Adaptive numerical competency in a food-hoarding songbird

Most animals can distinguish between small quantities (less than four) innately. Many animals can also distinguish between larger quantities after extensive training. However, the adaptive significance of numerical discriminations in wild animals is almost completely unknown. We conducted a series of experiments to test whether a food-hoarding songbird, the New Zealand robin Petroica australis, uses numerical judgements when retrieving and pilfering cached food. Different numbers of mealworms were presented sequentially to wild birds in a pair of artificial cache sites, which were then obscured from view. Robins frequently chose the site containing more prey, and the accuracy of their number discriminations declined linearly with the total number of prey concealed, rising above-chance expectations in trials containing up to 12 prey items. A series of complementary experiments showed that these results could not be explained by time, volume, orientation, order or sensory confounds. Lastly, a violation of expectancy experiment, in which birds were allowed to retrieve a fraction of the prey they were originally offered, showed that birds searched for longer when they expected to retrieve more prey. Overall results indicate that New Zealand robins use a sophisticated numerical sense to retrieve and pilfer stored food, thus providing a critical link in understanding the evolution of numerical competency.

Vitamin D induces innate antibacterial responses in human trophoblasts via an intracrine pathway

The active form of vitamin D, 1,25-dihydroxyvitamin D (1,25(OH)(2)D), is a potent inducer of the antimicrobial protein cathelicidin, CAMP (LL37). In macrophages this response is dependent on intracrine synthesis of 1,25(OH)(2)D from precursor 25-hydroxyvitamin D (25OHD), catalyzed by the enzyme 25-hydroxyvitamin D-1alpha-hydroxylase (CYP27B1). In view of the fact that trophoblastic cells also express abundant CYP27B1, we postulated a similar intracrine pathway for induction of CAMP in the placenta. Analysis of placenta explants, primary cultures of human trophoblast, and the 3A trophoblastic cell line treated with 1,25(OH)(2)D (1-100 nM) revealed dose-dependent induction of CAMP similar to that observed with primary cultures of human macrophages. Also consistent with macrophages, induction of trophoblastic CAMP was enhanced via intracrine conversion of 25OHD to 1,25(OH)(2)D. However, in contrast to macrophages, induction of CAMP by vitamin D in trophoblasts was not enhanced by costimulation with Toll-like receptor ligands, such as lipopolysaccharide. Despite this, exposure to vitamin D metabolites significantly enhanced antibacterial responses in trophoblastic cells: 3A cells infected with Escherichia coli showed decreased numbers of bacterial colony-forming units compared with vehicle-treated controls when treated with 25OHD (49.6% +/- 10.9%) or 1,25(OH)(2)D (45.4% +/- 9.2%), both P < 0.001. Treatment with 25OHD (1-100 nM) or 1,25(OH)(2)D (0.1-10 nM) also protected 3A cells against cell death following infection with E. coli (13.6%-26.9% and 22.3%-40.2% protection, respectively). These observations indicate that 1,25(OH)(2)D can function as an intracrine regulator of CAMP in trophoblasts, and may thus provide a novel mechanism for activation of innate immune responses in the placenta.

Screening for distress in cancer patients: is the distress thermometer a valid measure in the UK and does it measure change over time? A prospective validation study

A prospective validation study was conducted in 171 consenting patients from oncology and palliative care outpatient clinics to validate the Distress Thermometer (DT) against the Hospital Anxiety and Depression Scale (HADS), General Health Questionnaire-12 (GHQ-12) and Brief Symptom Inventory-18 (BSI-18) at baseline, four weeks and eight weeks. Receiver Operating Characteristic analysis was used to examine the sensitivity and specificity of the DT scores against the clinically significant cut-off scores of the criterion measures reporting 95% confidence intervals. Standardised response means were used to compare DT scores with criterion measures over time. For a cut-off of 4 vs 5, sensitivity against HADS was 79%, specificity 81%; against GHQ-12, sensitivity was 63%, specificity 83%; and against BSI-18, sensitivity was 88%, specificity 74%. At both four and eight weeks, DT scores tended to change significantly in the same direction as the criterion measures. Ninety-five percent of patients found completing the DT acceptable. The DT is valid and acceptable for use as a rapid screening instrument for patients in the UK with cancer. Our results indicate that it can be used to monitor change in psychological distress over time, but further work is needed to confirm this.

