A database of thermodynamic quantities for the reactions of glycolysis and the tricarboxylic acid cycle

Analysis of biochemical systems requires reliable and self-consistent databases of thermodynamic properties for biochemical reactions. Here a database of thermodynamic properties for the reactions of glycolysis and the tricarboxylic acid cycle is developed from measured equilibrium data. Species-level free energies of formation are estimated on the basis of comparing thermodynamic model predictions for reaction-level equilibrium constants to previously reported data obtained under different experimental conditions. Matching model predictions to the data involves applying state corrections for ionic strength, pH, and metal ion binding for each input experimental biochemical measurement. By archiving all of the raw data, documenting all model assumptions and calculations, and making the computer package and data available, this work provides a framework for extension and refinement by adding to the underlying raw experimental data in the database and/or refining the underlying model assumptions. Thus the resulting database is a refinement of preexisting databases of thermodynamics in terms of reliability, self-consistency, transparency, and extensibility.

Determining which automatic digital blood pressure device performs adequately: a systematic review

The aim of this study is to systematically examine the proportion of accurate readings attained by automatic digital blood pressure (BP) devices in published validation studies. We included studies of automatic digital BP devices using recognized protocols. We summarized the data as mean and s.d. of differences between measured and observed BP, and proportion of measurements within 5 mm Hg. We included 79 articles (10 783 participants) reporting 113 studies from 22 different countries. Overall, 25/31 (81%), 37/41 (90%) and 34/35 (97%) devices passed the relevant protocols [BHS, AAMI and ESH international protocol (ESH-IP), respectively]. For devices that passed the BHS protocol, the proportion of measured values within 5 mm Hg of the observed value ranged from 60 to 86% (AAMI protocol 47–94% and ESH-IP 54–89%). The results for the same device varied significantly when a different protocol was used (Omron HEM-907 80% of readings were within 5 mm Hg using the AAMI protocol compared with 62% with the ESH-IP). Even devices with a mean difference of zero show high variation: a device with 74% of BP measurements within 5 mm Hg would require six further BP measurements to reduce variation to 95% of readings within 5 mm Hg. Current protocols for validating BP monitors give no guarantee of accuracy in clinical practice. Devices may pass even the most rigorous protocol with as few as 60% of readings within 5 mm Hg of the observed value. Multiple readings are essential to provide clinicians and patients with accurate information on which to base diagnostic and treatment decisions.

055. EVEN REPTILES DO IT, THE STRUCTURE AND FUNCTION OF PLACENTAE IN VIVIPAROUS LIZARDS

Live birth (viviparity) has evolved independently more than 100 times in squamate reptiles (lizards and snakes). Most viviparous lineages are characterised by a simple placenta with squamous epithelia on both maternal and embryonic sides, and the remnants of an eggshell persist for some, if not all, of pregnancy. The embryos are predominantly lecithotrophic, with maternal-embryonic exchanges being limited mostly to inorganic ions, water and respiratory gases. Nevertheless, there is differentiation of a chorioallantoic placenta and a yolk sac (omphalo) placenta in all species. Complex placentae have evolved in the Squamata in only four or five lineages, all in the lizard family Scincidae (skinks). In species with complex placentation, the uterus differentiates to allow different functions in association with each embryonic membrane type. Species with complex placentae are characterised by a hypertrophy of maternal and embryonic cells, elaboration of the maternal surface, a reduction in yolk with a concomitant increase in placentotrophy and, in some, regional differentiation of the choriallantois into a placentome and a paraplacentome. Both the placentome and omphaloplacenta are organs of embryonic nutrition, but they transport nutrients by different mechanisms; the paraplacentome is a specialised gas exchange organ. The most placentotrophic species are in the South American genus Mabuya, where the females produce micro-lecithal eggs and the placenta is more complex than in any mammal, with four specialised structures for nutrient exchange and one for gas exchange. The number of independent origins of viviparity and the range of placental complexities exhibited by skinks enables us to infer the evolutionary trajectories that have resulted in microlecithal eggs and an almost complete reliance of placentotrophy from oviparous ancestors.

