Reductions in cardiovascular risk in association with population screening: a 10-year longitudinal study

BACKGROUND

This study was carried out in order to examine changes in cardiovascular risk associated with a population-based screening programme.

METHOD

Cardiovascular disease (CVD) risk factor data from a representative sample of residents aged between 45 and 55 years who attended screening a total of three times over a 10-year period were chosen for analysis (n=4113). Cohorts were defined as either 'high risk' or 'normal risk' at baseline for risk factors including blood pressure, body mass index (BMI), cholesterol, smoking and alcohol intake. Mean changes were observed for both groups over three screening episodes, and results were stratified by gender.

RESULTS

For the high-risk cohorts (after controlling for age and regression to the mean effects), there were significant decreases in all risk factors, except BMI. Conversely, the observed changes in the normal risk cohorts indicated significant increases in risk factors over the 10-year period. After adjusting for age, the pattern in the normal risk cohorts fluctuated and there were some decreases in risk, but they were not as large as the decreases in risk for the high-risk cohorts.

CONCLUSIONS

Population screening for CVD is an effective strategy for identifying and reducing risk in high-risk individuals. These results have significant implications for the role of screening in preventing and controlling cardiovascular disease.

Impact of rapid molecular screening for meticillin-resistant Staphylococcus aureus in surgical wards

Background

This study aimed to establish the feasibility and cost-effectiveness of rapid molecular screening for hospital-acquired meticillin-resistant Staphylococcus aureus (MRSA) in surgical patients within a teaching hospital.

Methods

In 2006, nasal swabs were obtained before surgery from all patients undergoing elective and emergency procedures, and screened for MRSA using a rapid molecular technique. MRSA-positive patients were started on suppression therapy of mupirocin nasal ointment (2 per cent) and undiluted chlorhexidine gluconate bodywash.

Results

A total of 18 810 samples were processed, of which 850 (4·5 per cent) were MRSA positive. In comparison to the annual mean for the preceding 6 years, MRSA bacteraemia fell by 38·5 per cent (P < 0·001), and MRSA wound isolates fell by 12·7 per cent (P = 0·031). The reduction in MRSA bacteraemia and wound infection was equivalent to a saving of 3·78 beds per year (£276 220), compared with the annual mean for the preceding 6 years. The cost of screening was £302 500, making a net loss of £26 280. Compared with 2005, however, there was a net saving of £545 486.

Conclusion

Rapid MRSA screening of all surgical admissions resulted in a significant reduction in staphylococcal bacteraemia during the screening period, although a causal link cannot be established.

Chronic relapsing experimental allergic encephalomyelitis (CREAE) in plasminogen activator inhibitor-1 knockout mice: the effect of fibrinolysis during neuroinflammation

During neuroinflammation in multiple sclerosis (MS) fibrinogen, not normally present in the brain or spinal cord, enters the central nervous system through a compromised blood-brain barrier. Fibrin deposited on axons is ineffectively removed by tissue plasminogen activator (tPA), a key contributory factor being the upregulation of plasminogen activator inhibitor-1 (PAI-1).

AIMS

This study investigated the role of PAI-1 during experimental neuroinflammatory disease.

METHODS

Chronic relapsing experimental allergic encephalomyelitis (CREAE), a model of MS, was induced with spinal cord homogenate in PAI-1 knockout (PAI-1(-/-)) and wild type (WT) mice, backcrossed onto the Biozzi background.

RESULTS

Disease incidence and clinical severity were reduced in PAI-1(-/-) mice, with animals developing clinical signs significantly later than WTs. Clinical relapses were absent in PAI-1(-/-) mice and the subsequent reduction in neuroinflammation was coupled with a higher capacity for fibrinolysis in spinal cord samples from PAI-1(-/-) mice, in association with increased tPA activity. Axonal damage was less apparent in PAI-1(-/-) mice than in WTs, implicating fibrin in both inflammatory and degenerative events during CREAE.

CONCLUSIONS

PAI-1 is a potential target for therapy in neuroinflammatory degenerative diseases, allowing effective fibrin removal and potentially reducing relapse rate and axonal damage.

Toward high-resolution prediction and design of transmembrane helical protein structures

The prediction and design at the atomic level of membrane protein structures and interactions is a critical but unsolved challenge. To address this problem, we have developed an all-atom physical model that describes intraprotein and protein-solvent interactions in the membrane environment. We evaluated the ability of the model to recapitulate the energetics and structural specificities of polytopic membrane proteins by using a battery of in silico prediction and design tests. First, in side-chain packing and design tests, the model successfully predicts the side-chain conformations at 73% of nonexposed positions and the native amino acid identities at 34% of positions in naturally occurring membrane proteins. Second, the model predicts significant energy gaps between native and nonnative structures of transmembrane helical interfaces and polytopic membrane proteins. Third, distortions in transmembrane helices are successfully recapitulated in docking experiments by using fragments of ideal helices judiciously defined around helical kinks. Finally, de novo structure prediction reaches near-atomic accuracy (<2.5 A) for several small membrane protein domains (<150 residues). The success of the model highlights the critical role of van der Waals and hydrogen-bonding interactions in the stability and structural specificity of membrane protein structures and sets the stage for the high-resolution prediction and design of complex membrane protein architectures.

Cannabinoid control of neuroinflammation related to multiple sclerosis

The cannabis plant (Cannabis sativa) has been known by many names but the question remains 'Can we call it medicine?' There has been renewed interest in the value of cannabis for the control of neuroinflammatory conditions such as multiple sclerosis, where it has been shown to have some effect on spasticity and pain both experimentally and in clinical trials in humans. However, in addition to symptom control potential, the question remains whether cannabinoids can modify the neuroinflammatory element which drives relapsing neurological attacks and the accumulation of progressive disability. In experimental studies it has been recently shown that synthetic cannabinoids can affect the immune response both indirectly via CB1 receptor-mediated signalling nerve centres controlling the systemic release of immunosuppressive molecules and directly by CB2 receptor-mediated inhibition of lymphocyte and macrophage/microglial cell function. However, these immunosuppressive possibilities that would limit the frequency of relapsing attacks will probably not be realized clinically, following use of medical cannabis, due to dose constraints. However, cannabinoids may still affect the glial response within the damaged central nervous system, which facilitate the slow, neurodegenerative processes that account for progressive neurodegeneration, and therefore may have utility in addition to value of cannabis-related drugs for symptom control.