The use of complementary therapy by men with prostate cancer in the UK

The study aims were to determine the use of complementary therapies (CT) by men with prostate cancer, and to explore factors influencing CT use and attitudes toward CT use. A cross-sectional survey design was used in which a postal questionnaire was mailed to an eligible sample of 405 patients with prostate cancer receiving outpatient treatment in a London teaching hospital. The primary outcomes were the prevalence of CT use and the relationship between CT use and mental health status. Two hundred and ninety-four patients (73%) responded, of whom 25% were using CT. The most frequently used CTs were vitamins, low-fat diets, lycopene and green tea. Multivariate analyses revealed no differences in mental health scores between CT users and non-users. CT users were younger (OR 0.93, 95% CI 0.89-0.97) and were more likely to be receiving conservative management in the form of 'active surveillance' (OR 5.23, 95% CI 1.78-15.41) compared with non-users. Over half of the participants (55%) wanted to learn more about CT. Forty-three per cent of CT users had not informed any doctor about their CT use. Clinicians need to be aware of the prevalence of CT use amongst patients with prostate cancer, considering the potential harm that could be caused by interactions with conventional treatments.

Metabolic acidosis in the critically ill: part 2. Causes and treatment

The correct identification of the cause, and ideally the individual acid, responsible for metabolic acidosis in the critically ill ensures rational management. In Part 2 of this review, we examine the elevated (corrected) anion gap acidoses (lactic, ketones, uraemic and toxin ingestion) and contrast them with nonelevated conditions (bicarbonate wasting, renal tubular acidoses and iatrogenic hyperchloraemia) using readily available base excess and anion gap techniques. The potentially erroneous interpretation of elevated lactate signifying cell ischaemia is highlighted. We provide diagnostic and therapeutic guidance when faced with a high anion gap acidosis, for example pyroglutamate, in the common clinical scenario 'I can't identify the acid--but I know it's there'. The evidence that metabolic acidosis affects outcomes and thus warrants correction is considered and we provide management guidance including extracorporeal removal and fomepizole therapy.

Importation of Polish trichinellosis cases to Ireland, June 2007

A Polish national in his late 20s presented in June to the emergency department of a hospital in Dublin.

A Phase II study of 3-aminopyridine-2-carboxaldehyde thiosemicarbazone (3-AP) and gemcitabine in advanced pancreatic carcinoma. A trial of the Princess Margaret hospital Phase II consortium

3-Aminopyridine-2-carboxaldehyde thiosemicarbazone (3-AP, Triapine, Vion Pharmaceuticals, New Haven, CT) is an inhibitor of the M2 subunit of ribonucleotide reductase (RR). Preclinical testing demonstrates synergy between 3-AP and gemcitabine. Phase I studies of the combination have suggested tolerability and some initial evidence of efficacy. Therefore, a phase II study of gemcitabine plus 3-AP in advanced pancreatic carcinoma was undertaken. In this two-step phase II trial, patients with advanced pancreatic adenocarcinoma who had not received prior chemotherapy for advanced disease were treated with 3-AP 105 mg/m(2) given over 2 h. Four hours after the 3-AP infusion was completed, gemcitabine 1,000 mg/m(2) was given over 30 min. Both drugs were given on days 1, 8 and 15 of a 28-day cycle.Twenty-six patients were enrolled to the study. One patient withdrew consent prior to receiving any treatment and is excluded from all further analyses. Four patients discontinued treatment due to adverse effects. Grade 3/4 hematological adverse events included neutropenia, thrombocytopenia, lymphopenia, leukopenia and anemia and the most frequent non-hematological adverse events were fatigue and pain. No objective responses were observed. Eleven patients had stable disease (SD). In five of these eleven patients, SD lasted for more than 6 months. The median time to progression was 4.1 months and the 6 month progression-free survival rate was 29%. The median survival was 9.0 months with a 1-year survival of 28.0%. The combination of 3-AP and gemcitabine is associated with moderate toxicity in patients with advanced pancreatic cancer. This two-stage trial was stopped after stage I due to lack of antitumour activity. On the basis of this clinical trial, the combination of gemcitabine and 3-AP at this dose and schedule does not warrant further study in this patient population.

