Hereditary angioedema and pregnancy: successful management of recurrent and frequent attacks of angioedema with C1-inhibitor concentrate, danazol and tranexamic acid - a case report

Hereditary angioedema (HAE) is a rare but potentially life-threatening condition caused by deficiency of C1 esterase inhibitor. It is characterized by subcutaneous swelling in any part of the skin, gastrointestinal and respiratory tracts. We present the case of a pregnant woman with known HAE that deteriorated during pregnancy with frequent attacks that were managed successfully with danazol, tranexamic acid and regular intravenous administration of C1 esterase inhibitor.

Functional interaction of HTLV-1 tax protein with the POZ domain of the transcriptional repressor BCL6

The Tax protein encoded by human T-cell leukaemia virus type 1 (HTLV-1) has a pivotal role in T-cell transformation by deregulating cellular signalling pathways. Using the yeast two-hybrid system to screen a human leukocyte cDNA library, we identified BCL6 (B-cell lymphoma 6) as a cellular protein, which interacts with Tax 1. The BCL6 gene encodes a sequence-specific transcriptional repressor that contains a conserved N-terminal poxvirus and zinc finger (POZ) repressor domain and a C-terminal Kruppel-like zinc finger DNA binding domain. Using both in vivo and in vitro methods, we demonstrate that the POZ domain of BCL6 is sufficient for its interaction with Tax 1. Using functional assays, we demonstrate that Tax 1 enhanced the repressive activity of BCL6 and increased the levels of apoptosis induced by BCL6 in osteosarcoma cells indicating that both proteins cooperate in vivo to cause a physiological affect. Furthermore, BCL6 recruited Tax 1 into punctate nuclear structures, which suggests that Tax 1 colocalizes with BCL6 in repressor complexes in vivo. BCL6 expression significantly downregulated both basal and Tax-induced nuclear factor-kappaB and long terminal repeat activation. This suggests that the expression of BCL6 in HTLV infected cells may contribute to the silencing of viral gene expression and to the long clinical latency associated with HTLV infection.

Integrating partners into erectile dysfunction treatment: improving the sexual experience for the couple

INTRODUCTION

Erectile dysfunction (ED) is a common condition estimated to affect more than 150 million men worldwide. ED should be regarded as a shared sexual problem which has significant detrimental effects both on the men who experience this condition and on their partners.

EVIDENCE TO SUPPORT PARTNER INVOLVEMENT IN ED THERAPY

Evidence shows that the partner plays a key supportive role in the man's ED treatment and in successful long-term ED therapy. Including the partner in consultations may highlight discordant attitudes and communication problems between couple members which may indicate treatment acceptance or rejection, or realistic or unrealistic treatment expectations.

OPTIONS FOR PARTNER INVOLVEMENT IN ED THERAPY

Most patients with ED consult their physician in the absence of their partner. Therefore, involving the partner in therapy can be challenging. Two options which physicians should consider are: encouraging the patient to bring the partner into the office and, often more realistically, seeking information about, and providing information to, the partner, via the patient.

OBJECTIVES

The objective of these recommendations is to provide practical guidance on treating couples affected by ED, and suggest techniques that may be helpful in integrating the partner into the process of ED treatment.

A review of the job satisfaction and current practice of consultant diabetologists in England--barriers and successes

AIMS

The project aimed to describe the perceptions of consultant diabetologists about their work, explore models of care, identify problem areas, consider potential solutions, and outline strategic issues for retention and recruitment.

METHODS

The study was based on semistructured qualitative interviews with 92 consultant diabetologists, recruited via a purposive sample. Interviews were recorded, transcribed and anonymized, and analysed by the project team, assisted by QSR Nvivo software.

RESULTS

The consultant diabetologist role encompasses a diversity of skills/expertise, with differing emphases between individuals. Integration with general medicine is seen by some as crucial to maintaining proficiency in diabetes, and by others as hindering fulfilment of other roles. Successful team working across organizational boundaries is recognized as essential to effective services, but often impeded by the continuous reorganization and competitive culture of the National Health Service. Significant differences between consultant diabetologist perspectives of primary care colleagues and of primary care trusts emerged. Some consultants have adopted innovative working approaches, adapting national guidance to local environments, but there is general resistance to adopting centrally imposed solutions. Training programmes are not sufficiently explicit about the core skills/attributes required of consultant diabetologists.

CONCLUSIONS

The skills of specialist teams are not fully exploited. Competing calls on time could be addressed by encouraging multifaceted consultant teams, allowing individuals to concentrate in specific areas. Clear definition of core skills required by consultant diabetologists underpins training programme development. Collaboration in cross-boundary services reflecting local needs is impeded by competition between sectors. Protected time is necessary for cultivating multidisciplinary teams, cross-boundary partnerships and effective, relevant education programmes. Specialist training must reflect the changing role of consultant diabetologists, and include role-specific programmes.

