An orchestrated gene expression component of neuronal programmed cell death revealed by cDNA array analysis

Programmed cell death (PCD) during neuronal development and disease has been shown to require de novo RNA synthesis. However, the time course and regulation of target genes is poorly understood. By using a brain-biased array of over 7,500 cDNAs, we profiled this gene expression component of PCD in cerebellar granule neurons challenged separately by potassium withdrawal, combined potassium and serum withdrawal, and kainic acid administration. We found that hundreds of genes were significantly regulated in discreet waves including known genes whose protein products are involved in PCD. A restricted set of genes was regulated by all models, providing evidence that signals inducing PCD can regulate large assemblages of genes (of which a restricted subset may be shared in multiple pathways).

Developmental regulation of neurogenesis in the pluripotent human embryonal carcinoma cell line NTERA-2

Embryonal carcinoma (EC) cells provide a caricature of pluripotent embryonic stem (ES) cells and may be used as surrogates for investigating the mechanisms that regulate cell differentiation during embryonic development. NTERA-2 is a human EC cell line that differentiates in response to retinoic acid yielding cells that include terminally differentiated neurons. The expression of genes known to be involved in the formation of the vertebrate nervous system was examined during retinoic acid-induced NTERA-2 differentiation. Differentiation of these human EC cells into neurons could be divided into three sequential phases. During phase 1, in the first week of differentiation, hath1 mRNA showed a small transient increase that correlated with the rapid accumulation of nestin message, a marker of neuroprogenitors. Transcripts of nestin were quickly downregulated during phase 2 as expression of neuroD1, characteristic of neuroprogenitors exiting the cell cycle, was induced. A neural cell surface antigen, detected by the monoclonal antibody A2B5, was expressed by cells exiting the cell cycle, correlating with the expression of neuroD1 as the cells became post-mitotic. Markers of mature neural cells (e.g. synaptophysin and neuron-specific enolase) were subsequently increased during phase 3 and were maintained. This regulated pattern of gene expression and commitment to the neural lineage indicates that differentiation of NTERA-2 neurons in vitro follows a similar pathway to that observed by neural ectodermal precursors during vertebrate neurogenesis in vivo.

Regulation of Tiam1 nucleotide exchange activity by pleckstrin domain binding ligands

Rho family GTPases play roles in cytoskeletal organization and cellular transformation. Tiam1 is a member of the Dbl family of guanine nucleotide exchange factors that activate Rho family GTPases. These exchange factors have in common a catalytic Dbl homology and adjacent pleckstrin homology domain. Previous structural studies suggest that the pleckstrin domain, a putative phosphoinositide-binding site, may serve a regulatory function. We identified ascorbyl stearate as a compound that binds to the pleckstrin domain of p120 Ras GTPase-activating protein. Furthermore, ascorbyl stearate appears to be a general pleckstrin domain ligand, perhaps by mimicking an endogenous amphiphilic ligand. Tiam1 nucleotide exchange activity was greatly stimulated by ascorbyl stearate. Certain phosphoinositides also stimulated Tiam1 activity but were less potent than ascorbyl stearate. Tiam1 contains an additional N-terminal pleckstrin domain, but only the C-terminal pleckstrin domain was required for activation. Our results suggest that the pleckstrin domains of Dbl-type proteins may not only be involved in subcellular localization but may also directly regulate the nucleotide exchange activity of an associated Dbl homology domain. In addition, this paper introduces ascorbyl stearate as a pleckstrin domain ligand that can modulate the activity of certain pleckstrin domain-containing proteins.

Percutaneous dilatational tracheostomy: haemorrhagic complications and the vascular anatomy of the anterior neck. A review based on 497 cases

In a series of 497 PDT procedures done in the intensive therapy unit at Morriston Hospital between 1992 and 1999, PDT was abandoned because of bleeding in 6 patients and was noted to be a problem in a further 18 cases (overall incidence 4.8%). In all cases, haemorrhage was successfully arrested. Surgical tracheostomy was necessary in 6 of these 24 cases. The source of bleeding in 4 of these patients was attributed to the inferior thyroid vein (2 cases), high brachiocephalic vein, and possibly an aberrant anterior jugular communicating vein, respectively. In one patient, the vessel presumed injured could not be identified and in another patient, bleeding was related to multi-system disease. We conclude that the risk of bleeding, although low, can be minimised if the operator maintains a high index of suspicion for aberrant vascular anatomy and investigates possible abnormalities with diagnostic ultrasound. Injury to vessels low in the neck can be reduced by not fully extending the neck and siting the stoma at the upper tracheal rings. The possibility of developing a tracheoarterial fistula is reduced if the stoma is situated above the 4th tracheal ring and fibreoptic endoscopy is used to confirm correct tracheostomy tube placement.

Population-based study of the pattern of molecular markers of minimal residual disease in childhood and adult acute lymphoblastic leukemia: an assessment of the practical difficulty of representative sampling for trial purposes. Northern Region Haematology Group

BACKGROUND

The prevalence, in unselected patients with acute lymphoblastic leukaemia (ALL), of clonal rearrangements suitable for minimal residual disease (MRD) studies has not been formally investigated.

PROCEDURE

This was a prospective, demographic study of the frequency of molecular markers of MRD in all patients with ALL presenting over 5 years within the Northern Health Region of England (population 3.1 million). Presentation marrow samples were examined to detect informative markers.