Inhibition of poly (ADP-ribose) polymerase (PARP) by ABT-888 in patients with advanced malignancies: Results of a phase 0 trial

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Background: Inhibition of PARP activity sensitizes tumor cells to the effects of DNA damaging agents. We conducted a phase 0 pharmacokinetic (PK) and pharmacodynamic (PD) study of ABT-888, an oral inhibitor of PARP. Methods: The objectives were to determine a dose range at which ABT-888 inhibits PARP in tumor tissue and in peripheral blood mononuclear cells (PBMC); and the PK of ABT-888. Patients with advanced solid tumors refractory to at least one line of therapy were eligible; patients with CLL or follicular lymphomas were also eligible if standard therapy was not currently indicated. A single oral dose of ABT-888 was administered per patient, dose escalations were planned in cohorts of 3 patients each (10 mg, 25 mg, 50 mg, 100 mg, and 150 mg). PBMC and tumor sampling were performed before and after drug administration for real time PK and PD analyses. All patients underwent PBMC sampling; tumor biopsies were planned once significant inhibition of PARP activity in PBMCs was seen in 1 of 3 patients in a cohort or plasma Cmax of 210 nM was achieved in at least 1 patient. Tumor biopsies were performed at baseline in the week prior to drug administration and then 3–6 hours post drug administration. Significant inhibition of PARP activity was defined as at least 0.69 reduction on the log scale, which also satisfied statistical significance. Results: A total of 6 patients have been studied so far, 3 each for the 10 mg and 25 mg cohorts. No treatment related adverse events have been observed. Target Cmax was exceeded in the first cohort, all patients in the next cohort underwent tumor biopsies in addition to PBMC sampling. A trend towards inhibition of PARP activity in PBMCs was observed in the first cohort. Significant inhibition of PAR levels was observed in tumor biopsies from all 3 patients in the second cohort (92%, 99%, 100% reductions respectively, as compared to baseline). Greater than 85% reduction of PAR levels was observed in PBMCs from 2 of the 3 patients in the second cohort (one patient was not evaluable). Conclusions: ABT-888 is orally bioavailable and inhibits PARP activity in PBMCs and tumor cells. Target assay feasibility was established in human samples. Funded in part by NCI Contract N01-CO-12400

No significant financial relationships to disclose.

Statistical considerations for a phase 0 trial

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Background: Phase ‘0’ clinical trials are small first in man studies to determine a dose or dose range which results in a desired biologic effect. Novel statistical designs are needed due to the limited number of patients and the complexities of analyzing primary pharmacodynamic endpoints. Methods: In general, the effect of the agent will be evaluated, based on a biologic endpoint(s), at two levels, the individual participant level (for a given dose amount), and the agent dose amount level (across individual participants). At the participant level, the effect is preferably defined as a dichotomous outcome. The statistical criteria should be such that the threshold is not surpassed with more than .10 probability, for a given participant, at a given dose amount, for the null hypothesis case of no true biologic effect. At the dose amount level, the effect rate is defined as the probability that a randomly chosen participant will satisfy the participant level threshold. The statistical criteria for declaring an observed effect rate to be significant should be such that the over-all probability of declaring the agent effective (summed across all dose amounts) should not exceed .10 for the null hypothesis case of no true biologic effect. A target effect rate, measured across participants, should be given, and the power to detect it, for a given dose amount, should be estimated. Ideally, there will be multiple pre-agent administration endpoint measurements, per participant, to define variability. Examples: 1. If 10 participants are accrued to a single dose amount, an observed effect rate for that dose amount could be defined to be significant if at least 2 of the 10 participants satisfy the participant threshold, yielding 85–90% power to detect a 35% effect rate. 2. If 5 participants are accrued to each of 2 dose amounts, an observed effect rate for a particular dose amount could be defined to be significant if at least 2 of the 5 participants satisfy the participant threshold, yielding approximately 90% power to detect a 60% effect rate. 3. If 3 participants are accrued to each of 4 dose amounts, an observed effect rate for a particular dose amount could be defined to be significant if at least 2 of the 3 participants satisfy the participant threshold, yielding approximately 90% power to detect an 80% effect rate.

No significant financial relationships to disclose.

The Dundee University Scottish Keratoconus study: demographics, corneal signs, associated diseases, and eye rubbing

AIM

To investigate and correlate the corneal, refractive, topographic and familial characteristics of a large cohort with keratoconus.

METHODS

Prospective observational study of 200 consecutive patients presenting with keratoconus during the 4 year-period 1997-2000. Subjects were examined at enrolment and at a final review. Data were collected on demographic characteristics, referral route, symptoms, refractive correction, eye rubbing, family history, medical history, slit-lamp biomicroscopic corneal signs, and computerized corneal topography.