Vascular pharmacology of a novel cannabinoid-like compound, 3-(5-dimethylcarbamoyl-pent-1-enyl)-N-(2-hydroxy-1-methyl-ethyl)benzamide (VSN16) in the rat

BACKGROUND AND PURPOSE

A putative novel cannabinoid receptor mediates vasorelaxation to anandamide and abnormal-cannabidiol and is blocked by O-1918 and by high concentrations of rimonabant. This study investigates VSN16, a novel water-soluble agonist, as a vasorelaxant potentially acting at non-CB1, non-CB2 cannabinoid receptors in the vasculature.

EXPERIMENTAL APPROACH

VSN16 and some analogues were synthesized and assayed for vasodilator activity in the rat third generation mesenteric artery using wire myography. Also carried out with VSN16 were haemodynamic studies in conscious rats and binding studies to CB1 receptors of rat cerebellum.

KEY RESULTS

VSN16 relaxed mesenteric arteries in an endothelium-dependent manner. The vasorelaxation was antagonized by high concentrations of the classical cannabinoid antagonists, rimonabant and AM 251, as well as by O-1918, an antagonist at the abnormal-cannabidiol receptor but not at CB1 or CB2 receptors. It did not affect [3H]CP55,940 binding to CB1 receptors in rat cerebellum. The vasorelaxation was not pertussis toxin-sensitive but was reduced by inhibition of nitric oxide synthesis, Ca(2+)-sensitive K+ channels (KCa) and TRPV1 receptors. In conscious rats VSN16 transiently increased blood pressure and caused a longer-lasting increase in mesenteric vascular conductance. Structure-activity studies on vasorelaxation showed a stringent interaction with the target receptor.

CONCLUSIONS AND IMPLICATIONS

VSN16 is an agonist at a novel cannabinoid receptor of the vasculature. It acts on the endothelium to release nitric oxide and activate KCa and TRPV1. As it is water-soluble it might be useful in bringing about peripheral cannabinoid-like effects without accompanying central or severe cardiovascular responses.

Inflammatory biomarkers, disease activity and spinal disease measures in patients with ankylosing spondylitis after treatment with infliximab

Objective:

To evaluate the relationship between biomarker levels and disease activity and the spinal inflammation detected by magnetic resonance imaging (MRI) in patients with ankylosing spondylitis (AS).

Methods:

Patients with AS were randomly assigned in a 3:8 ratio to receive infusions of placebo or 5 mg/kg infliximab at weeks 0, 2, 6, 12 and 18. Sera were collected for biomarker analysis at weeks 0, 2 and 24 and were analysed for levels of interleukin-6 (IL-6), vascular endothelial growth factor (VEGF) and C-reactive protein (CRP). Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores and pre- and post-gadolinium T1 and short τ inversion recovery MRIs were collected at baseline and week 24.

Results:

Significantly greater reductions in IL-6, VEGF and CRP were observed at weeks 2 and 24 in the infliximab group compared with the placebo group (all p<0.001). Baseline IL-6 levels >7.38 pg/ml and CRP levels >1.5 mg/dl were associated with increased rates of clinical response after 24 weeks. Multiple regression analyses showed that reductions from baseline to week 2 in IL-6, but not CRP or VEGF, were significantly associated with reductions in MRI activity and BASDAI scores from baseline to week 24 in the infliximab group (p<0.001).

Conclusions:

Significant reductions in IL-6, VEGF and CRP were observed with infliximab compared with placebo. High levels of baseline IL-6 and CRP were associated with clinical response after infliximab treatment. Early reductions in IL-6 were significantly associated with improvements in disease activity and the spinal inflammation detected by MRI.

Identification of genomic DNA signatures predicting relapse in low- and intermediate-risk neuroblastoma using a case control design and high-density SNP genotyping: A Children's Oncology Group (COG) study

9500

Background: Neuroblastoma (NB) is a childhood malignancy with a heterogeneous clinical course. Clinical and genomic markers are powerful predictors of outcome and are used to stratify cases for treatment intensity, but imprecision remains. Methods: We identified all disease recurrences from the recently closed COG low- (P9641: 903 eligible, 63 events) and intermediate-risk (A3961: 467 eligible, 40 events) NB phase III trials. To date, tumor DNA from 35 cases and 90 controls (P9641/A3961 patients without event) was used for whole genome copy number and genotype evaluation on the Illumina HumanHap550 (550K SNPs) array. An in-house algorithm was developed to assign genomic copy number and loss of heterozygosity based on probe intensity (log R ratio) and degree of allelic imbalance (B allele frequency). Results: A total of 988 chromosomal aberrations were identified; 231 (23.4%) were whole chromosome (WC) copy number aberrations (CNA). Unsupervised hierarchical clustering identified 10 tumor subsets, with 2 highly enriched with cases showing progression events (13/21; 61%), and 2 dominated by WC gains (chromosomes 2, 6, 7 and 18) with only 2/20 events. Regional aberrations most highly associated with EFS included loss of 11q14-qter (p=0.036), and gain of 11p (p=0.003), 11q13 (p=0.020), and 17q23-qter (p=0.005). Other regional CNAs at borderline univariate significance for EFS included partial gain at 2p, 2q, 6q, 7q, 12q and 13q. The pattern 11p and proximal 11q gain associated with loss of distal 11q was associated with relapse and death (p=0.006 and p=0.023). Conclusion: Whole genome SNP genotyping detects patterns of chromosomal CNAs predictive of EFS, even in situations where events are rare such as low- and intermediate- risk NB. These data support chromosomal 11 and 17 structural CNAs as being most highly predictive of relapse in otherwise favorable NBs, but also suggest that other CNAs likely cooperate and may improve precisions for risk prediction. These data can be used to identify patients eligible for chemotherapy reduction/elimination, and perhaps others for intensification. Ongoing analyses of the remaining samples will extend these conclusions.