RESULTS

One hundred twenty-four children (age <15 years) developed non-Burkitt ALL. No material was available for study in 21. Eighty-six had clonal gene rearrangements (BCR/ABL, immunoglobulin heavy chain (IGH) and/or T cell receptor (TCR) gene rearrangements). All entered remission; 84 (68% of the original cohort) survived to become eligible for MRD studies. One hundred sixteen adults developed ALL, of whom 48 were not studied due to insufficient cellular material in the bone marrow aspirate or to logistical problems in central referral of samples from other hospitals. Material from elderly adults (age >55 years) was less likely to be sent for analysis, 36% vs. 59% (P = 0.024). Thirty-eight had BCR/ABL and/or IGH/TCR gene rearrangements. Thirty-one (27% of the original cohort) entered remission and became eligible for MRD studies. Informative gene rearrangements were more common in children than adults (83% vs. 63%, P < 0.003).

CONCLUSIONS

The results reveal substantial potential, unintentional, selection bias. Large-scale multicentre studies of MRD in children may well produce clinically relevant and representative data. Those who mount similar studies in adults should not assume they will be similarly representative or as successful in accrual of material.

Orf virus encodes a novel secreted protein inhibitor of granulocyte-macrophage colony-stimulating factor and interleukin-2

The parapoxvirus orf virus encodes a novel soluble protein inhibitor of ovine granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin-2 (IL-2). The GM-CSF- and IL-2-inhibitory factor (GIF) gene was expressed as an intermediate-late viral gene in orf virus-infected cells. GIF formed homodimers and tetramers in solution, and it bound ovine GM-CSF with a K(d) of 369 pM and ovine IL-2 with a K(d) of 1.04 nM. GIF did not bind human GM-CSF or IL-2 in spite of the fact that orf virus is a human pathogen. GIF was detected in afferent lymph plasma draining the skin site of orf virus reinfection and was associated with reduced levels of lymph GM-CSF. GIF expression by orf virus indicates that GM-CSF and IL-2 are important in host antiviral immunity.

RADARx: Recognizing, Assessing, and Documenting Adverse Rx events

BACKGROUND

Adverse events are a leading cause of morbidity and mortality. Adverse Drug Events (ADEs) are frequent, under-reported, costly, and largely preventable. Computerized tools expose effectively ADEs and can reduce their impact.

METHODS

RADARx is a Veterans Administration (VA) VistA-compatible M software program that integrates computerized ADE screening, probability assessment, documentation, and reporting capabilities. Data dictionary mapping tools have enabled RADARx implementation at 3 sites. All RADARx alerts generated at VA Medical Center (VAMC) Nashville from 7/1/99 to 9/30/99 were evaluated.

RESULTS

Total ADEs documented using RADARx numbered 57. RADARx discovered 34 ADEs and 48 'potential' ADEs; 23 ADEs were found using traditional means. Overall, 11% of RADARx alerts were true positives. Pharmacist review of the 8-20 alerts generated daily costs between 10 and 30 minutes.

Rating the appropriateness of coronary angiography, coronary angioplasty and coronary artery bypass grafting: the ACRE study. Appropriateness of Coronary Revascularisation study

BACKGROUND

Previous studies investigating the appropriateness of invasive management of coronary disease had not reported the internal consistency of their ratings and may now be out of date. The aim of this study was to measure the influence of clinical factors on contemporary ratings of the appropriateness of coronary angiography, percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) in the Appropriateness of Coronary Revascularisation (ACRE) study.

METHODS

The Delphi-RAND technique was used, in which an expert panel (four cardiologists, three cardiothoracic surgeons, a general physician and a general practitioner), meeting in 1995, rated mutually exclusive indications (n = 2178 for angiography, n = 995 for PTCA and n = 984 for CABG). The main outcome measures were the appropriateness category (inappropriate, uncertain or appropriate) for each of the three procedures and treatment preference.

RESULTS

For revascularization, the strongest determinant of inappropriateness was coronary anatomy. The odds ratio (OR) for inappropriate PTCA was 10.6 (95 per cent confidence interval (CI) 4.8-23.5) for the effect of left main stem or three-vessel disease versus single-vessel disease, and for CABG it was 0.06 (95 per cent CI 0.03-0.15). The number of diseased vessels was strongly related to preference for medical, PTCA or CABG treatment (p for linear trend <0.001). Mild versus severe anginal symptoms were associated with inappropriate angiography (OR 2.0 (95 per cent CI 0.9-9.8), although this effect was stronger when only the cardiologists' ratings were considered (OR 10.1 (95 per cent CI 2.4-42.6)).

CONCLUSION

These are the first UK ratings of appropriateness covering all three procedures. The associations with clinical factors provide evidence of the internal consistency of these ratings. Prospective validation of these ratings against clinical outcomes is under way in the ACRE study.