RESULTS

Mean age at enrolment was 30.9+/-10.4 (range, 12.2-72) years (N=200, 62.5% male, 93% white Caucasian) with a 5% family history of keratoconus. Atopic diseases included asthma (23%), eczema (14%), and hay fever (30%). Only 9% wore contact lenses before referral. Mean follow-up was 1004 days +/-282 (range, 390-1335) and 9.7+/-8.9 (range, 1.1-60) years from diagnosis. The mean simulated K1 corneal power at enrolment was 51.74+/-5.36 (range, 42.59-67.32) D and 88.5% exhibited bilateral keratoconus. Fifty-three (15%) topographically confirmed cones exhibited no clinical corneal signs at presentation. At enrollment, 56% had a pachymetry <0.480 mm increasing to 77% at final review. Forty-eight percent of subjects reported significant eye rubbing and there was a highly statistically significant difference (two sample t-test P=0.018) between keratoconus and control groups. TMS-2 axial corneal power was strongly associated with corneal scarring and age at diagnosis. The size of the scarring effect was 2.2 D (95% confidence interval (CI) 1.34, 3.06).

CONCLUSIONS

This study provides an overview of a large population with keratoconus highlighting presenting features and clinical and topographic progression over a 4 year-period.

Control of an outbreak of multi-drug-resistant Acinetobacter baumannii in an intensive care unit and a surgical ward

We describe an outbreak of multi-drug-resistant Acinetobacter baumannii (MRAB) that occurred in an intensive care unit (ICU) and a surgical ward from December 2003 to March 2004. Mapping patient movements on a timeline indicated that the outbreak was confined to these two areas. Investigation by the hospital's infection prevention service found that a possible source of spread was improper cleaning methods used on respiratory equipment. Pulsed-field gel electrophoresis analysis of available isolates indicated the presence of two distinct strains. One strain was seen in patients from the ICU and the other strain was seen in the surgical ward patients. Cleaning and environmental decontamination as well as staff education were implemented to halt further immediate spread. The deficiencies identified during the investigation were also resolved. The final outcome was the successful termination of this outbreak.

Prospective evaluation of somatic and autonomic small fibers in selected autonomic neuropathies

BACKGROUND

There are a number of distal and generalized small-fiber neuropathies. The neuropathologic basis is poorly understood as somatic and autonomic C fibers are not usually studied in the same region of the body.

OBJECTIVE

To evaluate prospective somatic and autonomic C-fiber function in 11 healthy control subjects and 38 patients with different clinical patterns of neuropathy.

METHODS

Distal small-fiber neuropathy (DSFN), peripheral neuropathy (PN), diabetic neuropathy (DN), neuropathic postural tachycardia syndrome (POTS), and idiopathic autonomic neuropathy (IAN) were evaluated. Intraepidermal nerve fiber density was used to evaluate distal somatic C fibers. Both quantitative sudomotor axon reflex test and skin norepinephrine content were measured for the biopsy site to assess distal autonomic C-fiber function. Postganglionic sudomotor, adrenergic, and cardiovagal functions were evaluated by autonomic reflex testing and quantified using a Composite Autonomic Severity Scale.

RESULTS

Skin norepinephrine concentration was significantly related to CASS. DN was associated with somatic and autonomic C-fiber impairment with good agreement. POTS was associated with selective distal autonomic deficit. DSFN had combined distal somatic and C-fiber impairment. IAN showed combined and selective distal and generalized autonomic C-fiber impairment. The somatic neuropathies had C-fiber impairment affecting both populations to varying degrees.

CONCLUSION

Although a general agreement exists between the loss of somatic C fibers and autonomic deficits, selective involvement occurs for specific autonomic neuropathies.

Bowel surgery for epithelial ovarian cancer--an early case series

OBJECTIVES

The aims of this study were to review our local experience with bowel surgery for epithelial ovarian cancer at the Gynaecological Cancer Centre, KK Women's and Children's Hospital, and to document the outcome of such surgery as well as their complication rates.

MATERIALS AND METHODS

The retrospective medical records of 38 patients with epithelial ovarian cancer who underwent surgery including bowel surgery from January 1997 to May 2002 at the Gynaecological Cancer Centre, KK Women's and Children's Hospital, Singapore, were reviewed.