EUS-guided tissue sampling: comparison of "dual sampling" (Trucut biopsy plus FNA) with "sequential sampling" (Trucut biopsy and then FNA as required)

BACKGROUND AND STUDY AIMS

Both endoscopic ultrasound- (EUS-) guided tissue sampling techniques, fine-needle aspiration (FNA) and Trucut biopsy, have advantages and limitations. The aim of this study was to develop a strategy of combining these two EUS-guided sampling techniques in order to maximize the diagnostic accuracy and minimize duplication.

PATIENTS AND METHODS

In this multicenter study we performed "dual sampling" (i. e. with both FNA and Trucut biopsy) in 95 patients during phase 1 of the study and "sequential sampling" (i. e. performing FNA only when Trucut biopsy tissue cores were macroscopically inadequate) in 72 patients during phase 2.

RESULTS

During the study period, 167/401 patients referred for EUS-guided sampling were eligible for the study; only solid lesions were included. In 143/167 patients (86 %), sampling was performed via the transesophageal or transgastric routes. When the dual sampling strategy was used, an accurate diagnosis was achieved in 78/95 patients by FNA, compared with 85/95 by Trucut biopsy ( P = 0.21). The combined accuracy of the dual sampling strategy was higher than FNA alone (88/95 vs. 78/95, P = 0.048), but was not significantly higher than Trucut biopsy alone (88/95 vs. 85/95, P = 0.61). Using the sequential sampling strategy, an accurate diagnosis was achieved in 66/72 patients (92 %) compared with 88/95 (93 %) for dual sampling ( P = 1.0), and 8/72 patients (11 %) had to undergo FNA after Trucut biopsy failed to obtain an adequate sample. One patient with mediastinal tuberculosis developed a cold abscess following Trucut biopsy.

CONCLUSION

A sequential sampling strategy, in which EUS-guided Trucut biopsy is attempted first, and FNA performed only when Trucut biopsy fails to obtain a macroscopically adequate sample, achieves a diagnostic accuracy of 92 %, with 11 % of patients requiring both sampling procedures.

Spontaneous preterm birth of liveborn infants in women at low risk in Australia over 10 years: a population-based study

OBJECTIVES

To describe a 10-year trend in preterm birth.

DESIGN

Population-based study.

SETTING

Australia.

POPULATION

All women who gave birth during 1994-03.

METHODS

The proportion of spontaneous preterm births (greater than or equal to 22 weeks of gestation and less than 37 completed weeks of gestation) was calculated by dividing the number of women who had a live spontaneous preterm birth (excluding elective caesarean section and induction of labour) by the total number of women who had a live birth after spontaneous onset of labour (excluding elective caesarean section and induction of labour). This method was repeated for the selected population of women at low risk.

MAIN OUTCOME MEASURE

Preterm birth rates among the overall population of women; preterm birth among all women with a spontaneous onset of labour; and preterm birth in a selected population of women who were either primiparous or multiparous, non-Indigenous; aged 20-40 years and who gave birth to a live singleton baby after the spontaneous onset of labour.

RESULTS

Over the 10-year study period, the proportion of all women having a live preterm birth in Australia increased by 12.1% (from 5.9% in 1994 to 6.6% in 2003). Among women with a spontaneous onset of labour, there was an increase of 18.3% (from 5.7 to 6.7%). Among the selected population of low-risk women after the spontaneous onset of labour, the rate increased by 10.7% (from 5.6 to 6.2%) among first time mothers and by 19.2% (4.4-5.2%) among selected multiparous women.

CONCLUSIONS

Over the 10-year period of 1994-03, the rate of spontaneous preterm birth among low-risk women having a live singleton birth has risen in Australia.

Acute systemic complications in the preterm fetus after asphyxia: role of cardiovascular and blood flow responses

1. Poor perfusion of the kidneys and gut, and associated functional impairment, are major problems in the first days of life in very preterm infants. These complications can be associated with a substantial mortality and further problems such as reduced kidney growth and chronic renal problems in later childhood. 2. There is very little information, and consequently considerable debate, about how or even whether to improve perfusion of the vital organs of this most vulnerable group of babies. Current treatments simply do not consistently improve babies' perfusion generally or kidney and gut perfusion and function in particular. 3. In this review we critically examine clinical and experimental evidence that suggests that exposure to low oxygen levels before and during birth may be a significant contributor to impaired systemic perfusion, and highlight areas requiring further research. 4. This knowledge is essential to develop and refine ways of improving perfusion of the kidneys and other vital organs in premature babies.

Cellular response to conditional expression of the hepatitis B virus precore and core proteins in cultured hepatoma (Huh-7) cells

BACKGROUND

The expression of the hepatitis Be antigen (HBeAg) is one of several strategies used by hepatitis B virus (HBV) to ensure persistence. The HBeAg may function as a toleragen in utero and has been shown to regulate the host's immune response.

AIM

The aim of this study was to examine the effect of the HBV precore and core protein on cellular gene expression in the hepatoma cell line Huh-7.