No significant financial relationships to disclose.

Novel methods of time-resolved fluorescence data analysis for in-vivo tissue characterization: application to atherosclerosis

This study investigates the ability of new analytical methods of time-resolved laser-induced fluorescence spectroscopy (TR-LIFS) data to characterize tissue in-vivo, such as the composition of atherosclerotic vulnerable plaques. A total of 73 TR-LIFS measurements were taken in-vivo from the aorta of 8 rabbits, and subsequently analyzed using the Laguerre deconvolution technique. The investigated spots were classified as normal aorta, thin or thick lesions, and lesions rich in either collagen or macrophages/foam-cells. Different linear and nonlinear classification algorithms (linear discriminant analysis, stepwise linear discriminant analysis, principal component analysis, and feedforward neural networks) were developed using spectral and TR features (ratios of intensity values and Laguerre expansion coefficients, respectively). Normal intima and thin lesions were discriminated from thick lesions (sensitivity >90%, specificity 100%) using only spectral features. However, both spectral and time-resolved features were necessary to discriminate thick lesions rich in collagen from thick lesions rich in foam cells (sensitivity >85%, specificity >93%), and thin lesions rich in foam cells from normal aorta and thin lesions rich in collagen (sensitivity >85%, specificity >94%). Based on these findings, we believe that TR-LIFS information derived from the Laguerre expansion coefficients can provide a valuable additional dimension for in-vivo tissue characterization.

Urgent liver transplantation for acute liver failure due to parvovirus B19 infection complicated by primary Epstein?Barr virus and cytomegalovirus infections and aplastic anaemia

An 11-year-old boy presented with hepatic failure secondary to parvovirus B19 infection, requiring urgent liver transplantation. His recovery was complicated by primary Epstein-Barr virus and cytomegalovirus infections. He subsequently developed aplastic anaemia that has been refractory to antithymocyte globulin and cyclosporine therapy and may now require bone marrow transplantation. We present this case to emphasize parvovirus as a rare cause of hepatic failure and of aplastic anaemia as a complication of the virus.

Control of spasticity in a multiple sclerosis model is mediated by CB1, not CB2, cannabinoid receptors

BACKGROUND AND PURPOSE

There is increasing evidence to suggest that cannabis can ameliorate muscle-spasticity in multiple sclerosis, as was objectively shown in experimental autoimmune encephalomyelitis models. The purpose of this study was to investigate further the involvement of CB1 and CB2)cannabinoid receptors in the control of experimental spasticity.

EXPERIMENTAL APPROACH

Spasticity was induced in wildtype and CB1-deficient mice following the development of relapsing, experimental autoimmune encephalomyelitis. Spastic-hindlimb stiffness was measured by the resistance to flexion against a strain gauge following the administration of CB1 and CB2 agonists.

KEY RESULTS

As previously suggested, some CB2-selective agonists (RWJ400065) could inhibit spasticity. Importantly, however, the anti-spastic activity of RWJ400065 and the therapeutic effect of non-selective CB1/CB2 agonists (R(+)WIN55,212-2 and CP55, 940) was lost in spastic, CB1-deficit mice.

CONCLUSIONS AND IMPLICATIONS

The CB1 receptor controls spasticity and cross-reactivity to this receptor appears to account for the therapeutic action of some CB2 agonists. As cannabinoid-induced psychoactivity is also mediated by the CB1 receptor, it will be difficult to truly dissociate the therapeutic effects from the well-known, adverse effects of cannabinoids when using cannabis as a medicine. The lack of knowledge on the true diversity of the cannabinoid system coupled with the lack of total specificity of current cannabinoid reagents makes interpretation of in vivo results difficult, if using a purely pharmacological approach. Gene knockout technology provides an important tool in target validation and indicates that the CB1 receptor is the main cannabinoid target for an anti-spastic effect.

New Methods for Time-resolved Fluorescence Spectroscopy Data Analysis Based on the Laguerre Expansion Technique

Objectives : A new deconvolution method for the analysis of time-resolved laser-induced fluorescence spectroscopy (TR-LIFS) data is introduced and applied for tissue diagnosis.

Method : The intrinsic TR-LIFS decays are expanded on a Laguerre basis, and the computed Laguerre expansion coefficients (LEC) are used to characterize the sample fluorescence emission. The method was applied for the diagnosis of atherosclerotic vulnerable plaques.

Results : At a first stage, using a rabbit atherosclerotic model, 73 TR-LIFS in-vivo measurements from the normal and atherosclerotic aorta segments of eight rabbits were taken. The Laguerre deconvolution technique was able to accurately deconvolve the TR-LIFS measurements. More interesting, the LEC reflected the changes in the arterial biochemical composition and provided discrimination of lesions rich in macrophages/foamcells with high sensitivity (> 85%) and specificity (> 95%). At a second stage, 348 TR-LIFS measurements were obtained from the explanted carotid arteries of 30 patients. Lesions with significant inflammatory cells (macrophages/foam-cells and lymphocytes) were detected with high sensitivity (> 80%) and specificity (> 90%), using LEC-based classifiers.

Conclusion : This study has demonstrated the potential of using TR-LIFS information by means of LEC for in- vivo tissue diagnosis, and specifically for detecting inflammation in atherosclerotic lesions, a key marker of plaque vulnerability.

New methods for time-resolved fluorescence spectroscopy data analysis based on the Laguerre expansion technique--applications in tissue diagnosis

OBJECTIVES

A new deconvolution method for the analysis of time-resolved laser-induced fluorescence spectroscopy (TR-LIFS) data is introduced and applied for tissue diagnosis.

METHOD

The intrinsic TR-LIFS decays are expanded on a Laguerre basis, and the computed Laguerre expansion coefficients (LEC) are used to characterize the sample fluorescence emission. The method was applied for the diagnosis of atherosclerotic vulnerable plaques.