Effect of oral rotavirus/iscom vaccines on immune responses in gnotobiotic lambs

A comparison of the effect on the immune responses in gnotobiotic lambs was made between an iscom vaccine prepared from recombinant rotavirus VP6 protein, an inactivated rotavirus/iscom-matrix vaccine and a vaccine comprising inactivated rotavirus alone. All three vaccines induced immunological priming and some degree of protection was observed after a single oral dose. However, different immune responses were induced in response to a virulent infection. The group vaccinated with the rotavirus/iscom-matrix vaccine showed a Th2-like response characterised by rotavirus-specific antibodies and a down-regulation of IFNgamma in jejunal Peyer's patches. Both Th1-like and Th2-like immune responses were induced in the group receiving the VP6 vaccine as seen by significantly increased expressions of IFNgamma and IL-6 in the jejunal Peyer's patch together with an increased percentage of CD8+ T cells in the intestine and rotavirus-specific antibodies at mucosal surfaces. Iscom vaccines given orally have the ability to induce both Th1-like and Th2-like immune responses in a ruminant model.

A comparison of the effects of olanzapine, haloperidol and placebo on cognitive and psychomotor functions in healthy elderly volunteers

The cognitive and psychomotor effects of olanzapine (3 mg) were compared with haloperidol (3 mg) and placebo in a double-blind, cross-over study. Fourteen healthy elderly volunteers (>65 years) were randomized to receive once daily medication for 4 days with a 16-day interval between treatment periods. Assessments of attention, memory and motor control were made prior to dosing on each day, at 2, 4, 6 and 8 h after dosing on days 1 and 4, and at 24 and 48 h following the last dose. On day 1, detectable impairment was observed at all time points in both groups. On day 4, haloperidol treated subjects showed increased impairment compared with day 1 and this was sustained throughout the 48 h of testing. Olanzapine treated subjects showed reduced day 4 deficit (compared with day 1), with no significant difference from placebo beyond 6 h post dose. These results suggest that both haloperidol and olanzapine have a measurable initial effect on cognitive and psychomotor function in elderly volunteers. However, acute effects associated with olanzapine decrease with repeated dosing and show substantial adaptation within 4 days. In contrast, effects seen with haloperidol are sustained and increase with repeated dosing over the same period.

An in vivo analysis of the effectiveness of the osteoarthritic knee brace during heel-strike of gait

The objective of this study was to analyze the effects of off-loading knee braces in patients diagnosed with symptomatic unicompartmental osteoarthritis. Under fluoroscopic surveillance, 15 patients were asked to perform normal gait on a treadmill. Each patient was asked initially to walk without using a knee brace and then to walk while wearing a brace. The fluoroscopic images of the patients at heel-strike were downloaded to a workstation computer. Condylar separation angle of the knee joint and the distances from the medial and lateral femoral condyles to the tibial plateau (condylar separation) were measured. Twelve of 15 patients (80%) reported relief of pain and demonstrated condylar separation of the degenerative compartment with the use of the off-loading brace. The 3 patients who did not demonstrate condylar separation were obese, making accurate brace fitting difficult. The average change in condylar separation and condylar separation angle was 1.2 mm (range, 0.0-4.5 mm) and 2.2 degrees (range, 0.0 degrees-7.8 degrees). This study demonstrated that condylar separation of a degenerative knee compartment can be achieved with off-loading braces with subsequent subjective relief of knee pain.

Antitumor efficacy of AG3340 associated with maintenance of minimum effective plasma concentrations and not total daily dose, exposure or peak plasma concentrations

Oral administration of AG3340, a novel metalloprotease (MMP) inhibitor, suppresses the growth of human colon adenocarcinoma (COLO-320DM) tumors in vivo (Proc Am Assoc Cancer Res 39: 2059, 1998). In this report, we tested the hypothesis that the growth inhibition of these tumors is associated with maintaining minimum effective plasma concentrations of AG3340. Nude mice were given a total oral daily dose of 25 or 200 mg/kg; 6.25 mg/kg was given four times per day (QID) (25 mg/kg/day), and 100 mg/kg was given in two daily doses (BID) (200 mg/kg/day). Peak plasma concentrations (Cmax) of 83 +/- 43 (mean +/- SD) and 1998 +/- 642 ng/ml were detected 30 min after a single dose with 6.25 mg/kg and 100 mg/kg AG3340, respectively. AUC(0-24 h) values estimated from dosing with 25 and 200 mg/kg/day AG3340 were 672 and 10882 ng*h/ml, respectively. Importantly, both regimen inhibited tumor growth equivalently (74 to 82%). Efficacy was also compared at a total daily dose of 25 mg/kg by giving AG3340: QID (6.25 mg/kg per dose), BID (12.5 mg/kg per dose), and once daily (25 mg/kg per dose). The Cmax of these regimens was 83 +/- 43, 287 +/- 175 and 462 +/- 495 ng/ml, respectively. AG3340 did not inhibit tumor growth with the latter two regimens. The efficacy of 6.25 mg/kg QID (25 mg/kg/day) was superior to the efficacy of 25 mg/kg BID (50 mg/kg/day), substantiating the independence of efficacy from the total daily dose and Cmax. Expectedly, peak to trough fluctuations were significantly smaller with the QID regimen than with BID and QD dosing. After 24 h, the trough was greater than 1 ng/ml with QID dosing but was less than 1 ng/ml after QD and BID dosing. These results suggest that the antitumor efficacy of AG3340 was associated with maintaining minimum effective plasma concentrations of AG3340 and demonstrate that the antitumor efficacy of AG3340 was independent of the total daily dose, peak plasma concentration, and drug exposure in this tumor model.