Attention deficit hyperactivity disorder in pre-school children: current findings, recommended interventions and future directions

This paper outlines the presentation, aetiology and treatment of attention deficit hyperactivity disorder (ADHD) in pre-school children. A review of current parenting training interventions demonstrates that there is good evidence for their efficacy in reducing symptoms of ADHD in pre-school children, and three interventions are evaluated: The new forest parent training programme (NFPP); the triple P - positive parenting programme and the incredible years parent training programme (IY). The evaluation of the NFPP provides strong evidence demonstrating its effectiveness for pre-school children with ADHD, while the efficacy of the Triple - P and the IY programme have, to date, only been demonstrated on children with conduct problems and co-morbid ADHD. It is suggested that parent training should be the first choice treatment for pre-school children presenting signs of ADHD, and medication introduced only for those children where parent training is not effective. Few moderators of outcome have been identified for these interventions, with the exception of parental ADHD. Barriers to intervention and implementation fidelity will need to be addressed to achieve high levels of attendance, completion and efficacy. The IY programme is a good model for addressing fidelity issues and for overcoming barriers to intervention. The future directions for parent training are also discussed.

How well do vital signs identify children with serious infections in paediatric emergency care?

OBJECTIVES

To determine whether vital signs identify children with serious infections, and to compare their diagnostic value with that of the Manchester triage score (MTS) and National Institute for Health and Clinical Excellence (NICE) traffic light system of clinical risk factors.

DESIGN

Prospective cohort of children presenting with suspected acute infection. We recorded vital signs, level of consciousness, activity level, respiratory distress, hydration and MTS category.

SETTING

Paediatric assessment unit at a teaching hospital in England.

PARTICIPANTS

700 children (median age 3 years), of whom 357 (51.0%) were referred from primary care, 198 (28.3%) self-referrals and 116 (16.6%) emergency ambulance transfers. Just over half (383 or 54.7%) were admitted.

MAIN OUTCOME MEASURES

Severity of infection categorised as serious, intermediate, minor or not infection.

RESULTS

Children with serious or intermediate infections (n = 313) were significantly more likely than those with minor or no infection (n = 387) to have a temperature >or=39 degrees C, tachycardia, saturations <or=94% or capillary refill time (CRT) >2 seconds. Having one or more of temperature >or=39 degrees C, saturations <or=94%, tachycardia and tachypnoea was 80% (95% CI 75% to 85%) sensitive and 39% (95% CI 34% to 44%) specific for serious or intermediate infection. This was comparable to the MTS score (84% sensitive, 38% specific), and the NICE traffic light system (85% sensitive, 29% specific).

CONCLUSIONS

A combination of vital signs can be used to differentiate children with serious infections from those with less serious infections in a paediatric assessment unit and has comparable sensitivity to more complicated triage systems. The diagnostic value of combined vital signs and the NICE traffic light system remains to be determined in populations where the prevalence of severe illness is much lower.

The biology of platelet-rich plasma and its application in trauma and orthopaedic surgery: a review of the literature

Although mechanical stabilisation has been a hallmark of orthopaedic surgical management, orthobiologics are now playing an increasing role. Platelet-rich plasma (PRP) is a volume of plasma fraction of autologous blood having platelet concentrations above baseline. The platelet alpha granules are rich in growth factors that play an essential role in tissue healing, such as transforming growth factor-beta, vascular endothelial growth factor, and platelet-derived growth factor. PRP is used in various surgical fields to enhance bone and soft-tissue healing by placing supraphysiological concentrations of autologous platelets at the site of tissue damage. The easily obtainable PRP and its possible beneficial outcome hold promise for new regenerative treatment approaches. The aim of this literature review was to describe the bioactivities of PRP, to elucidate the different techniques for PRP preparation, to review animal and human studies, to evaluate the evidence regarding the use of PRP in trauma and orthopaedic surgery, to clarify risks, and to provide guidance for future research.

Long-term survival benefits of docetaxel plus cyclophosphamide compared to doxorubicin plus cyclophosphamide in the adjuvant treatment of operable breast cancer