RESULTS

At a first stage, using a rabbit atherosclerotic model, 73 TR-LIFS in-vivo measurements from the normal and atherosclerotic aorta segments of eight rabbits were taken. The Laguerre deconvolution technique was able to accurately deconvolve the TR-LIFS measurements. More interesting, the LEC reflected the changes in the arterial biochemical composition and provided discrimination of lesions rich in macrophages/foam-cells with high sensitivity (> 85%) and specificity (> 95%). At a second stage, 348 TR-LIFS measurements were obtained from the explanted carotid arteries of 30 patients. Lesions with significant inflammatory cells (macrophages/foam-cells and lymphocytes) were detected with high sensitivity (> 80%) and specificity (> 90%), using LEC-based classifiers.

CONCLUSION

This study has demonstrated the potential of using TR-LIFS information by means of LEC for in vivo tissue diagnosis, and specifically for detecting inflammation in atherosclerotic lesions, a key marker of plaque vulnerability.

The use and performance of BioSand filters in the Artibonite Valley of Haiti: a field study of 107 households

INTRODUCTION

Approximately one billion people world-wide lack access to adequate amounts of safe water. Most are in developing countries, especially in rapidly expanding urban fringes, poor rural areas, and indigenous communities.

METHODS

In February and March 2005, a field study of 107 households was conducted to evaluate the use and performance of the Manz BioSand filter in the Artibonite Valley of Haiti. Approximately 2000 filters had been installed in this area over the preceding 5 years by the staff in Community Development at Hospital Albert Schweitzer, Deschappelle, Haiti. Interviews, observations, and water samplings were carried-out by two teams of Haitian enumerators, each consisting of a nurse and a filter technician. Water analyses were performed by Haitian lab technicians using the membrane filtration method to determine Escherichia coli counts. The enumerators and the lab technicians completed a 2 week training program before beginning the study; they worked under the direct supervision of the primary investigator. Laboratory quality was monitored by running 10% blank and 10% duplicate samples.

RESULTS

The households contained an average of 5.4 persons. Filters had been in use for an average of 2.5 years, and participants were generally satisfied with their filter's performance. Shallow, hand-dug wells provided the only source of water for 61% of the households, with 26% using water piped from springs or deep wells, and 13% having access to both. Only 3% had plumbing in their homes. Source water from shallow wells contained an average of 234 E. coli cfu/100 mL. Piped sources averaged 195 E. coli cfu/100 mL. Of the source water samples 26% contained 0-10 E. coli cfu/100 mL. Of the filtered water samples 97% contained 0-10 E. coli cfu/100 mL (80% with 0 cfu/100 mL, and 17% with 1-10 cfu/100 mL). Overall bacterial removal efficiency for the filters was calculated to be 98.5%. Turbidity decreased from an average of 6.2 NTU in source water samples to 0.9 NTU in the filtered water. None of the households treated the water after filtering; 91% used the filtered water only for drinking. No problems related to filter construction were observed; 13% were found to have significantly decreased flow rates (all restored by cleaning the filter). Recontamination was found to occur, with only 3% of the samples from the filters' spouts containing >10 E. coli cfu/100 mL and 22% of the stored filtered water samples at point-of-use containing >10 cfu/100 mL.

CONCLUSION

The Manz BioSand filters are an attractive option for supplying water treatment to family units in rural areas of poorly developed countries.

Diagnosis of vulnerable atherosclerotic plaques by time-resolved fluorescence spectroscopy and ultrasound imaging

In this study, time-resolved laser-induced fluorescence spectroscopy (TR-LIFS) and ultrasonography were applied to detect vulnerable (high-risk) atherosclerotic plaque. A total of 813 TR-LIFS measurements were taken from carotid plaques of 65 patients, and subsequently analyzed using the Laguerre deconvolution technique. The investigated spots were classified by histopathology as thin, fibrotic, calcified, low-inflamed, inflamed and necrotic lesions. Spectral and time-resolved parameters (normalized intensity values and Laguerre expansion coefficients) were extracted from the TR-LIFS data. Feature selection for classification was performed by either analysis of variance (ANOVA) or principal component analysis (PCA). A stepwise linear discriminant analysis algorithm was developed for detecting inflamed and necrotic lesion, representing the most vulnerable plaques. These vulnerable plaques were detected with high sensitivity (>80%) and specificity (>90%). Ultrasound (US) imaging was obtained in 4 carotid plaques in addition to TR-LIFS examination. Preliminary results indicate that US provides important structural information of the plaques that could be combined with the compositional information obtained by TR-LIFS, to obtain a more accurate diagnosis of vulnerable atherosclerotic plaque.

Immunohistochemical localization of cannabinoid type 1 and vanilloid transient receptor potential vanilloid type 1 receptors in the mouse brain