Broad antitumor and antiangiogenic activities of AG3340, a potent and selective MMP inhibitor undergoing advanced oncology clinical trials

We studied AG3340, a potent metalloproteinase (MMP) inhibitor with pM affinities for inhibiting gelatinases (MMP-2 and -9), MT-MMP-1 (MMP-14), and collagenase-3 (MMP-13) in many tumor models. AG3340 produced dose-dependent pharmacokinetics and was well tolerated after intraperitoneal (i.p.) and oral dosing in mice. Across human tumor models, AG3340 produced profound tumor growth delays when dosing began early or late after tumor implantation, although all established tumor types did not respond to AG3340. A dose-response relationship was explored in three models: COLO-320DM colon, MV522 lung, and MDA-MB-435 breast. Dose-dependent inhibitions of tumor growth (over 12.5-200 mg/kg given twice daily, b.i.d.) were observed in the colon and lung models; and in a third (breast), maximal inhibitions were produced by the lowest dose of AG3340 (50 mg/kg, b.i.d.) that was tested. In another model, AG3340 (100 mg/kg, once daily, i.p.) markedly inhibited U87 glioma growth and increased animal survival. AG3340 also inhibited tumor growth and increased the survival of nude mice bearing androgen-independent PC-3 prostatic tumors. In a sixth model, KKLS gastric, AG3340 did not inhibit tumor growth but potentiated the efficacy of Taxol. Importantly, AG3340 markedly decreased tumor angiogenesis (as assessed by CD-31 staining) and cell proliferation (as assessed by bromodeoxyuridine incorporation), and increased tumor necrosis and apoptosis (as assessed by hematoxylin and eosin and TUNEL staining). These effects were model dependent, but angiogenesis was commonly inhibited. AG3340 had a superior therapeutic index to the cytotoxic agents, carboplatin and Taxol, in the MV522 lung cancer model. In combination, AG3340 enhanced the efficacy of these cytotoxic agents without altering drug tolerance. Additionally, AG3340 decreased the number of murine melanoma (B16-F10) lesions arising in the lung in an intravenous metastasis model when given in combination with carboplatin or Taxol. These studies directly support the use of AG3340 in front-line combination chemotherapy in ongoing clinical trials in patients with advanced malignancies of the lung and prostate.

The prevention of corticosteroid-induced bone loss with intermittent cyclical etidronate

A prospective, randomised, double-blind, placebo controlled primary prevention trial was undertaken in 28 patients commencing low to moderate doses of corticosteroids for the first time. Patients were randomised to intermittent cyclical etidronate (400 mg daily for 2 weeks) and calcium (500 mg daily for 11 weeks) or intermittent cyclical placebo with calcium. After 52 weeks of treatment, lumbar spine BMD increased by 1.8% in the etidronate group, while it decreased by 3.7% in the placebo group. The differences in bone loss rate were statistically significant (p<0.01) at both 6 and 12 months. Similar trends were observed at the proximal femur, but differences were not statistically significant. These results suggest that intermittent cyclical etidronate therapy is effective in the primary prevention of corticosteroid-induced bone loss at the lumbar spine.

Changes in neuron size in cynomolgus macaques infected with various immunodeficiency viruses and poliovirus

Human immunodeficiency virus (HIV) infection leads to clinically significant neuronal pathology, but the underlying mechanism remains unclear. Infection of rhesus macaques with the simian immunodeficiency virus SIVmac251 has been shown to cause atrophy of hippocampal pyramidal cells. The aim of the current investigation was to determine whether SIVmac251 and other viruses with differing abilities to cause immune suppression or encephalitis could cause neuronal atrophy in cynomolgus macaques. Animals infected with SIVmac251 (n = 22), HIV-2 (n = 6). SIVmac239 (n = 7) and poliovirus (n = 10) were investigated, together with 16 controls. Hippocampal pyramidal cell diameter, averaged across the four CA subfields, was reduced by 16.6% in the SIVmac251 group (P < 0.0001) and by 13.3% in the HIV-2 group (P < 0.001), even though the latter virus does not generally cause immunosuppression. Conversely, SIVmac239, which does cause immunosuppression, caused an average neuronal hypertrophy of 6.8% (P = 0.033). Of possible relevance to the different behaviour of the two SIVs is that SIVmac239 is lymphocyte tropic and does not infect CNS microglia in vivo whereas SIVmac251 does. Animals inoculated with poliovirus into the lumbar spinal cord for polio vaccine neurovirulence testing acted as positive controls for CNS inflammation and they also showed an increase in neuronal diameter (4.1%, P = 0.025). The atrophy seen with SIVmac251 and HIV-2 involved all CA subfields but the hypertrophy following SIVmac239 or poliovirus infection was restricted to CA1 and CA2. These observations show a dissociation between the ability of immunodeficiency viruses to cause immune suppression and neuronal pathology and demonstrate that CNS inflammation per se may cause neuronal hypertrophy.

