Hypoalbuminaemia and colonic polyps: a case of protein-losing enteropathy with cap polyposis?

A 69-year-old woman was admitted in September 2005 dehydrated and unwell. She had a 6-month history of constipation, poor appetite and weight loss, and was hypoalbuminaemic (21 g/litre). She had initially been referred for colonoscopy in March to exclude colonic malignancy. Multiple pedunculated polyps up to the splenic flexure were seen, with histology felt to be consistent with hyperplastic polyps and mild inflammation. Her symptoms persisted, and by August she had lost 3 stone in weight. She started to experience loose stools, and repeat colonoscopy was planned. However, the bowel preparation made her feel unwell. She couldn't walk, and so presented to the acute medical take.

The patient looked pale and dehydrated. Her chest was clear, with a diffusely tender abdomen. Bowel sounds were present, and there were no palpable masses. Bloods showed a corrected calcium of 1.58 mmol/litre. Fluid resuscitation and calcium replacement was started. A malignant process was queried. Liver function tests showed a low albumin of 21 g/litre but were otherwise unremarkable. A computed tomography scan of the abdomen and chest were normal. A gastroscopy showed mild oesophagitis with Candida in the mid and lower oesophagus, gastritis in the antrum of the stomach with heavy Helicobacter pylori growth, and a normal duodenum. Biopsies showed no evidence of coeliac disease or giardia.

The patient's albumin fell to 8 g/litre. A 24-hour urine protein collection was 0.46 g, excluding nephrotic syndrome. Nasogastric feeding was commenced.

Gut hormones showed a modestly elevated chromogranin A (164 pmol/litre) and gastrin (307 pmol/ litre) but were not diagnostic of a neuroendocrine tumour. Amyloid was queried and the original colonic biopsies re-examined. This was not found, but cap polyposis was suggested.

The patient failed to improve and died 15 days after admission. Post mortem found the distal large bowel to contain multiple dark sessile polyps, looking like slugs, on exaggerated mucosal folds (Figure 1). The histological findings comprised elongated, tortorous and distended crypts, with evidence of inflammation and a 'cap' of granulation tissue, confirming cap polyposis. In addition the patient had a right haemothorax. This was caused by a dissection in the pulmonary artery, with evidence of atheroma identified. The right ventricle was hypertrophic, with the lungs showing multiple haemorrhagic infarcts. These changes suggested pulmonary hypertension. Whether this was related to the cap polyposis was unclear. A reasonable explanation is that the patient had showered off pulmonary emboli from a deep vein thrombosis (DVT) for some time, secondary to immobility associated with her poor state of health. This was supported by a right calf DVT identified at post mortem. The dissection of the pulmonary artery was probably secondary to the low protein state and pulmonary artery hypertension.

Vesicoureteric reflux in the adult

Vesicoureteric reflux (VUR) is a well-recognized entity in the paediatric population, but is not well described or understood in the adult population. This is partly explained by the fact that its incidence declines with advancing age. Its diagnosis is, however, still important, with VUR accounting for at least 10% of adult patients with end-stage renal disease. With early detection and careful management, the secondary complications of VUR such as renal failure can be prevented. Imaging plays a major role in the detection and evaluation of VUR in the adult patient. Conventional techniques such as micturating cystourethrograms have now been supplemented by cross-sectional imaging with CT and MRI. In this review article, we comprehensively review the up to date status of imaging the adult patient with VUR and discuss important subgroups of patients such as pregnant and transplant patients.

Fluid restriction during running increases GI permeability

The purpose of this study was to determine gastrointestinal (GI) permeability during prolonged treadmill running (60 min at 70 % V.O2max) with and without fluid intake (3 ml/kg body mass/10 min). Twenty runners (11 males, 9 females; age = 22 +/- 3 (SD) yrs; mean V.O2max = 55.7 +/- 5.0 ml/kg/min) completed four experiments: 1) rest, 2) running with no fluid (NF), 3) running with ingestion of a 4 % glucose solution (GLU), and 4) running with ingestion of a water placebo (PLA). To determine GI permeability, subjects also drank a solution containing 5 g sucrose (S), 5 g lactulose (L), and 2 g rhamnose (R) immediately prior to each trial. Gastroduodenal permeability was determined by urinary S excretion, while small intestinal permeability was determined by the L/R excretion ratio. Percent body mass loss (i.e., dehydration) was negligible during rest, GLU and PLA, while NF resulted in a 1.5 % loss of body mass (p < 0.05). Gastroduodenal and intestinal permeability were significantly (p < 0.008) increased in NF compared to rest. There were no other differences in GI permeability. These results indicate that fluid restriction during 1 h of steady-state running increases GI permeability above resting levels.

Contribution of full-thickness supraspinatus tendon tears to acquired subcoracoid impingement

AIM

To assess the relationship between the severity of full-thickness supraspinatus tendon tears and the development of subcoracoid impingement.

MATERIALS AND METHODS

Fifty-one magnetic resonance imaging (MRI) shoulder examination reports with full-thickness supraspinatus tears were retrospectively identified and reviewed by two dedicated musculoskeletal radiologists. The appearances of the rotator cuff muscles, biceps tendon and the lesser tubercle were recorded. The acromio-humeral distance and the axial coraco-humeral distance were measured. The data were recorded and analysed electronically.

RESULTS

The kappa values for inter-observer agreement were: 0.91 for acromio-humeral distance and 0.85 for coraco-humeral distance measurements. Twenty-six patients had significant retraction of the supraspinatus tendon, 85% (22 cases) of this group had imaging evidence of tear or tendonopathy of the subscapularis tendon. Twenty-five patients had no significant retraction of the supraspinatus, 56% (14 cases) of this group had imaging evidence of a subscapularis tear or tendonopathy. The acromio-humeral distance was significantly less in patients with supraspinatus tears and retraction (p<0.05). The subscapularis tendon was significantly more likely to be abnormal if the supraspinatus was retracted than if no retraction was present (p<0.05). There were no significant differences in coraco-humeral distances between the groups.