RESULTS

Indications for surgery were predominantly debulking of disease. Fifty-eight per cent of patients had primary debulking surgery, 34% had debulking of recurrence and 3% had interval debulking. Only 5% of patients had bowel obstruction as the only indication for surgery. Rectosigmoid resection was the most common bowel operation overall, being performed in 76.3% of patients. The stoma rate for rectosigmoid resection was 61%. The remaining procedures included 7 colectomies, 1 intestinal bypass procedure and 1 intestinal diversion procedure. Optimal debulking (defined as < 1 cm of residual disease) was achieved in the majority (71%). The median operating time was 4 hours. The median blood loss was 1300 mL. The major complication rate was 10.5%. Major complications encountered were as follows: 1 patient (2.6%) had an anastomotic leak, 2 patients (5.3%) had intra-abdominal abscess and 1 patient (2.6%) developed intestinal fistula. Three patients (7.8%) required a re-operation within 30 days. There were 3 deaths (7.8%) within 30 days of surgery.

CONCLUSION

Bowel surgery is commonly indicated for epithelial ovarian cancer to facilitate optimal debulking. Such surgery is feasible with acceptable complication rates in our local centre.

Stroke rehabilitation after hospital discharge: a randomized trial comparing domiciliary and day-hospital care

OBJECTIVES

To compare the effectiveness and costs of a new domiciliary rehabilitation service for elderly stroke patients with geriatric day-hospital care.

DESIGN

Randomized controlled trial.

PARTICIPANTS

Stroke patients aged 55+ who required further rehabilitation after hospital discharge or after referral to geriatricians from the community.

SETTING

Poole area, East Dorset, a mixed urban/rural area on the south coast of England.

MAIN OUTCOMES

Primary-changes between hospital discharge and 6-month follow-up in physical function as measured by Barthel index. Secondary-changes over this period in Rivermead Mobility Index and mental state (Philadelphia Geriatric Centre Morale Scale) and differences in social activity (Frenchay Activities Index) and generic health status (SF-36). Health service and social service cost per patient were compared for the two groups.

RESULTS

180 patients were eligible and 140 (78%) were randomized. The groups were well balanced for age, sex, social class and initial Barthel index. We achieved follow-up in 88% of subjects who were alive at 6 months. We detected no significant differences in patient outcomes, although there was a non-significant improvement in measures of physical function and social activity in the domiciliary group. Domiciliary patients had more physiotherapy time per session and more district nurse time, and made greater use of social service day centres and home helps. Total cost per patient did not differ significantly between the two groups, with reduced health service costs in the domiciliary arm offset by higher social service costs.

CONCLUSION

No significant differences were detected in the effectiveness of the two services. Neither service influenced patients' mental state, and their social activity remained low. Total costs were similar. A mixed model of day-hospital and domiciliary care may be most cost-effective for community stroke rehabilitation, but this requires further evaluation.

The effect of compliance on clinical outcomes for patients with dysphagia on videofluoroscopy

This study investigates clinical outcomes and the degree of compliance in patients who received advice on dysphagia management and the effect of the level of compliance on the incidence of chest infections and aspiration pneumonia, cause of death, and hospital readmission. We performed a retrospective cohort study of 140 patients who had videofluoroscopic studies at Princess Margaret Hospital, Christchurch, New Zealand, from 1 January 1996 to 30 June 1997. The degree to which recommendations on dysphagia management were followed was correlated with the incidence of chest infections, aspiration pneumonia, and readmissions to the hospital. Cause of death, including the contribution of aspiration pneumonia, was assessed by review of medical records and death certificates. Information was available for 89% of the cohort. Twenty-one percent of the survivors never complied with the advice given. Noncompliant subjects were younger (p < 0.05) and more likely to be living at home rather than receiving institutional care (p = 0.05). Noncompliers had more hospital admissions because of chest infections or aspiration pneumonia (22% vs. 1.5%; p < 0.001). Home-dwelling noncompliant subjects received more courses of antibiotics (p < 0.02), but there was no difference in the number of chest infections. Fifty-four people died during the study period. Aspiration pneumonia was recorded as a definite or probable cause of death in 26 (52%) of the 50 subjects for whom reliable information was available and in 6 of 7 subjects who made a deliberate and documented decision not to comply. We conclude that noncompliance with recommendations about dysphagia management is associated with adverse outcomes. There was a high mortality rate and aspiration pneumonia was a common cause of death.