Enhanced neuronal differentiation of NTera-2 cells expressing neuronally restricted beta2 adrenergic receptor

NTera-2/D1 (NT2) is a human teratocarcinoma cell line which can be cultured as a dividing population of precursor cells that can be manipulated with retinoic acid (RA) to yield post-mitotic neurons. Precursor cells were transfected with the human beta2 adrenergic receptor, controlled by the neuronal cell specific rat synapsin-1 promoter. Transfected precursor cells did not display elevated expression of the beta2 adrenergic receptor. Upon differentiation to a neuronal phenotype with RA, betaSyn2 and betaSyn4 (beta2Syn-NT2; ATCC CRL-12356) displayed elevated beta2 adrenergic receptor levels, and an elevated coupling to cAMP production. It was also observed that the elevated expression of the beta2 adrenergic receptor in the neuronal NT2 cells resulted in an enhanced level of neuronal differentiation compared to the wild type cells. These results demonstrate that the neuronally restricted expression of the human beta2 adrenergic receptor in NT2 neurons results in increased receptor levels and receptor stimulated generation of cAMP, this may result in the observed improvement in neuronal differentiation.

Absent pulmonary valve syndrome with interrupted aortic arch

A surgically treated case of absent pulmonary valve syndrome associated with type B interrupted aortic arch is presented. The presence of a restrictive ductus arteriosus promoted the development of a collateral circulation between ascending and descending thoracic aorta, allowing the child to remain clinically stable after birth.

Contagious bovine pleuropneumonia. The costs of control in Central/southern Africa

Contagious bovine pleuropneumonia (CBPP) caused by Mycoplasma mycoides subspecies mycoides small colony (M. mycoides) has been endemic in many parts of Africa for the greater part of this century. Because of an international vaccination campaign the disease was almost eliminated from the continent. With the deteriorating economic situation of many countries, vaccination programs have been allowed to slip; drought conditions have resulted in great movements of livestock and the disease has spread rapidly to the east and south. For Government Veterinary Departments, the implications of this resurgence of CBPP, are serious. The costs threaten to overwhelm completely under-funded government, services. Where cost-recovery measures are introduced, the charging for vaccines may damage rapport with communities and erode the credibility of the government services. Farmers may find the loss of cattle and the costs of vaccine severe burdens which threaten their livelihoods and social well-being (Zambia) and even, in extreme cases, their survival (Botswana). Controlling the disease today presents new possibilities which include increased cross-border collaboration (Malawi/Tanzania), increased emphasis on monitoring (N. Zambia) and the greater involvement of communities in disease control (W. Zambia).

Periaortic fat pad mimicking an intramural hematoma of the thoracic aorta: lessons for transesophageal echocardiography

We report a patient whose clinical and echocardiographic findings were compatible with a diagnosis of aortic intramural hematoma, but magnetic resonance imaging demonstrated a prominent and localized periaortic deposit of fat as the cause of the transesophageal echocardiographic appearance. This is a significant caveat that must be borne in mind when interpreting echocardiographic images obtained in patients with suspected intramural aortic hematomas.

The action of three antiseptics/disinfectants against enveloped and non-enveloped viruses

The antiviral action of chloroxylenol, benzalkonium chloride and cetrimide/chlorhexidine was assessed against a range of enveloped and non-enveloped human viruses using a suspension test method. Viral suspensions of 10(6)-10(7) pfu/TCID50 or sfu were prepared in each of the antiseptic/disinfectant solutions in the presence of a bovine serum/yeast extract mixture to simulate 'dirty conditions'. During incubation, aliquots were removed at predetermined timepoints up to 10 min to assess the kinetics of inactivation. Results indicate that all products were effective in inactivating the enveloped viruses herpes simplex virus type 1 and human immunodeficiency virus type 1, whilst being ineffective in inactivating human coronavirus, also enveloped, and the non-enveloped viruses. The exception to this was the benzalkonium chloride-based product (Dettol Hospital Concentrate) which was active against the non-enveloped human coxsackie virus. Four antiseptic/disinfectant solutions with chloroxylenol, benzalkonium chloride, cetrimide/chlorhexidine and povidone-iodine were also assessed for antiviral effect against human immunodeficiency virus in the presence of whole human blood. All four solutions proved to be effective within 1 min despite the cytotoxic nature of the compounds to the detection system.

The orf virus OV20.0L gene product is involved in interferon resistance and inhibits an interferon-inducible, double-stranded RNA-dependent kinase

The parapoxvirus orf virus was resistant to type 1 (IFN-alpha) and type 2 (IFN-gamma) interferons in cultures of ovine cells. The recently identified orf virus OV20.0L gene exhibits 31% predicted amino acid identity to the vaccinia virus E3L interferon-resistance gene, and is referred to as the (putative) orf virus interferon-resistance gene (OVIFNR). The objective of this study was to determine whether OVIFNR was involved in interferon resistance. Recombinant OVIFNR as a thioredoxin fusion protein (OVIFNR-Tx) inhibited the activation (by autophosphorylation) of an interferon-inducible, double-stranded (ds) RNA-dependent kinase (PKR) of sheep, which was shown to bind dsRNA (poly I:C). PKR in other species is involved in the inhibition of protein synthesis as part of the antiviral state in infected cells. Virus-infected cell lysates, but not control lysates, from cells grown in the presence of cytosine arabinoside also contained PKR inhibitory activity, which indicated that the inhibitory activity was associated with early viral gene expression. Significantly, the OVIFNR gene expressed in interferon-treated ovine fibroblasts protected the unrelated Semliki Forest virus from the antiviral effect of both type 1 and type 2 interferons. Taken together, the results indicate that the OVIFNR gene functions as an interferon-resistance gene, the product of which inhibits PKR in a similar way to the vaccinia virus E3L gene product.