Cannabinoid type 1 receptors and transient receptor potential vanilloid type 1 channels have been proposed to act as metabotropic and ionotropic receptors, respectively, for two classes of endogenous polyunsaturated fatty acid amides, the acylethanolamides and the acyldopamides. Furthermore, we and others have shown that functional crosstalk occurs between these two receptors when they are expressed in the same cell. Although demonstrated in sensory neurons of the dorsal root ganglia, spinal cord and myenteric neurons, co-expression of cannabinoid type 1 and transient receptor potential vanilloid type 1 has not yet been studied in the brain. In the present study, we addressed this issue by using commercially available specific antibodies whose specificity was confirmed by data obtained with brains from cannabinoid type 1(-/-) and transient receptor potential vanilloid type 1(-/-) mice. Double cannabinoid type 1/transient receptor potential vanilloid type 1 immunofluorescence and single cannabinoid type 1 or transient receptor potential vanilloid type 1 avidin-biotin complex immunohistochemistry techniques were performed and both methods used point to the same results. Cannabinoid type 1/transient receptor potential vanilloid type 1 expression was observed in the hippocampus, basal ganglia, thalamus, hypothalamus, cerebral peduncle, pontine nuclei, periaqueductal gray matter, cerebellar cortex and dentate cerebellar nucleus. In particular, in the hippocampus, cannabinoid type 1/transient receptor potential vanilloid type 1 expression was detected on cell bodies of many pyramidal neurons throughout the CA1-CA3 subfields and in the molecular layer of dentate gyrus. In the cerebellar cortex, expression of cannabinoid type 1/transient receptor potential vanilloid type 1 receptors was found surrounding soma and axons of the vast majority of Purkinje cell bodies, whose cytoplasm was found unstained for both receptors. Cannabinoid type 1 and transient receptor potential vanilloid type 1 immunoreactivity was also detected in: a) the globus pallidus and substantia nigra, in which some intensely transient receptor potential vanilloid type 1 immunopositive cell bodies were found in dense and fine cannabinoid type 1/transient receptor potential vanilloid type 1 positive and cannabinoid type 1 positive nerve fiber meshworks, respectively; b) the cytoplasm of thalamic and hypothalamic neurons; and c) some neurons of the ventral periaqueductal gray. These data support the hypothesis of a functional relationship between the two receptor types in the CNS.

Cannabinoid-receptor 1 null mice are susceptible to neurofilament damage and caspase 3 activation

Administered cannabinoids have been shown to ameliorate signs of CNS inflammatory disease in a number of animal models, including allergic encephalomyelitis. More recently, neuroprotective actions have been attributed to activation of the cannabinoid 1 receptor in a number of in vitro and in vivo models. One of these, chronic relapsing experimental allergic encephalomyelitis, is considered a robust analog of multiple sclerosis. In this study, spinal cord tissue from cannabinoid receptor 1 knockout mice was analyzed for neurofilament H and myelin basic protein content, as markers of neurons/axons and myelin respectively, during the course of chronic relapsing experimental allergic encephalomyelitis. Dephosphorylation of a neurofilament H epitope, immunoreactive to the SMI32 antibody, was assessed as a marker of axonal damage and levels of the endpoint cell death mediator caspase 3 were evaluated. It was found that both neurofilament and myelin basic protein levels decrease over the course of disease, indicating concomitant neuronal/axonal loss and demyelination. Loss of each marker was more severe in cannabinoid receptor 1 knockout animals. Increased SMI32 reactivity was observed as disease progressed. SMI32 reactivity was significantly increased in knockout animals over wildtype counterparts, an indication of greater axonal dephosphorylation and injury. Active caspase 3 levels were increased in all animals during disease, with knockout animals displaying highest levels, even in knockout animals prior to disease induction. These results indicate that lack of the cannabinoid receptor 1 is associated with increased caspase activation and greater loss and/or compromise of myelin and axonal/neuronal proteins. The increase of caspase 3 in knockout mice prior to disease induction indicates a latent physiological effect of the missing receptor. The data presented further strengthen the hypothesis of neuroprotection elicited via cannabinoid receptor 1 signaling.

Randomized, placebo-controlled, phase I/IIa evaluation of the safety and immunogenicity of fowlpox virus expressing HIV gag-pol and interferon-gamma in HIV-1 infected subjects

We conducted a randomized, placebo-controlled double-blind trial to examine the safety and immunogenicity of a candidate HIV therapeutic vaccine based upon a recombinant fowl pox virus capable of coexpressing the human cytokine interferon-gamma and/or genes from HIV-1. Thirty-five eligible subjects were randomized (12 placebo, 11 fowlpox + HIV genes, 12 fowl pox + HIV genes + interferon gamma). All but one subject (placebo group) received three immunizations (by intramuscular injection on day 0, week 4 and week 12) and all completed 52 weeks of follow-up. All subjects continued to take combination antiretroviral therapy for the duration of study. There were no significant toxicity or safety concerns and the distribution of adverse events and their severity was consistent across each randomly assigned vaccine group. Comparison of placebo recipients with the combined recipients of the two vaccine constructs, in terms of anti-HIV gag ELISpot or lymphoproliferative responses, tended to favour the placebo group, but were not significantly different (difference in time-weighted mean change from baseline = 56 Spot forming units (sfu)/10(6) PBMC; p = 0.062 and 4.4 SI; p = 0.337). There were no significant changes in CTL responses by standard Cr(51) release assay. Anti-FPV antibodies were detected by week 14 in 0 placebo and 20 (87%) vaccine recipients. Although safe, neither vaccine construct appeared to possess detectable T-cell mediated anti-HIV immunogenic properties in HIV infected individuals, as measured by standard T cell assays.

A review of methods currently used for assessment of in vivo endothelial function

An intact vascular endothelium is critical to the maintenance of normal arterial tone and coagulation status. Endothelial injury leading to dysfunction is thought to be a precursor to most if not all vascular disease, and has been implicated as a critical event in atherosclerosis. At present there are several methods available for detection of in vivo endothelial function, and the aim of this study was to critically review these methods. Five distinct methods were identified and studied in detail. These methods are diverse and each assesses a different vascular bed. Importantly there is no uniformity among investigators over choice of method and protocol, making it difficult to compare in vivo enothelial dysfunction between groups. These issues need to be addressed in large scale comparative analyses so that investigators can agree a common approach to endothelial function assessment.

Prescribing patterns in high-need Health Authority populations: how does an ethnically mixed composition affect volume and cost?

BACKGROUND

Prescribing is the most common therapeutic intervention in primary care, and there is substantial variation in prescribing practice across England. We investigate broad patterns of prescribing across Health Authorities in England, concentrating on ethnically diverse populations.

METHODS

Initially we examined the association between a number of prescribing indicators from the Prescribing Support Unit Prescribing Toolkit and 'Needs Profiles'. We then considered whether the observed patterns of prescribing were appropriate, that is, could be largely explained by variations in the prevalence of a medical condition for which the corresponding group of drugs would be prescribed.