CONCLUSION

Subscapularis tendon signal and structural changes are frequently associated with full-thickness supraspinatus tendon tears, particularly if the supraspinatus is significantly retracted. In this static MRI series, the data do not support the occurrence of classical subcoracoid impingement as an aetiology; however, they may support the possibility of a dynamic mechanism, to which future studies could be directed.

[Pertussis: incidence, symptoms and costs]

BACKGROUND AND OBJECTIVE

A prospective sentinel study into the population-based incidence of pertussis in adults was done between 2001 and 2004 in Rostock (former East Germany) and Krefeld (former West Germany).

PATIENTS AND METHODS

971 outpatients, who consulted general practitioners or internists, were included. Clinical inclusion criteria were coughing for one week or more and no chronic respiratory diseases. Bordetella infection was diagnosed by PCR on nasopharyngeal swabs and ELISA for serology (IgG-anti-PT, IgA-anti-PT, IgG-anti-FHA, IgA-anti-FHA).

RESULTS

We found a total of 97 cases of pertussis in this cohort. The main symptom was coughing for a median of 7-8 weeks. Population-based incidence was estimated in Krefeld at 169 cases/100000 population per year, and in Rostock at 160/100000 per year. Resource use was 120 EUR of direct medical cost and 434 euro of indirect medical cost, not including hospitalization in this study.

CONCLUSIONS

Pertussis is a frequent cause of longer lasting cough in German adults, and it causes significant morbidity and costs.

An unusual case of elevated liver enzymes (2006: 10b)

HELLP syndrome is a form of severe pre-eclampsia with multisystem involvement. Laboratory markers include haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). We present a patient to our institution with HELLP syndrome complicated by liver necrosis. The patient underwent urgent Caesarian section prior to transfer.

Differences in neuropathologic characteristics across the Lewy body dementia spectrum

BACKGROUND

The objective of this comparative neuropathologic study was to determine the extent to which dementia with Lewy bodies (DLB) and Parkinson disease dementia (PDD) are distinct entities or part of a continuum with respect to the duration of parkinsonism.

METHODS

We evaluated the relationship between cortical alpha-synuclein pathology, plaques (Consortium to Establish a Registry for Alzheimer's Disease [CERAD]), tangles (Braak staging), and cholinergic deficits (choline acetyltransferase in temporal cortex) in 57 prospectively assessed patients (29 DLB, 28 PDD), confirmed at autopsy. The PDD group was divided according to the median duration of parkinsonism prior to dementia.

RESULTS

There was an association between longer duration of parkinsonism prior to dementia and less severe cortical alpha-synuclein pathology (chi(2) 10.4, df 2, p = 0.006) and lower CERAD plaque scores (chi(2) 26.6, df 9, p = 0.002), but not Braak staging. These findings were confirmed in a further correlation analysis, which also identified an unexpected correlation between more pronounced cortical cholinergic deficits and longer duration of parkinsonism prior to dementia (R = -0.37, p = 0.04).

CONCLUSION

While there is a clear relationship between the duration of Parkinson disease prior to the onset of dementia and key neuropathologic and neurochemical characteristics, there is a gradation of these differences across the dementia with Lewy bodies/Parkinson disease dementia spectrum and the findings do not support an arbitrary cut-off between the two disorders.

Approaches to the risk assessment of genotoxic carcinogens in food: A critical appraisal

The present paper examines the particular difficulties presented by low levels of food-borne DNA-reactive genotoxic carcinogens, some of which may be difficult to eliminate completely from the diet, and proposes a structured approach for the evaluation of such compounds. While the ALARA approach is widely applicable to all substances in food that are both carcinogenic and genotoxic, it does not take carcinogenic potency into account and, therefore, does not permit prioritisation based on potential risk or concern. In the absence of carcinogenicity dose-response data, an assessment based on comparison with an appropriate threshold of toxicological concern may be possible. When carcinogenicity data from animal bioassays are available, a useful analysis is achieved by the calculation of margins of exposure (MOEs), which can be used to compare animal potency data with human exposure scenarios. Two reference points on the dose-response relationship that can be used for MOE calculation were examined; the T25 value, which is derived from linear extrapolation, and the BMDL10, which is derived from mathematical modelling of the dose-response data. The above approaches were applied to selected food-borne genotoxic carcinogens. The proposed approach is applicable to all substances in food that are DNA-reactive genotoxic carcinogens and enables the formulation of appropriate semi-quantitative advice to risk managers.

Percutaneous vertebroplasty--initial clinical experience in osteoporotic and myelomatous compression fractures

BACKGROUND

To review the clinical impact of vertebroplasty in osteoporotic and myelomatous compression fractures

METHODS

Eleven compression fractures in eight patients were treated by percutaneous cement vertebroplasty over a three-year period, May 2000 to May 2003.

RESULTS

Successful percutaneous stabilisation and cement injection was performed in all compression fractures. In five of eight patients (eight of eleven compression fractures) injection of cement yielded dramatic reduction in pain within 24 hours of the procedure.

CONCLUSION

Preliminary experience suggests that percutaneous cement vertebroplasty is an effective well tolerated method of stabilisation of spinal wedge compression fractures resulting in dramatic reduction in associated pain in most cases.

Proton magnetic resonance spectroscopy in frontotemporal dementia

This study of frontotemporal dementia (FTD) was carried out to determine whether MR spectroscopy can provide an in vivo marker for the neuronal loss and gliosis that occur in this condition. We compared spectra in frontal and temporal regions known to be affected early in the course of the disease with spectra in the parietal lobe that is spared until late stages of FTD. We were interested in the relative concentrations of two compounds, NAA (a marker of neuronal integrity) and mI (a marker of gliosis), expressed as ratios to creatine (a relatively stable brain constituent). MR spectroscopy was performed on the temporal, parietal, and anterior cingulate cortices of five patients with the established semantic dementia form of FTD, two patients with the frontal form of FTD and 13 age matched controls. Structural MRI and neuropsychometry were also performed. Patients with FTD had reduced NAA/Cr in frontal and temporal, but not parietal lobes. The two patients with the frontal form of FTD had increased mI/Cr in their cingulate cortices. These data show for the first time that MR spectroscopy can reveal regionally selective abnormalities in patients with FTD. This opens up the possibility of using MR spectroscopy as a clinical tool to identify earlier presentations of the condition.