Which depressed patients respond to cognitive-behavioral treatment?

OBJECTIVE

To identify predictors of remission from major depression in adolescent patients given cognitive-behavioral therapy (CBT).

METHOD

The study was based on 50 patients aged between 10 and 17 years who were obtained from two studies of CBT. A wide range of possible predictors was examined.

RESULTS

Sixty percent remitted by the end of treatment. In multivariate analyses remission was associated with younger age and less social impairment.

CONCLUSIONS

Depressed patients who respond to CBT tend to be younger and less severely impaired than those who do not respond.

Early high dose chemotherapy intensification with autologous bone marrow transplantation in lymphoma associated with retention of fertility and normal pregnancies in females. Scotland and Newcastle Lymphoma Group, UK

As more centres consider autologous bone marrow and peripheral blood stem cell transplantation for patients with high risk Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL) in first complete remission (CR1) the long term sequelae of such treatments have to be considered. One of the most important side effects of such intensive treatment is loss of fertility. Sperm banking before treatment commences is available for males but unfortunately cryopreservation of ova/ovarian tissue is not yet possible for females. We have transplanted 30 women, 23 were under 40 years and report ten females who have had successful pregnancies (including two twin pregnancies and one triplet pregnancy), leading to live births following autologous bone marrow transplantation (ABMT) for poor prognosis HD and NHL in first or second complete remission. None of these children have shown evidence of birth defects (median follow up of two years). Of the twenty one pregnancies reported to the European Bone Marrow Transplantation Registry (EBMTR) following ABMT for lymphoma, eight of the seventeen unassisted cases came from our centres. The Newcastle/SNLG autotransplant differs from the approach in many EBMTR centres in that it uses melphalan or melphalan/etoposide alone instead of the more common four drug containing regimens and yet sustained complete remission rates indicate that the non-ablative approach is equally effective as more aggressive regimens on the disease with the huge advantage of preserved fertility in females. This approach to conditioning for ABMT should be considered when treating women in the reproductive age group.

Alpha interferon gene deletions in post-transplant lymphoma

Post-transplant lymphoproliferative disorder (PTLD) is a well-recognized complication of organ transplant and has been associated with high mortality using conventional chemotherapy. We have investigated 11 cases of PTLD for alterations to the interferon alpha (IFNA) and p16 genes on chromosome 9p using archival material. 4/9 (44%) cases had deletions of the IFNA genes, in contrast to 1/59 (1.7%) cases of intermediate/high-grade de novo NHL drawn from the same geographical region. PTLD may therefore represent a distinct NHL subgroup exhibiting distinct gene pathology.

Developing a multidisciplinary protocol for enteral feeding

The management of planned change is discussed using a change model. Protocols are described and defined. The process of multidisciplinary protocol development is identified. Nurses are encouraged to reflect upon the process of practice change.

Glial lineages and myelination in the central nervous system

Oligodendrocytes, derived from stem cell precursors which arise in subventricular zones of the developing central nervous system, have as their specialist role the synthesis and maintenance of myelin. Astrocytes contribute to the cellular architecture of the central nervous system and act as a source of growth factors and cytokines; microglia are bone-marrow derived macrophages which function as primary immunocompetent cells in the central nervous system. Myelination depends on the establishment of stable relationships between each differentiated oligodendrocyte and short segments of several neighbouring axons. There is growing evidence, especially from studies of glial cell implantation, that oligodendrocyte precursors persist in the adult nervous system and provide a limited capacity for the restoration of structure and function in myelinated pathways damaged by injury or disease.

Noonan syndrome: coagulation and clinical aspects

The study aims were to review the clinical features of a group of patients with Noonan syndrome and to further elucidate their bleeding tendency. Eighteen patients (12M, 6F) aged 2.6-13.3 years underwent a clinical assessment, a questionnaire of their bleeding tendency and laboratory coagulation studies. Nine had cyanotic spells or breathing difficulties after birth; 11 had poor feeding or weight gain. Increased bruising or bleeding was reported in 12 (67%), four of whom had bleeding from the oral cavity. Excessive bleeding was not reported from operative procedures in other sites. Partial thromboplastin time was prolonged in 10 (56%) associated with low levels of clotting factors, particularly XI and XII. Bleeding times were normal; one had marginal thrombocytopenia. Coagulation results did not correlate with bruising history and may not predict bleeding risk. Care is required when Noonan syndrome patients undergo surgery, particularly of the oropharynx, with immediate availability of suitable blood products.

Clinical validity of major depression-endogenous subtype in adolescent patients

This paper explored the validity of the distinction between endogenous and nonendogenous forms of major depression in a clinical sample of adolescents, average age 13.6 years. The criteria used to establish this distinction were features of the disorder itself and the external criteria of demography, family history and psychosocial stressors. Endogenous subjects had a more severe form of depressive disorder than nonendogenous subjects. However, there were no significant differences between the depressed groups on any of the external criteria. The distinction between endogenous and nonendogenous major depression in early and mid-adolescence appears therefore to be quantitative rather than qualitative.