RESULTS

The volume and cost of prescribing was generally lower in more ethnically diverse Health Authority populations when compared with more elderly or deprived populations. There was a significant negative association between ethnic composition and net-ingredient-cost per patient of cardiovascular drugs, but this disappeared upon adjusting for mortality from coronary heart disease.

CONCLUSIONS

The volume and cost of prescribing was generally lower in more ethnically diverse Health Authority populations relative to other high-need population profiles. Further work on this subject matter is merited, particularly if individual level data is available.

Antipsychotic depot medication and attitudes of community psychiatric nurses

Utilization of long-acting antipsychotic injections (depots) shows wide regional variation. In many countries, community psychiatric nurses (CPNs) administer depots but their concerns and attitudes regarding these drugs are seldom considered. We aimed to investigate attitudes and knowledge towards depots in a cross-sectional survey of CPNs in London, and compare them with those of psychiatrists obtained in a previous study. Three subscales of a depot attitude/knowledge questionnaire were used with additional items which referred to aspects of the CPN role. Participants were 70 CPNs who attended an academic meeting. Most CPNs reported that they were involved in treatment decisions (78%) although some CPNs seldom asked their patients about side effects (19%) and felt that they did not have sufficient time for consultations (23%) or training (23%). Several CPNs believed that depots are old fashioned (34%) and stigmatizing (44%). Compared to psychiatrists, CPNs believed more that depots compromised patient autonomy (28%, P = 0.003) and were coercive (42%, P < 0.001). Familiarity with depots and their knowledge of side effects were positively associated with favourable attitudes. CPNs have several strongly endorsed attitudes towards depot medication. Interprofessional group differences also exist which may undermine the treatment process. Training/refresher courses about depots should highlight systematic treatment decision-making and side effect monitoring which, in turn, may improve professionals' attitudes, knowledge and clinical monitoring of depots.

Dynamic creep and mechanical characteristics of SmartSet GHV bone cement

The restrained dynamic creep behaviour and mechanical properties of SmartSet GHV bone cement have been investigated at both room temperature and body temperature. It was found that the bone cement behaves significant differently at room temperature from that at body temperature. The test temperature had a strong effect on the creep performance of the bone cements with a higher creep rate observed at body temperature at each loading cycle. For both temperatures, two stages of creep were identified with a higher creep rate during early cycling followed by a steady state creep rate. The relationship between creep deformation and loading cycle can be expressed by a Hyperb 1 model. As a visco-elastic material, the sensitivity of bone cement to the temperature change was evident during mechanical testing. Compared to the mechanical strength at room temperature, a decreased value was demonstrated at body temperature. The bending modulus was very sensitive to the change in testing temperature, where a reduction of 52% was recorded. A significant reduction in compressive and bending strength, 31 and 23% were recorded respectively. The effect of temperature on bending strength was less apparent, where only 13% reduction was exhibited at body temperature compared to room temperature.

Hemophilia therapy innovation: development of an advanced category recombinant factor VIII by a plasma/albumin-free method. Proceedings of a Special Symposium at the XIXth Congress of the International Society on Thrombosis and Haemostasis, July 12-18, 2003, Birmingham, UK

Replacement therapy for hemophilia A has evolved from the early use of whole blood, citrated plasma, and cryoprecipitate, to purified factor VIII (FVIII) concentrates, first derived from plasma, then produced by recombinant DNA technology. Recombinant FVIII (rFVIII) concentrates have provided improved safety for patients with hemophilia A since they significantly reduce the risk of transmission of blood-borne infections. Nevertheless, human- or animal-derived plasma proteins are still included at some step in preparation of all previously licensed rFVIII, thereby introducing the potential for transmission of human or animal pathogens. Anti-hemophilic factor (recombinant), plasma/albumin-free method (rAHF-PFM), a novel advanced category rFVIII produced without the addition of human or animal plasma proteins, has been developed with the goal of providing the greatest possible margin of safety to hemophilia patients. This report, based on a symposium of the XIXth International Society on Thrombosis and Haemostasis Congress, provides an overview of the rAHF-PFM development program as well as current findings from the global clinical evaluation of rAHF-PFM in pediatric and adult previously treated patients.

Quantitative measurement of the stresses induced during polymerisation of bone cement

When bone cement cures, residual stresses due to bulk and thermal shrinkage will result. Present finite element (FE) simulations of implanted constructs often do not account for these stresses as an initial condition; this may lead to overestimations of the fatigue life of the cement. In the present study, an instrumented stem equipped with strain gauges and a thermocouple was employed to experimentally quantify the residual stresses induced as a result of bone cement curing within a simulated bone/cement/stem construct. Residual stresses as high as 10 MPa were observed in the cement mantle. Residual stresses of this magnitude are potentially high enough to initiate damage within the cement mantle or at the stem/cement interface immediately post-implantation. The acoustic emission technique has demonstrated that cracking and sliding mechanisms are occurring during curing, resulting in partial relaxation of these stresses. The implications for FE simulations of the implanted construct are discussed.

A look at a Hispanic and African American population in an urban prenatal diagnostic center: Referral reasons, amniocentesis acceptance, and abnormalities detected

PURPOSE

To describe the Hispanic and African-American population referred to our inner city Los Angeles Prenatal Diagnostic Center. To evaluate trends in referral reasons, amniocentesis acceptance, and to assess the number and types of fetal abnormalities found from 1995 to 2001.

METHODS

A retrospective study using the data from 3085 daily log entries on patients referred for prenatal counseling. The data included race, age, referral reason, amniocentesis decision and results, and fetal abnormalities.

RESULTS

The population was 76% Hispanic and 22% African American. Most referrals were for advanced maternal age (42%) and maternal serum screening (28%). The overall amniocentesis acceptance rate was 52%; advanced maternal age amniocentesis acceptance rate was 46%, and maternal serum screen positive amniocentesis acceptance rate was significantly higher at 64%. There was a significant difference between the overall amniocentesis acceptance rate for Hispanics (48%) and African Americans (63%). There was also a significant downward trend in amniocentesis acceptance between 1995 (63%) and 2001 (39%). Amniocentesis acceptance was significantly greater among patients who were < 35 years of age (65%) than those who were older (47%). An incidence of 7% abnormalities was detected by ultrasound and amniocentesis.

