-frequency speech spectra would be audible to infants and only at a speech-to-noise ratio of approximately 5 to 10 dB with a raised vocal effort.