Controlled trial of a brief cognitive-behavioural intervention in adolescent patients with depressive disorders

Fifty-three child and adolescent psychiatric patients with depressive disorders were randomly allocated to brief cognitive-behaviour therapy (CBT) or to a control treatment, relaxation training. Forty-eight patients completed the treatment phase of the trial, which comprised 5-8 treatment sessions. Post-treatment assessments showed a clear advantage of CBT over relaxation on measures of both depression and overall outcome. However, there were no significant differences between the treatments on comorbid anxiety and conduct symptoms. At follow-up, the differences between the groups were reduced, partly because of a high relapse rate in the DTP group and partly because subjects in the relaxation group continued to recover.

Paradoxical embolism in a young woman

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Exogenous glycosaminoglycans (GAG) differentially modulate GAG synthesis by anchorage-independent cultures of the outer cells from neonatal rat calvaria in the absence and presence of TGF-beta

In anchorage-dependent (AD) cultures of the outer cell population (OCP) from neonatal rat calvaria, transforming growth factor-beta 1 (TGF-beta) specifically upregulated the synthesis of chondroitin sulfate (CS) proteoglycan (PG) and uncoupled the inhibitory effect of increasing cell density on CS PG synthesis (reference #30). Utilizing the same cell population, we have further examined the possibility that glycosaminoglycans (GAG) known to be synthesized and secreted by bone cells might exert feedback effects on GAG synthesis and/or its stimulation by TGF-beta. Although addition of TGF-beta alone stimulated net synthesis of HA and CS in both AD and anchorage-independent (AI) cultures, significant alterations of basal and TGF-beta-stimulated GAG synthesis by exogenous GAGs were observed only in AI cultures. In AI cultures exogenously added hyaluronic acid (HA) markedly enhanced the basal synthesis of HA and CS while heparin (H) suppressed the basal synthesis of HA, CS as well as dermatan sulfate (DS). Also, the addition of HA markedly potentiated the stimulation by TGF-beta of HA and CS synthesis as did heparan sulfate (HS) for CS and DS synthesis. H suppressed the stimulation of the synthesis of HA, CS and DS by TGF-beta. Overall, our results indicate specific effects of individual GAGs on basal and TGF-beta-stimulated GAG synthesis in OCP cultures. We suggest that some of the GAGs in the OCP microenvironment (which with the exception of HA are covalently linked to protein cores of secreted PGs), acting in concert with TGF-beta, may serve as an amplification system for upregulating GAG synthesis in the rapidly growing neonatal calvarium.

Emergency thoracotomy for thoracic trauma in the accident and emergency department: indications and outcome

To assess the efficacy of emergency thoracotomy performed for thoracic trauma in the accident and emergency department, a retrospective analysis of patients who underwent this procedure and were brought to hospital by the Helicopter Emergency Medical Service was carried out. Between 1991 and 1994, 16 patients had emergency thoracotomy performed in the accident department. Twelve patients had sustained blunt trauma and four patients had sustained penetrating injuries. Three patients first assessed at the scene and 11 patients on arrival at the emergency department had Glasgow Coma Scores < 3. Eight thoracotomies were performed by the cardiothoracic team and eight by the trauma team. There was one survivor in this group; he had been stabbed at multiple sites and emergency thoracotomy was required to control bleeding from an intercostal vessel. Our results demonstrate experience of one of the first phase Level One trauma centres in the United Kingdom. From our small series, we believe that selection criteria for emergency thoracotomy in trauma patients need to be revised. From this series and a review of the literature, patients with penetrating injuries, vital signs at the scene and those with a high index of suspicion for tamponade seem to benefit most from thoracotomy in the emergency setting.

CD59 expression and complement susceptibility of human neuronal cell line (NTera2)

The present study analysed the susceptibility of neuronal cells to human complement. A human neuronal precursor cell line (NTera2) which can be induced to differentiate into post-mitotic neuronal cells was employed. Using immunocytochemistry, NTera2 neurones, but not their precursors (stem cells), were shown to activate complement in the absence of antibody and to lack CD59, an inhibitor of the terminal stages of the complement cascade. Following exposure to human serum, neurones but not stem cells were lysed by complement, as demonstrated by a cell viability assay and consistent rise in intracellular calcium. This response was abrogated when cells were treated with complement-depleted serum by heat inactivation or cobra venom factor. Protection from lysis was observed following incorporation of CD59 with its glycolipid anchor in the neuronal cell membrane.

Patterns of supradiaphragmatic metastases in testicular germ cell tumours

The imaging and clinical findings of 31 patients with supradiaphragmatic nodal metastases from primary testicular germ cell cancers were reviewed. In 11 patients the primary testicular tumor was a seminoma, and in 20 a non-seminomatous germ cell tumour (NSGCT). The patterns of spread of these tumour types were compared. All patients had chest radiographs (CXR): 27 had chest computed tomography (CT). One patient with seminoma and eight with NSGCT (40%) had lung metastases. Mediastinal lymphadenopathy was seen on CT in seven patients with seminoma (64%) and in nine patients with NSGCT (45%). Neck lymphadenopathy was present in 10 of 11 (91%) patients with seminoma, and 13 of 20 (65%) patients with NSGCT. Neck disease co-existed with mediastinal disease in six of 11 (55%) patients with seminoma, but in only two of 20 (10%) patients with NSGCT (P=0.012). This study gives further supporting evidence for the relative importance of haematogenous spread in teratoma, and lymphatic spread in seminoma. The contiguous nature of disease spread from abdomen to chest and neck in seminoma is confirmed. In NSGCT, supradiaphragmatic spread is more random but tends to occur in the paraoesophageal and subcarinal groups.