CONCLUSIONS

Acceptance of amniocentesis in the Hispanic and African American population in our prenatal diagnostic center is significantly lower than what has previously been reported in the literature for Caucasians and reported in California statewide prenatal diagnostic center data for non-MS-AFP. There was a significant decline in amniocentesis acceptance from 1995 to 2001. Our incidence of fetal abnormalities was higher than reported in California statewide data.

Association between baseline radiographic damage and improvement in physical function after treatment of patients with rheumatoid arthritis

OBJECTIVES

To identify factors associated with poor physical function in rheumatoid arthritis and to assess whether baseline joint damage has an impact on improvement in physical function during infliximab treatment.

METHODS

428 patients with active rheumatoid arthritis despite methotrexate treatment received methotrexate alone or with infliximab (3 mg/kg or 10 mg/kg every four or eight weeks) for 54 weeks (the ATTRACT trial). Data on clinical outcomes and physical function (assessed by the health assessment questionnaire (HAQ)) were collected. Structural damage was assessed using the van der Heijde modification of the Sharp score. Odds ratios (OR) for factors associated with severe functional disability (HAQ > or =2.0) at baseline were estimated using multiple logistic regression analyses, and baseline factors related to the change in physical function after treatment at week 54 were determined.

RESULTS

Baseline radiographic scores were correlated with baseline HAQ scores. After adjustment for demographic characteristics in the logistic regression model, baseline disease activity scores, radiological joint damage, fatigue, and morning stiffness were found to be associated with severe functional disability (HAQ >2.0), with OR values of 2.00 (1.53 to 2.63), 1.82 (1.15 to 2.87), 1.19 (1.05 to 1.34), and 1.07 (1.01 to 1.13), respectively. In multiple linear regression analysis, physical disability, joint damage, and fatigue at baseline were correlated with less improvement in physical function after treatment. Infliximab treatment was associated with greater improvement in physical function.

CONCLUSIONS

Greater joint damage at baseline was associated with poorer physical function at baseline and less improvement in physical function after treatment, underlining the importance of early intervention to slow the progression of joint destruction.

Measuring empathy: reliability and validity of the Empathy Quotient

BACKGROUND

Empathy plays a key role in social understanding, but its empirical measurement has proved difficult. The Empathy Quotient (EQ) is a self-report scale designed to do just that. This series of four studies examined the reliability and validity of the EQ and determined its factor structure.

METHOD

In Study 1, 53 people completed the EQ, Social Desirability Scale (SDS) and a non-verbal mental state inference test, the Eyes Task. In Study 2, a principal components analysis (PCA) was conducted on data from 110 healthy individuals and 62 people reporting depersonalisation (DPD). Approximately 1 year later, Study 3, involved the re-administration of the EQ (n = 24) along with the Interpersonal Reactivity Index (IRI; n = 28). In the last study, the EQ scores of those with DPD, a condition that includes a subjective lack of empathy, were examined in depth.

RESULTS

An association was found between the Eyes task and EQ, and only three EQ items correlated with the SDS. PCA revealed three factors: (1) 'cognitive empathy'; (2) 'emotional reactivity', and (3) 'social skills'. Test-retest reliability was good and moderate associations were found between the EQ and IRI subscales, suggesting concurrent validity. People with DPD did not show a global empathy deficit, but reported less social competence.

CONCLUSIONS

The EQ is a valid, reliable scale and the different subscales may have clinical applications.

Carbon fibre plates in the treatment of femoral periprosthetic fractures

A retrospective review of fractures occurring around the femoral component of total hip replacements was performed using patient notes and X rays. Between 1996 and 2002, 12 patients with total hip replacement had fixation of their periprosthetic femoral shaft fracture with carbon fibre plates. The mean patient age was 76 years (range 57-94). With regard to fracture type (Johansson Classification), three were Type 2 and nine were Type 3. In 11 cases the average time to union was 4 months (range 3-6). There was one non-union leading to implant failure. This was subsequently treated with a revision arthroplasty. There were no other significant complications. Although designed to fit the supracondylar region of the femur, we had no difficulty in applying the plate over the trochanteric region. Our results indicate that carbon fibre plates are effective in the management of femoral periprosthetic fractures in the elderly and this may be related to the unique properties of the plate.

Medicinal cannabis: is delta9-tetrahydrocannabinol necessary for all its effects?

Cannabis is under clinical investigation to assess its potential for medicinal use, but the question arises as to whether there is any advantage in using cannabis extracts compared with isolated Delta9-trans-tetrahydrocannabinol (Delta9THC), the major psychoactive component. We have compared the effect of a standardized cannabis extract (SCE) with pure Delta9THC, at matched concentrations of Delta9THC, and also with a Delta9THC-free extract (Delta9THC-free SCE), using two cannabinoid-sensitive models, a mouse model of multiple sclerosis (MS), and an in-vitro rat brain slice model of epilepsy. Whilst SCE inhibited spasticity in the mouse model of MS to a comparable level, it caused a more rapid onset of muscle relaxation, and a reduction in the time to maximum effect compared with Delta9THC alone. The Delta9THC-free extract or cannabidiol (CBD) caused no inhibition of spasticity. However, in the in-vitro epilepsy model, in which sustained epileptiform seizures were induced by the muscarinic receptor agonist oxotremorine-M in immature rat piriform cortical brain slices, SCE was a more potent and again more rapidly-acting anticonvulsant than isolated Delta9THC, but in this model, the Delta9THC-free extract also exhibited anticonvulsant activity. Cannabidiol did not inhibit seizures, nor did it modulate the activity of Delta9THC in this model. Therefore, as far as some actions of cannabis were concerned (e.g. antispasticity), Delta9THC was the active constituent, which might be modified by the presence of other components. However, for other effects (e.g. anticonvulsant properties) Delta9THC, although active, might not be necessary for the observed effect. Above all, these results demonstrated that not all of the therapeutic actions of cannabis herb might be due to the Delta9THC content.