Valsalva and gravitational variability of the internal jugular vein and common femoral vein: Ultrasound assessment

PURPOSE

Central venous cannulation via the common femoral vein is an important starting point for many interventions. The purpose of this study was to determine the optimum conditions for cannulation of the femoral vein and to compare these with the relative changes in the internal jugular vein.

METHODS

High-resolution 2D ultrasound was utilised to determine variability of the calibre of the femoral and internal jugular veins in 10 healthy subjects. Venous diameter was assessed during the Valsalva manoeuvre and in different degrees of the Trendelenburg position.

RESULTS

The Valsalva manoeuvre significantly increased the size of the femoral and internal jugular veins. There was a relatively greater increase in femoral vein diameter when compared with the internal jugular vein of 40 and 29%, respectively. Changes in body inclination (Trendelenburg position) did not significantly alter the luminal diameter of the femoral vein. However, it significantly increased internal jugular vein diameter.

CONCLUSIONS

Femoral vein cannulation is augmented by the Valsalva manoeuvre but not significantly altered by the gravitational position of the subject.

Cyclooxygenase-1 haplotype modulates platelet response to aspirin

BACKGROUND

Aspirin (acetylsalicylic acid) irreversibly inhibits platelet cyclooxygenase (COX)-1, the enzyme that converts arachidonic acid (AA) to the potent platelet agonist thromboxane (TX) A2. Despite clear benefit from aspirin in patients with cardiovascular disease (CAD), evidence of heterogeneity in the way individuals respond has given rise to the concept of 'aspirin resistance.'

AIMS

To evaluate the hypothesis that incomplete suppression of platelet COX as a consequence of variation in the COX-1 gene may affect aspirin response and thus contribute to aspirin resistance.

PATIENTS AND METHODS

Aspirin response, determined by serum TXB2 levels and AA-induced platelet aggregation, was prospectively studied in patients (n = 144) with stable CAD taking aspirin (75-300 mg). Patients were genotyped for five single nucleotide polymorphisms in COX-1 [A-842G, C22T (R8W), G128A (Q41Q), C644A (G213G) and C714A (L237M)]. Haplotype frequencies and effect of haplotype on two platelet phenotypes were estimated by maximum likelihood. The four most common haplotypes were considered separately and less common haplotypes pooled.

RESULTS

COX-1 haplotype was significantly associated with aspirin response determined by AA-induced platelet aggregation (P = 0.004; 4 d.f.). Serum TXB2 generation was also related to genotype (P = 0.02; 4 d.f.).

CONCLUSION

Genetic variability in COX-1 appears to modulate both AA-induced platelet aggregation and thromboxane generation. Heterogeneity in the way patients respond to aspirin may in part reflect variation in COX-1 genotype.

Clinical impact of timely reporting of IgM for West Nile Virus

BACKGROUND

In 2002 diagnostic testing for West Nile Virus (WNV) infection was not ideal because commercial products were unavailable. Although testing was performed without charge by public health (PH), testing is not intended to be used for patient management and generally results are not available in a timely or reliable manner.

OBJECTIVES

This study was conducted to determine the clinical impact of having WNV serology available by a diagnostic laboratory within a few days of sample collection.

STUDY DESIGN

An IgM immunoassay (FT, from Focus Technologies) was performed August 13, 2003 to October 31, 2003 Monday, Wednesday and Friday in our hospital's virology laboratory with split sample testing at PH. All results (positive and negative) were called to physicians.

RESULTS AND CONCLUSIONS

Turn-around time for the FT assay was within 0-3 days; for PH, it was approximately 8 days. Of 95 samples, 6 were positive and 89 negative. For the FT negative samples, all were concordant with PH, but four FT positive samples (three sera and one cerebrospinal fluid) were discrepant. After resolution of the discrepancies, the FT test had a sensitivity of 100% and a specificity of 99%. Physicians reacted positively to having results faster. Fifty-eight percent of the results had clinical impact, 22% had undetermined impact, 13% were patient requests, and 4% had no impact. Concluding, the FT assay is 100% sensitive and 99% specific and in 58% there was clinical impact for WNV reporting in a timely manner.

Ultrasound biomicroscopy: role in diagnosis and management in 130 consecutive patients evaluated for anterior segment tumours

BACKGROUND/AIM

Ultrasound biomicroscopy (UBM) is an important tool for assessing anterior segment pathology. This study sought to evaluate UBM in the management of anterior segment tumours.

METHODS

Retrospective analysis of medical records of consecutive patients referred to the ocular oncology unit, University of California San Francisco (UCSF), for suspected anterior segment tumours from 1999 to 2004.

RESULTS

132 eyes from 130 patients were evaluated, including 55 uveal melanomas (UM), 21 iris naevi, 30 iris cysts, and 26 remaining lesions. Of the melanomas, 45 were also evaluated with conventional A/B-scan. There was 29% correspondence between the anatomical structures invaded by melanoma as identified by B-scan v disease extent defined by UBM. Ciliary body and peripheral iris involvement by melanomas was significantly more frequently observed by UBM than B-scan. Seven of 30 benign cysts were diagnosed as cystic before UBM evaluation. In three cases, neuroepithelial cysts were associated with intercurrent pathology including iris naevus (n = 2) and ciliary body melanoma (n = 1). Two ciliary body melanomas showed cavitation, including one patient with a pseudocyst. Histopathological correlation was possible in six cases.

CONCLUSION

UBM is an indispensable tool for the management of anterior segment tumours. This study demonstrates the superiority of UBM v conventional B-scan for the precise localisation of uveal melanoma, especially involving the ciliary body and peripheral iris.