Interobserver variation in the chest radiograph component of the lung injury score

The lung injury score is a semi-quantitative system used in the definition and grading of the acute respiratory distress syndrome. It is composed of two, three or four equally weighted components. One component is derived from the chest radiograph, which may contribute up to 50% of the total score. A score of 1 is awarded for each quadrant on the chest radiograph which contains alveolar consolidation. We examined the interobserver variation between two anaesthetists, two radiologists and two critical care physicians who scored blindly 100 chest radiographs from patients with adult respiratory distress syndrome. There was very good agreement between the two radiologists in the total scores (kappa 0.97) and in individual scores in each of the 4 quadrants (kappa 0.97-1.0). The agreement between anaesthetists and radiologists was only fair for the total score (kappa 0.37-0.42), but moderate to good for individual quadrant scores (kappa 0.43-0.73). The agreement between the two anaesthetists was moderate for individual quadrant scores (kappa 0.44-0.60), but only fair for total score (kappa 0.34). There was poor agreement between the two critical care physicians for total score (kappa 0.05) and for individual quadrant scores (kappa 0.04-0.20). Agreement between the physicians and other observers was poor to fair for the total score (kappa 0.12-0.32) and poor to moderate for the individual quadrant scores (kappa 0.15-0.63). Both anaesthetists and physician 2 underestimated the overall chest scores (median scores 2, 3 and 1 respectively) in comparison to the radiologists (median scores 3.5). Physician 1 significantly overscored (median score 4). The chest radiograph component of the lung injury score can be consistently assessed by radiologists, but significant variations may be introduced when assessed by other clinicians. This has significant implications for the use of the lung injury score in studies of adult respiratory distress syndrome and other studies which incorporate radiographic appearances in the definition.

Guidance of oligodendrocytes and their progenitors by substratum topography

Oligodendrocyte progenitors arise in subventricular zones and migrate extensively during development before differentiating into mature oligodendrocytes, which myelinate nerve tracts in the central nervous system. We have used microfabricated substrata, containing periodic patterns of contours similar to those of central nervous system axons to assess the influence in vitro of substratum topography on oligodendrocytes isolated from 7 day rat optic nerve. Antiganglioside antibody A2B5 positive oligodendrocyte-type 2 astrocyte progenitors, and galactocerebroside positive and myelin basic protein positive oligodendrocytes, were highly aligned by surface contours as small as 100 nm depth and 260 nm repeat spacing. Rat optic nerve astrocytes also aligned on surface contours, but rat hippocampal and cerebellar neurons were unresponsive. Oligodendrocytes demonstrated enhanced parallel extension of their processes on narrow repeating topography in an arrangement similar to that found in the intact optic nerve. This is in marked contrast to the phenotype displayed by this cell type on planar substrata. Neither oligodendrocytes nor oligodendrocyte-type 2 astrocyte progenitors showed high-order F-actin cytoskeletal networks; thus their alignment on gratings is unlikely to result from deformation of actin cables and focal contacts. In contrast, aligned astrocytes showed striking arrangements of actin stress fibres. These results establish glial cells as potentially the most topographically sensitive cell types within the central nervous system. Furthermore, the topographical pattern inducing maximal alignment of oligodendrocyte lineage cells corresponds to the diameters of single axons within the 7 day optic nerve. Thus the migration of oligodendrocyte-type 2 astrocyte progenitors and axonal ensheathment by oligodendrocytes may be guided by axonal topography within the developing nerve.

Transient global amnesia and cortical blindness after vertebral angiography: further evidence for the role of arterial spasm

We describe a series of six patients who experienced severe retrograde amnesia (five cases) or cortical blindness (one case) during selective vertebral angiography. All angiograms were obtained with the same nonionic contrast medium. Analysis of the contrast batch demonstrated no abnormalities, but investigation of the angiographic suite revealed a faulty contrast warming cabinet resulting in injection of contrast material above body temperature. The warming cabinet was withdrawn, and the complication has not recurred. We believe that these symptoms reflect ischemia caused by vertebral arterial spasm.

Properties of the mood and feelings questionnaire in adolescent psychiatric outpatients: a research note

This study examined the psychometric properties of the Mood and Feelings Questionnaire (MFQ) in 104 adolescent outpatients attending a psychiatric clinic. The clinic offers a special assessment and treatment service for young people with depressive disorders. In this sample the self-report version of the MFQ had acceptable reliability and was a satisfactory screen for major depressive disorder diagnosed by a standardised interview with the child. It was also a useful measure of clinical remission.

Case report: paratesticular rhabdomyosarcoma--colour Doppler appearances

Paratesticular rhabdomyosarcoma is a rare tumour of childhood and early adult life. We report a case in which the paratesticular location and colour Doppler appearances led to confusion with epididymitis.

Behavioural aspects and psychiatric findings in Noonan's syndrome

This study describes the behavioural phenotype and psychiatric symptoms of 21 children with Noonan's syndrome attending a paediatric genetics clinic. Data from the behavioural phenotypes questionnaire are presented that suggest that children with Noonan's syndrome tend to be clumsy, stubborn, irritable, have communication difficulties, and are 'faddy eaters'. Nearly 50% of the patients with Noonan's syndrome were psychiatric 'cases' as assessed by a standardised measure.