Isochromosome 22 in trisomy 22 mosaic with five cell lines

This report describes a full-term male infant with trisomy 22 due to an isochromosome 22. Prenatal diagnosis with amniotic fluid showed two cell lines, one with an isochromosome 22 and the other with a deleted isochromosome 22. Subsequent cytogenetic analyses of cord blood, umbilical cord tissue, and placenta revealed additional cell lines. A normal cell line was found in umbilical cord tissue and two of three placental sites. The newborn had numerous dysmorphic features and died within 48 hrs of birth.

HIV Lipodystrophy Case Definition using Artificial Neural Network Modelling

Objective

A case definition of HIV lipodystrophy has recently been developed from a combination of clinical, metabolic and imaging/body composition variables using logistic regression methods. We aimed to evaluate whether artificial neural networks could improve the diagnostic accuracy.

Methods

The database of the case-control Lipodystrophy Case Definition Study was split into 504 subjects (265 with and 239 without lipodystrophy) used for training and 284 independent subjects (152 with and 132 without lipodystrophy) used for validation. Back-propagation neural networks with one or two middle layers were trained and validated. Results were compared against logistic regression models using the same information.

Results

Neural networks using clinical variables only (41 items) achieved consistently superior performance than logistic regression in terms of specificity, overall accuracy and area under the ROC curve. Their average sensitivity and specificity were 72.4 and 71.2%, as compared with 73.0 and 62.9% for logistic regression, respectively (area under the ROC curve, 0.784 vs 0.748). The discriminating performance of the neural networks was largely unaffected when built excluding 13 parameters that patients may not have readily available. The average sensitivity and specificity of the neural networks remained the same when metabolic variables were also considered (total 60 items) without a clear advantage against logistic regression (overall accuracy 71.8%). The performance of networks considering also body composition variables was similar to that of logistic regression (overall accuracy 78.5% for both).

Conclusions

Neural networks may offer a means to improve the discriminating performance for HIV lipodystrophy, when only clinical data are available and a rapid approximate diagnostic decision is needed. In this context, information on metabolic parameters is apparently not helpful in improving the diagnosis of HIV lipodystrophy, unless imaging and body composition studies are also obtained.

HIV lipodystrophy: prevalence, severity and correlates of risk in Australia

OBJECTIVE

To establish the prevalence, severity and factors associated with the HIV lipodystrophy syndrome.

METHODS

Cross-sectional study of lipodystrophy conducted in high HIV caseload primary care sites and HIV outpatient clinics. A subset of patients was examined using dual energy X-ray absorptiometry (DEXA) and single cut abdominal computerized tomography (CT) at the L4 vertebral level to quantify regional and total body fat. Factors associated with lipodystrophy, lipoatrophy and lipohypertrophy were assessed using multiple logistic regression based on assignment of cases and non-cases.

RESULTS

One thousand, three hundred and forty-eight patients (95% male) were surveyed, 20% had AIDS, the mean CD4 lymphocyte count was 486 cells/microL, and 55% had <500 HIV-1 RNA copies/mL. Most participants (87%) had previously received or were currently receiving combination antiretroviral therapy, 73% with at least one protease inhibitor (PI) and 14% a non-PI-containing regimen. Lipodystrophy prevalence was 53% and of these, 55% reported both peripheral lipoatrophy and central lipohypertrophy, 31% experienced peripheral lipoatrophy only and 14% had central lipohypertrophy only. The prevalence of any body habitus change was 62% in PI-experienced patients, 33% in PI-naive patients and 21% in antiretroviral-naive patients. Lipodystrophy severity was less in antiretroviral-naive patients and most severe in PI-experienced patients. Increasing severity of lipodystrophy was both positively and significantly correlated with elevated liver enzymes, decreased testosterone levels, decreased skin-fold thickness, lower levels of total and peripheral fat (DEXA) and higher levels of visceral fat (CT). Lipodystrophy was also significantly associated with increasing age, symptomatic HIV disease, effective viral suppression, and increasing duration of therapy with both nucleoside reverse transcriptase inhibitors and PIs.

CONCLUSIONS

The prevalence and severity of lipodystrophy reflects both length and type of treatment with antiretroviral therapy and is associated with decreased testosterone, increases in liver enzymes and greater suppression of HIV RNA. The reports of lipodystrophy in a small percentage of antiretroviral-naive patients suggests that factors other than antiretroviral therapy may be involved in the aetiology of this syndrome or that some conditions, such as wasting or age-associated obesity, may mimic lipoatrophy and lipohypertrophy, respectively.

Cervical screening and health inequality in England in the 1990s

STUDY OBJECTIVE

s: To examine changing inequality in the coverage of cervical screening and its relation to organisational aspects of primary care and to inequality in cervical cancer incidence and mortality.

DESIGN

Retrospective time trends analysis (1991-2001) of screening coverage and cervical cancer incidence and mortality in England.

SETTING

The 99 district health authorities in England, as defined by 1999 boundaries were used to create a time series of incidence and mortality rates from cervical cancer per 100 000 population. A subset of 60 district health authorities were used to construct a time series of screening coverage data and GP and practice characteristics. Health authorities were categorised into one of three "deprivation" groups using the Townsend Deprivation Index.

PARTICIPANTS

Women aged <35 and 35-64 were selected from health authority populations as the main focus of the study.

RESULTS

Cervical cancer screening coverage was consistently higher in affluent areas from 1991-9 but ratio rates of inequality between affluent and deprived health authorities narrowed over time. The increase in coverage in deprived areas was most closely associated with an increase in the number of practice nurses. Cervical cancer incidence and mortality rates were consistently higher in deprived health authorities, but inequality decreased. Screening coverage and cervical cancer rates were highly negatively correlated in deprived health authorities.

CONCLUSION

A primary health care intervention such as an organised programme of cervical screening can contribute to reducing inequality in population health.