Improving scientists' interaction with complex computational-visualization environments based on a distributed grid infrastructure

The grid has the potential to transform collaborative scientific investigations through the use of closely coupled computational and visualization resources, which may be geographically distributed, in order to harness greater power than is available at a single site. Scientific applications to benefit from the grid include visualization, computational science, environmental modelling and medical imaging. Unfortunately, the diversity, scale and location of the required resources can present a dilemma for the scientific worker because of the complexity of the underlying technology. As the scale of the scientific problem under investigation increases so does the nature of the scientist's interaction with the supporting infrastructure. The increased distribution of people and resources within a grid-based environment can make resource sharing and collaborative interaction a critical factor to their success. Unless the technological barriers affecting user accessibility are reduced, there is a danger that the only scientists to benefit will be those with reasonably high levels of computer literacy. This paper examines a number of important human factors of user interaction with the grid and expresses this in the context of the science undertaken by RealityGrid, a project funded by the UK e-Science programme. Critical user interaction issues will also be highlighted by comparing grid computational steering with supervisory control systems for local and remote access to the scientific environment. Finally, implications for future grid developers will be discussed with a particular emphasis on how to improve the scientists' access to what will be an increasingly important resource.

Perioperative Plasma Concentrations of Stable Nitric Oxide Products Are Predictive of Cognitive Dysfunction After Laparoscopic Cholecystectomy

In this study our objectives were to determine the incidence of postoperative cognitive dysfunction (POCD) after laparoscopic cholecystectomy under sevoflurane anesthesia in patients aged >40 and <85 yr and to examine the associations between plasma concentrations of i) S-100beta protein and ii) stable nitric oxide (NO) products and POCD in this clinical setting. Neuropsychological tests were performed on 42 ASA physical status I-II patients the day before, and 4 days and 6 wk after surgery. Patient spouses (n = 13) were studied as controls. Cognitive dysfunction was defined as deficit in one or more cognitive domain(s). Serial measurements of serum concentrations of S-100beta protein and plasma concentrations of stable NO products (nitrate/nitrite, NOx) were performed perioperatively. Four days after surgery, new cognitive deficit was present in 16 (40%) patients and in 1 (7%) control subject (P = 0.01). Six weeks postoperatively, new cognitive deficit was present in 21 (53%) patients and 3 (23%) control subjects (P = 0.03). Compared with the "no deficit" group, patients who demonstrated a new cognitive deficit 4 days postoperatively had larger plasma NOx at each perioperative time point (P < 0.05 for each time point). Serum S-100beta protein concentrations were similar in the 2 groups. In conclusion, preoperative (and postoperative) plasma concentrations of stable NO products (but not S-100beta) are associated with early POCD. The former represents a potential biochemical predictor of POCD.

Guideline for the management of chronic obstructive pulmonary disease (COPD): 2004 revision

OBJECTIVE

To revise the South African Guideline for the Management of Chronic Obstructive Pulmonary Disease (COPD) in the light of new insights into the disease and the value of new treatment approaches and drugs. New aspects considered include: A growing awareness of the impact of COPD in South Africa, and the urgent need for prevention strategies. The role of concurrent exposures to domestic and occupational atmospheric pollution, and previous lung infections including tuberculosis. The need to consider as goals of treatment both prevention of exacerbations and improvement of quality of life (health status) of patients with COPD. The development of both long-acting beta2-agonist and anticholinergic drugs for use in COPD. Emerging evidence on a limited role for inhaled corticosteroids in the treatment of COPD.

RECOMMENDATIONS

These include primary and secondary prevention; early diagnosis; staging of severity; assessment of reversibility with bronchodilator and, in some, responsiveness to corticosteroids; use of bronchodilators and other forms of treatment; rehabilitation; and treatment of complications. Advice is provided on the management of acute exacerbations, and the approach to air travel, prescribing long-term oxygen, and lung surgery including lung volume reduction surgery. Prevention, both primary and secondary, remains the most cost-effective measure in the management of COPD, and deserves more emphasis, particularly on the part of health care professionals. Primary prevention involves reducing public exposure to cigarette and other forms of smoke, and reduction of atmospheric pollution, and secondary prevention limits exposure and resultant progression in those with established disease. Spirometry is essential for the diagnosis of COPD and in staging severity. In addition, a new classification of severity that considers other indices of functional impairment is provided. Treatment involves a progression from 'as-needed' bronchodilators, through the addition of other more effective bronchodilators, usually in combination, in more severe stages. The importance of assessing potential reversibility in every patient with persistent symptoms, and of the limited role of oral and inhaled corticosteroids (ICS), is emphasised. These approaches also reduce exacerbations and may result in cost savings and improved prognosis. A practical low-cost approach to rehabilitation is proposed.

OPTIONS

Treatment recommendations are based on the following: the recommendations of the Global Obstructive Lung Disease (GOLD) initiative, which provides an evidence-based comprehensive and up-to-date review of treatment options; independent evaluation of the level of evidence in support of some of the new treatment trends; and consideration of factors that influence COPD management in South Africa, including lung co-morbidity and drug availability and cost.

OUTCOMES

The use of bronchodilators is driven by the presence of symptoms, but regular assessment of benefit, based on objective criteria, is essential. Several forms of treatment reduce exacerbations, the most effective of these is smoking cessation.

EVIDENCE

Working group of clinicians and clinical researchers following detailed literature review, particularly of studies performed in South Africa, and the GOLD guidelines.

BENEFITS, HARMS AND COSTS

The guideline pays particular attention to cost-effectiveness in South Africa, and promotes the initial use of less costly options. It rejects empirical use of corticosteroids both oral and inhaled, and promotes smoking cessation, and selection of treatment based on objective evidence of benefit. It also rejects a nihilistic or punitive approach, even in those who are unable to break the smoking addiction.

VALIDATION

The COPD Working Group comprised experienced pulmonologists representing all university departments in South Africa and some from private practice. All contributed to the development of the previous version of the South African guideline, and attend international meetings. One (JRJ) represents South Africa on the GOLD Guideline Executive. GUIDELINE SPONSOR: The meeting of the Working Group of the South African Thoracic Society was sponsored by an unrestricted educational grant from Boehringer Ingelheim (South Africa) (Pty) Ltd.