STUDY DESIGN

Huh-7 cells with tight regulated expression of the HBV core or precore protein were produced using the Tet-Off tetracycline gene expression system. Changes in cellular gene expression in response to core/precore expression compared to Huh-7 cells not expressing the proteins were determined using a commercial high-density oligonucleotide array (Affymetrix Hu95A GeneChip) containing probes for 12,626 full-length human genes.

RESULTS

Analysis of differential mRNA gene expression profiles at 7 days post precore and core expression revealed 45 and 5 genes, respectively, with mRNA changes greater than three-fold. The most striking feature was in Huh-7 cells expressing the precore protein in which 43/45 genes were downregulated 3-11-fold. These included genes that encoded products that regulate transcription/DNA binding proteins, cell surface receptors, cell-cycle/nucleic acid biosynthesis and intracellular signalling and trafficking. The only known gene, which was upregulated encoded a cytoskeletal protein. For the core cell line, 4/5 genes were downregulated 3-15-fold upon core induction and included genes that encoded products that affect intermediary metabolism, cell surface receptors and intracellular signalling. The one gene, which was upregulated was a cytokine gene.

CONCLUSION

The results of this study show that HBV precore protein has a much greater effect on cellular gene expression in comparison to the core protein, suggesting that core and precore proteins may have diverse effects on cellular functions and equally different roles in modulating HBV pathogenesis.

Characterization of NKR+ T-cell subsets in human bone marrow: implications for immunosurveillance of neoplasia

In addition to hematopoietic progenitors, human bone marrow contains mature T/NK lymphocytes. Valpha24Vbeta11 NKT-cells, a subset of NK receptor+ (NKR+) T-cells in humans, are rare in bone marrow, suggesting the presence of other NKR+ T-cells which may contribute to tumor surveillance. NKR+/- T-cells were examined in blood (PB), and bone marrow from donors (DM) and patients with active hematopoietic malignancy (PM), or in remission (PR). T-cells in PR & PM were enriched for CD56+ and CD57+ subsets, compared to DM. All marrow NKR+/- T-cell subsets were more activated than PB. PM and, surprisingly, PR marrow contained more activated cells than DM. CD8+ cells were significantly increased in all patient marrows and there was evidence of the formation of an effector/memory pool in malignant marrow. These data suggest that NKR+ T-cell enrichment in human bone marrow that has been exposed to neoplastic transformation is compatible with a role in localized tumor surveillance/eradication.

The sexual habits of British men and women over 40 years old

OBJECTIVE

To obtain a greater understanding of sexual behaviour and habits among men with and without erectile dysfunction (ED), and their female partners, to improve the management of ED in heterosexual men.

SUBJECTS AND METHODS

A population-based study was conducted amongst men and women aged > 40 years. None of the subjects were partners in the same sexual relationship. Interviews were conducted on the Internet via a panel-based questionnaire.

RESULTS

In all, 225 (32%) men had self-reported ED and 88 (26%) women reported that their partner had ED. For all men (with or without ED) the mean time from first thinking of intercourse to beginning intercourse was just under 1 h. During their most recent period of sexual activity, 87% of men with and 78% of men without ED had intercourse with ejaculation at most once within 24 h; 81% of men and 89% of women felt that it was neither very nor extremely important to have intercourse with ejaculation more than once in a 24-h period.

CONCLUSIONS

This study reports for the first time the frequency of sexual activity in British men and women in heterosexual relationships, and describes the usual timings of sexual events. Few significant differences were identified between men with or with no ED.

Relationship of pre-1918 avian influenza HA and NP sequences to subsequent avian influenza strains

Wild waterfowl that were captured between 1915 and 1919 and preserved in 70% ethyl alcohol were tested for influenza A virus RNA. Most of the HA1 domain of the hemagglutinin (HA) gene segment was sequenced from one bird, captured in 1917, that was infected with a virus of the same HA subtype as the 1918 human pandemic virus. The 1917 HA sequence is closely related to modern avian HA sequences, suggesting little drift in avian sequences in 80 years and that the 1918 pandemic virus probably did not acquire its hemagglutinin directly from a bird. A 151-bp fragment of the nucleoprotein gene segment was sequenced from two pre-1918 birds and compared to avian and mammalian influenza strains. The 1917 avian NP sequences are also closely related to modern avian sequences and distinct from the mammalian clade in which the 1918 NP sequence is found.

Oesophageal stricturing secondary to adult Stevens-Johnson syndrome: similarities in presentation and management to corrosive injury

Clinical decisions often have to be made in the absence of evidence. In some cases, it is appropriate to use evidence from similar but more common conditions for which studies have resulted in evidence-based practice. This report describes a case of oesophageal stricture following Stevens-Johnson syndrome illustrating this concept, although it is likely that there are many other conditions in which the same principle will stand the clinician in good stead. Dilatation led to long-standing relief of dysphagia in our case.