Expression of clock gene products in the suprachiasmatic nucleus in relation to circadian behaviour

Circadian timing within the suprachiasmatic nucleus (SCN) is modelled around cell-autonomous, autoregulatory transcriptional/post-translational feedback loops, in which protein products of canonical clock genes Period and Cryptochrome periodically oppose transcription driven by CLOCK:BMAL complexes. Consistent with this model, mCLOCK is a nuclear antigen constitutively expressed in mouse SCN, whereas nuclear mPER and mCRY are expressed rhythmically. Peaking in late subjective day, mPER and mCRY form heteromeric complexes with mCLOCK, completing the negative feedback loop as levels of mPer and mCry mRNA decline. Circadian resetting by light or non-photic resetting (mediated by neuropeptide Y) involves acute up- and down-regulation of mPer mRNA, respectively. Expression of Per mRNA also peaks in subjective day in the SCN of the ground squirrel, indicating common clock and entrainment mechanisms for nocturnal and diurnal species. Oscillation within the SCN is dependent on intercellular signals, in so far as genetic ablation of the VPAC2 receptor for vasoactive intestinal polypeptide (VIP) suspends SCN circadian gene expression. The pervasive effect of the SCN on peripheral physiology is underscored by cDNA microarray analysis of the circadian gene expression in liver, which involves ca. 10% of the genome and almost all aspects of cell function. Moreover, the same molecular regulatory mechanisms driving the SCN appear also to underpin peripheral cycles.

Observation of an exotic S = +1 baryon in exclusive photoproduction from the deuteron

In an exclusive measurement of the reaction gammad-->K(+)K(-)pn, a narrow peak that can be attributed to an exotic baryon with strangeness S=+1 is seen in the K(+)n invariant mass spectrum. The peak is at 1.542+/-0.005 GeV/c(2) with a measured width of 0.021 GeV/c(2) FWHM, which is largely determined by experimental mass resolution. The statistical significance of the peak is (5.2+/-0.6)sigma. The mass and width of the observed peak are consistent with recent reports of a narrow S=+1 baryon by other experimental groups.

Guidance for the safety assessment of botanicals and botanical preparations for use in food and food supplements

There is a growing interest by both consumers and industry for the development of food products with 'functional' properties, or health benefits. These products may take the form of dietary supplements or of foods. The health benefits are given by particular ingredients, and in many cases these are derived from botanicals. The variety of plants providing these functions is large, ranging from staple food sources such as cereals, fruits and vegetables, to herbals as used in traditional medicine. The food or ingredient conferring health properties may consist of the plants themselves, extracts thereof, or more purified components. The scientific literature is abundant with articles not only on the beneficial properties, but also on possible adverse health effects of plants and their components. The present report discusses the data required to determine the safe use of these types of ingredients, and provides advice on the development of risk assessment strategies consistent with due diligence under existing food regulations. Product specifications, composition and characterisation of standardised and authentic materials, documented history of use and comparison to existing products (taking into account the effect of industrial processing), description of the intended use and consequent exposure are highlighted as key background information on which to base a risk evaluation. The extent of experimental investigation required, such as in vitro, animal, and/or human studies, depends on the adequacy of this information. A decision tree is presented as an aid to determine the extent of data requirements based on product comparison. The ultimate safety in use depends on the establishment of an adequate safety margin between expected exposure and identified potential hazards. Health hazards may arise from inherent toxicities or contaminants of the plant materials, including the mechanism of the intended beneficial effect. A lower safety margin may therefore be expected than for food ingredients or additives where no physiological effects are intended. In rare cases, post launch monitoring programmes may be envisaged to confirm expected exposures and adequacy of the safety margin. This guidance document was elaborated by an expert group of the Natural Toxin Task Force of the European Branch of the International Life Sciences Institute--ILSI Europe and discussed with a wider audience of scientists at a workshop held on 13-15 May 2002 in Marseille, France.

Connexin35 mediates electrical transmission at mixed synapses on Mauthner cells

Auditory afferents terminating as "large myelinated club endings" on goldfish Mauthner cells are identifiable "mixed" (electrical and chemical) synaptic terminals that offer the unique opportunity to correlate physiological properties with biochemical composition and specific ultrastructural features of individual synapses. By combining confocal microscopy and freeze-fracture replica immunogold labeling (FRIL), we demonstrate that gap junctions at these synapses contain connexin35 (Cx35). This connexin is the fish ortholog of the neuron-specific human and mouse connexin36 that is reported to be widely distributed in mammalian brain and to be responsible for electrical coupling between many types of neurons. Similarly, connexin35 was found at gap junctions between neurons in other brain regions, suggesting that connexin35-mediated electrical transmission is common in goldfish brain. Conductance of gap junction channels at large myelinated club endings is known to be dynamically modulated by the activity of their colocalized glutamatergic synapses. We show evidence by confocal microscopy for the presence of the NR1 subunit of the NMDA glutamate receptor subtype, proposed to be a key regulatory element, at these large endings. Furthermore, we also show evidence by FRIL double-immunogold labeling that the NR1 subunit of the NMDA glutamate receptor is present at postsynaptic densities closely associated with gap junction plaques containing Cx35 at mixed synapses across the goldfish hindbrain. Given the widespread distribution of electrical synapses and glutamate receptors, our results suggest that the plastic properties observed at these identifiable junctions may apply to other electrical synapses, including those in mammalian brain.

Assessment of health economics in Alzheimer's disease (AHEAD): treatment with galantamine in the UK

OBJECTIVE

To assess the long-term health and economic impact of treating mild to moderate Alzheimer's disease (AD) with galantamine (16 mg or 24 mg per day) compared to no cholinesterase therapy in the UK.

METHODS

The long-term costs and outcomes were assessed using a model developed from longitudinal data on a cohort of AD patients. The model predicts the time until patients require full-time care, defined as the consistent requirement for a significant amount of care and supervision each day. Efficacy data were obtained from three clinical trials comparing galantamine with placebo, forecasts were made for ten years. Costs were determined in 2001 British pounds and discounted at 6% per annum, while outcomes such as time to full-time care were discounted at 1.5%.

RESULTS

Without pharmacological treatment, patients are expected to incur costs of 28,134 British pounds over ten years, 70% of costs accrue from providing full-time care. Galantamine (16 mg per day) is predicted to reduce the duration of the full-time care state by 12%; approximately five patients need to be treated to avoid one year of full-time care. The ten-year incremental costs per month of full-time care avoided average pound 192 British pounds per patient and 8,693 British pounds per QALY. Savings (1380 British pounds) are predicted for patients who continue treatment beyond six months and whose cognitive function is maintained or improved. Comparable results were estimated for the 24 mg dose.

CONCLUSION

In addition to the clinical benefits associated with galantamine treatment, the savings predicted from delaying when full-time care is needed may offset the treatment costs.

Short-range functional interaction between connexin35 and neighboring chemical synapses

Auditory afferents terminating as mixed, electrical, and chemical, synapses on the goldfish Mauthner cells constitute an ideal experimental model to study the properties of gap junctions in the nervous system as well as to explore possible functional interactions with the other major form of interneuronal communication--chemically mediated synapses. By combining confocal microscopy and freeze-fracture replica immunogold labeling (FRIL), we found that gap junctions at these synapses contain connexin35 (Cx35), the fish ortholog of the neuron-specific human and mouse connexin36 (Cx36). Conductance of gap junction channels at these endings is known to be dynamically modulated by the activity of their co-localized chemically mediated glutamatergic synapses. By using simultaneous pre- and postsynaptic recordings at these single terminals, we demonstrate that such functional interaction takes place in the same ending, within a few micrometers. Accordingly, we also found evidence by confocal and FRIL double-immunogold labeling that the NR1 subunit of the NMDA glutamate receptor, proposed to be a key regulatory element, is present at postsynaptic densities closely associated with gap junction plaques containing Cx35. Given the widespread distribution of Cx35- and Cx36-mediated electrical synapses and glutamatergic synapses, our data suggest that the local functional interactions observed at these identifiable junctions may also apply to other electrical synapses, including those in mammalian brain.

The view of the General Medical Council

Information about a patient's health is recorded in order to provide for that patient's care. Most patients will not think about the other uses for their data and many assume that the information they provide will go no further than the health care professionals who have been caring for them. Information collected about patients is essential for developments in our understanding of health and health care. Most patients will be happy to allow their data to be used for these purposes, once this has been explained. Health care professionals have an obligation to ensure that patients know when identifiable data about them are to be used and to get their agreement about making disclosures. We know that this is not easily achieved; doctors, nurses and others providing care are already over-stretched. Patients may be anxious about their condition and treatment. They may not, for a variety of reasons, read leaflets or letters sent or given to them. This does not mean our obligations to respect patients by keeping them informed and seeking their agreement can be ignored. Openness about how health care professionals work and partnership with patients are essential to the continued trust of the public in the professions. The challenge is not to answer the question whether we need consent but rather how we can best obtain it.

Mechanical environment, donor age, and presence of endothelium interact to modulate porcine artery viability ex vivo

Though ex vivo culture of arteries is a widely used model of native arteries and is closely aligned with efforts to generate tissue-engineered arteries, the effects of culture conditions on artery viability are poorly characterized. To investigate factors regulating long-term viability of cultured arteries, carotid arteries from neonatal and adolescent pigs were perfused for up to 27 days with steady laminar flow ranging from approximately 2% to approximately 200% of physiological flow rates. Arteries from neonatal animals (2 weeks old, approximately 5 kg) were susceptible to spontaneous progressive endothelial denudation followed by deterioration of the vessel wall that spread from luminal to abluminal regions. Subphysiological levels of flow and pressure abrogated this deterioration. Arteries harvested from adolescent (6 months old, approximately 100 kg) animals maintained viability and retained structure for at least 9 days as assessed by normal histology, presence of intact endothelium, normal mitochondrial activity, and low levels of cell death and proliferation, unless the vessels were subjected to superphysiological levels of flow or the endothelium was intentionally denuded. Adolescent arteries perfused at subphysiological, but not physiological, flow rates maintained viability and normal structure for at least 27 days. These data indicate that under the appropriate conditions, arteries may be cultured long term but careful attention to the viability is merited.

Effect of sevoflurane on human neutrophil apoptosis

BACKGROUND AND OBJECTIVE

Both chronic occupational exposure to volatile anaesthetic agents and acute in vitro exposure of neutrophils to isoflurane have been shown to inhibit the rate of apoptosis of human neutrophils. It is possible that inhibition of neutrophil apoptosis arises through delaying mitochondrial membrane potential collapse. We assessed mitochondrial depolarization and apoptosis in unexposed neutrophils and neutrophils exposed to sevoflurane in vivo.

METHODS

A total of 20 mL venous blood was withdrawn pre- and postinduction of anaesthesia, the neutrophils isolated and maintained in culture. At 1, 12 and 24 h in culture, the percentage of neutrophil apoptosis was assessed by dual staining with annexin V-FITC and propidium iodide. Mitochondrial depolarization was measured using the dual emission styryl dye JC-1.

RESULTS

Apoptosis was significantly inhibited in neutrophils exposed to sevoflurane in vivo at 24 (exposed: 38 (12)% versus control: 28 (11)%, P = 0.001), but not at 1 or 12 h, in culture. Mitochondrial depolarization was not delayed in neutrophils exposed to sevoflurane.

CONCLUSIONS

The most important findings are that sevoflurane inhibits neutrophil apoptosis in vivo and that inhibition is not mediated primarily by an effect on mitochondrial depolarization.

Confidentiality and the duties of care

Doctors have an ethical and legal duty to respect patient confidentiality. We consider the basis for this duty, looking particularly at the meaning and value of autonomy in health care. Enabling patients to decide how information about them is disclosed is an important element in autonomy and helps patients engage as active partners in their care. Good quality data is, however, essential for research, education, public health monitoring, and for many other activities essential to provision of health care. We discuss whether it is necessary to choose between individual rights and the wider public interest and conclude that this should only rarely be necessary. The paper makes some recommendations on practical steps which could help ensure that good quality information is available for work which benefits society and the public health, while still enabling patients' autonomy to be respected.

Fluctuations in attention: PD dementia vs DLB with parkinsonism

BACKGROUND

Marked impairments in and fluctuation of attention are characteristic of dementia with Lewy bodies (DLB). The comparative impairment of these cognitive domains in PD and PD dementia (PD dementia) has not been studied, and is important to the conceptual understanding of parkinsonian dementias.

METHOD

Detailed evaluations of attention and fluctuating attention (Cognitive Drug Research computerized battery) were undertaken in 278 subjects (50 DLB, 48 PD dementia, 50 PD, 80 AD, 50 elderly controls) from the Newcastle dementia register and the Stavanger PD register (controls, PD, and PD dementia patients were recruited from both centers). DLB, AD, PD, and PD dementia were diagnosed using operationalized criteria.

RESULTS

Impairments in reaction time, vigilance, and fluctuating attention were comparable in patients with DLB and PD dementia, but were less substantially impaired in patients with DLB without parkinsonism. Patients with PD had significantly greater impairment of cognitive reaction time than elderly controls, and comparable impairments of cognitive reaction time to patients with AD. Patients with PD, however, did not exhibit fluctuation of attention.

CONCLUSION

The profile of attentional impairments and fluctuating attention is similar in PD dementia and DLB with parkinsonism. The current findings do not support the current arbitrary distinctions between these patient groups. Importantly, patients with PD do not experience fluctuating attention.

Genomic rearrangements of EYA1 account for a large fraction of families with BOR syndrome

Branchio-Oto-Renal (BOR) syndrome is transmitted as an autosomal dominant disorder, affects an estimated 2% of profoundly deaf children, and is caused by mutations in the human EYA1 gene. However, in up to half of the reported cases, EYA1 mutation screening is negative. This finding has been taken as evidence of genetic heterogeneity. Mutation screening of the coding region of EYA1 in a panel of families linked to chromosome 8 was conducted using SSCP and direct sequencing. Only one point mutation in five probands was detected. However, complex rearrangements, such as inversions or large deletions, were discovered in the other four patients using Southern blot analysis. These data suggest that more complex rearrangements may remain undetected in EYA1 since SSCP and sequencing were commonly used to detect mutations in this gene.

Omalizumab provides long-term control in patients with moderate-to-severe allergic asthma

The ability of omalizumab, an anti-immnoglobulin-E agent, to maintain long-term disease control in patients with moderate-to-severe allergic asthma was investigated in a 24-week double-blind extension to a 28-week core trial. During the extension, 483 of the initial 546 patients were maintained on randomised treatment and the lowest sustainable dose of beclomethasone dipropionate (BDP) as established during the steroid-reduction phase of the core trial. The use of concomitant asthma medication was permitted and investigators were allowed to adjust the BDP dose or switch patients from BDP to other asthma medications if deemed necessary. More omalizumab-treated patients (33.5%) than placebo-treated patients (13.5%) were able to complete the extension period without requiring inhaled corticosteroid treatment. The mean BDP equivalent dose throughout the extension was lower in the omalizumab group (25 microg x day(-1)) than in the placebo group (43 microg x day(-1)). Disease control was sustained in 76% of omalizumab patients compared with 59.4% of placebo patients free from an asthma exacerbation during the extension period. Compared with placebo, fewer patients in the omalizumab group used other concomitant asthma medication during the extension. Treatment with omalizumab was well tolerated and the incidence of adverse events was similar between groups. In conclusion, these results suggest that omalizumab is a promising new agent for the long-term control of allergic asthma.

Volumetric MRI study of the caudate nucleus in patients with dementia with Lewy bodies, Alzheimer's disease, and vascular dementia

OBJECTIVES

To determine whether parkinsonian symptoms in dementia with Lewy bodies (DLB) are associated with greater atrophy of the caudate nucleus in comparison with patients with Alzheimer's disease (AD) and vascular dementia (VaD).

METHODS

T1weighted MR scans were acquired in elderly patients with DLB, AD, VaD, and healthy controls. Normalised volumetric measurements of the caudate nucleus were obtained and parkinsonian symptoms rated using Hoehn and Yahr staging.

RESULTS

There were no significant differences in the volume of the caudate nucleus between patients with dementia. However, the left caudate volume was significantly reduced in AD and DLB compared with controls. Parkinsonian symptoms did not correlate with caudate nucleus volume.

CONCLUSIONS

Parkinsonian symptoms in DLB may be more closely coupled to neurochemical rather than structural changes in the caudate nucleus, and volumetric MRI analysis of caudate nucleus does not discriminate between patients with DLB, AD, and VaD.

Hazard characterisation of chemicals in food and diet. dose response, mechanisms and extrapolation issues

Hazard characterisation of low molecular weight chemicals in food and diet generally use a no-observed-adverse-effect level (NOAEL) or a benchmark dose as the starting point. For hazards that are considered not to have thresholds for their mode of action, low-dose extrapolation and other modelling approaches may be applied. The default position is that rodents are good models for humans. However, some chemicals cause species-specific toxicity syndromes. Information on quantitative species differences is used to modify the default uncertainty factors applied to extrapolate from experimental animals to humans. A central theme for extrapolation is unravelling the mode of action for the critical effects observed. Food can be considered as an extremely complex and variable chemical mixture. Interactions among low molecular weight chemicals are expected to be rare given that the exposure levels generally are far below their NOAELs. Hazard characterisation of micronutrients must consider that adverse effects may arise from intakes that are too low (deficiency) as well as too high (toxicity). Interactions between different nutrients may complicate such hazard characterisations. The principle of substantial equivalence can be applied to guide the hazard identification and hazard characterisation of macronutrients and whole foods. Macronutrients and whole foods must be evaluated on a case-by-case basis and cannot follow a routine assessment protocol.

Developing, evaluating and maintaining a standardized stormwater BMP effectiveness database

The Urban Water Resources Research Council of the American Society of Civil Engineers, under a cooperative agreement with the US Environmental Protection Agency, released Version 1.0 of the National Stormwater Best Management Practices (BMP) Database to the stormwater management community in 1999. The product included a loaded database of 71 BMPs, as well as data entry software for standardized reporting of BMP test data. In conjunction with the database, the project team developed BMP performance evaluation protocols and applied them to the data contained in the initial database. Since the initial database release, 42 new BMP data sets have been added to the database, which is now accessible via the Internet at www.bmpdatabase.org along with associated data evaluation reports and other project documentation. A national stormwater BMP data clearinghouse continues to screen and post new BMP data to the database, as well as respond to inquiries from the public. An overview of both of the database software and results of the data evaluation are provided in this paper.

Anion directed assembly of a dinuclear double helicate

The synthesis and structural characterisation of the diamino-bis-pyridine ligand L2 and its diammonium-bispyridinium salt [(H4L2Cl)2].6Cl.H2O 1, are reported; X-ray diffraction studies reveal that chloride coordination causes the latter to adopt a double-helicate structure in the solid-state.

Facial electromyographic (EMG) responses to emotionally significant visual images: differences between light and heavy drinkers

Fifty participants took part in an experiment designed to investigate individual differences in the effects of alcohol on facial EMG responses to emotionally significant stimuli. Participants took part in two experimental sessions during which they viewed emotionally negative and emotionally positive visual images. In one session they consumed alcohol (0.5 g/kg bodyweight) whilst in the other they consumed soft drink. We classified each participant as a light or heavy drinker on the basis of their self-reported alcohol consumption. Negatively valenced images elicited increases in both frontalis and corrugator activity but alcohol did not moderate this effect either in light or heavy drinkers. Nevertheless, heavy drinkers did respond more strongly to the negatively valenced images and this supports the view that responses to negative emotional stimuli may play a part in the development of heavy drinking as a result of negative reinforcement processes.

Reconstruction with rectus abdominis myocutaneous free flap after orbital exenteration in children

OBJECTIVE

To present a 1-stage technique for orbital reconstruction after exenteration with the use of myocutaneous rectus abdominis free flap in children.

SURGICAL TECHNIQUE

After orbital exenteration, a myocutaneous rectus abdominis free flap with long vascular pedicle is harvested from the abdomen. The flap is transferred to the orbit and the vascular pedicle is passed through an opening made in the lateral orbital wall, where it is anastomosed to superficial temporal vessels. The skin of the flap is trimmed to correspond to the eyelid defect and the incisions are closed.

METHODS

After informed consent was obtained, 2 children, 3 and 8 years old, underwent orbital reconstruction with a rectus abdominis free flap after exenteration for orbital rhabdomyosarcoma and orbital osteosarcoma in the setting of retinoblastoma.

RESULTS

This technique allowed easy postoperative wound care. Viability of the flap was excellent. The technique provided sufficient volume to fill the orbit, with improved aesthetic results and minimal donor site deformity.

CONCLUSIONS

The postoperative care and aesthetic outcome in patients with rectus abdominis free flap after exenteration are much improved over those provided with traditional surgical techniques. This primary reconstruction is recommended for any patient requiring orbital exenteration, but particularly for pediatric patients who tolerate debridement of traditional exenteration sites poorly.

Perceptions about advance directives by nurses in a community hospital

Despite the legal mandate for hospitals to comply with the Patient Self-Determination Act and recommendations by the American Nurses' Association for nurses to advocate for the participation of patients in end-of-life decisions, nurses' compliance has been less than enthusiastic. This study used an exploratory descriptive design and a 10-item self-reported questionnaire, which included both multiple-choice and open-ended questions. This study examined nurses' knowledge and comfort with the implementation of the Patient Self-Determination Act. An analysis of this research shows that two major themes emerged: a need for more education involving advance directives and a desire to have other healthcare workers involved in informing patients about advance directives.

A simple and effective separation and purification procedure for DNA fragments using dodecyltrimethylammonium bromide

In this work we describe a simple two step separation procedure for the separation and purification of short DNA fragments. The first step involves precipitating the DNA using the cationic surfactant dodecyltrimethylammonium bromide. Dodecyltrimethylammonium bromide, unlike cetyltrimethylammonium bromide will not precipitate DNA before complexation is complete thus providing a high purity DNA. The second step involves dissolution of the DNA-dodecyltrimethylammonium complex in 75% ethanol, followed by precipitation of the Sodium-DNA salt, by titrating in a salt solution. This method is particularly suited to purification of short fragments as it does not require high salt concentrations in the ethanol precipitation step, which can be damaging for short DNA. The ability of dodecyltrimethylammonium bromide to remove ethidium bromide from intercalation sites on the DNA is also discussed

How do memory clinics compare with traditional old age psychiatry services?

METHODS

100 consecutive referrals to the Northern Memory Clinic (NMC) were compared with 100 referrals to a traditional Old Age Psychiatry (OAPsych) service in the same city in terms of demographic variables, cognitive function (assessed by the Mini-Mental State Examination), and diagnosis. The study also examined the ability of psychometric assessments (CAMCOG, MMSE, Trail-Making Tests A & B, Word Fluency) and CT scans included in the NMC assessment to differentiate between those with and without DSM-IV dementia.

RESULTS

NMC patients were significantly younger than OAPsych patients, had lower levels of cognitive impairment, and had a wider range of diagnoses. The NMC patients who were diagnosed as having dementia were found to be at least 2 years earlier in the course of the disease than those seen by the OAPsych team. The CAMCOG and MMSE were proved to be effective at distinguishing between patients diagnosed as dementing versus non-dementing with cut-offs of 82/83 and 23/24 respectively, confirming previous findings. The Memory subscale of the CAMCOG, though much shorter, was equally as effective using a cut-off of 20/21. Trail-Making Tests, Word Fluency (FAS), and measurement of the minimum width of the medial temporal lobe (MTL) on angled CT scans were poor indicators of dementia in this sample.

CONCLUSIONS

This study confirms that the memory clinic is targeting a distinct patient group compared to traditional old age psychiatry services, is identifying cases of dementia much earlier, and as such has potential to make valuable contributions to patient care.