563

Background: The U.S. Oncology Adjuvant Trial 9735 recently demonstrated disease-free survival and overall survival (OS) benefits over 7 years for docetaxel plus cyclophosphamide (TC) compared with doxorubicin plus cyclophosphamide (AC) as adjuvant treatment for women with operable stage I-III invasive breast cancer (BC). The life-time benefits of TC vs. AC, however, are unknown. This analysis aimed to project potential life-time survival benefits of TC vs. AC as adjuvant therapy for operable BC. Methods: The 7-year follow-up results of the 9735 study combined with US average life expectancy were used to project the life-time survival benefits of TC vs. AC. In the base case (scenario 1), it was assumed the survival advantage of TC did not persist beyond the 7-year clinical trial period. Rather, all patients alive and disease-free at 7 years (from the starting age of 51 to the age of 58), regardless of treatment, were assumed to be cured and received the average remaining life expectancy of a 58-year old woman in the US general population. As survival benefits from chemotherapy may persist beyond the clinical trial period, two sensitivity analyses were conducted: 1) greater life expectancy in the TC arm of 1.8 months equivalent to the mean difference in OS between TC and AC within the clinical trial period (scenario 2) and 2) greater life expectancy in the TC arm of 22 months equivalent to the difference in survival at the end of 7 years (scenario 3). The total life years gained (LYs) and quality-adjusted life years gained (QALYs) were then calculated. Results: Per patient LYs gained in scenarios 1, 2, and 3 were 0.850, 0.930, and 1.755, respectively; while QALYs gained were slightly lower at 0.674, 0.736 and 1.383, respectively. Applying this benefit to a cohort of 167,133 women in the US with newly diagnosed stage I-III invasive BC in 2008, the gains were 142,063 LYs and 112,648 QALYS in scenario 1. Conclusions: In addition to survival benefit observed within the clinical trial period, the use of TC is associated with long-term survival benefits compared to AC in patients with stage I-III invasive BC. The results provide additional support of the value of TC in the management of early stage BC.

[Table: see text]

Deriving temperature and age appropriate heart rate centiles for children with acute infections

OBJECTIVES

To describe the reference range for heart rate in children aged 3 months-10 years presenting to primary care with self-limiting infections.

DESIGN

Cross-sectional study of children presenting to primary care with suspected acute infection. Heart rate was measured using a pulse oximeter and axillary temperature using an electronic thermometer. Centile charts of heart rates expected at given temperatures for children with self-limiting infections were calculated.

SETTING

Ten general practice surgeries and two out-of-hours centres in England.

PARTICIPANTS

1933 children presenting with suspected acute infections were recruited from in-hours general practice surgeries (1050 or 54.3%) or out-of-hours centres (883 or 45.7%). After excluding children who subsequently attended hospital and those without a final diagnosis of acute infection, 1589 children were used to create the centile charts of whom (859 or 54.1%) had upper respiratory tract infections and (215 or 13.5%) non-specific viral illness.

MAIN OUTCOME MEASURES

Median, 75th, 90th and 97th centiles of heart rate at each temperature level.

RESULTS

Heart rate increased by 9.9-14.1 bpm with each 1 degrees C increment in temperature. The 50th, 75th, 90th and 97th centiles of heart rate at each temperature level are presented graphically.

CONCLUSIONS

Age-specific centile charts of heart rates expected at different temperatures should be used by clinicians in the initial assessment of children with acute infections. The charts will identify children who have a heart rate higher than expected for a given temperature and facilitate the interpretation of changes in heart rate on reassessment. Further research on the predictive value of the centile charts is needed to optimise their diagnostic utility.

Diagnostic strategies used in primary care

The strategies used by general practitioners in making a diagnosis are being formally recognised; this article is the first in a series that will illustrate their application, and is accompanied by a case study (doi:10.1136/bmj.b1187)

Docetaxel plus cyclophosphamide is cost-effective compared to doxorubicin plus cyclophosphamide, based on an economic analysis of US oncology trial 9735: additional rationale to avoid anthracyclines in the adjuvant treatment of operable breast cancer?

Abstract #6105

Background: Extended 7-year follow-up of the US Oncology Adjuvant Trial 9735 demonstrated that docetaxel plus cyclophosphamide (TC) as adjuvant treatment of operable invasive breast cancer significantly improves disease-free survival (DFS) and overall survival (OS) compared to doxorubicin plus cyclophosphamide (AC). DFS was 81% vs. 75%, respectively (p = 0.033) and OS was 87% vs. 82%, respectively (p = 0.032). A lifetime cost-effectiveness analysis of TC versus AC was conducted from a Canadian (province of Ontario) government payer perspective, based on head-to-head clinical data from Trial 9735. Methods: Survival and monthly risk of disease recurrence of women with early stage breast cancer (base case typifying those entered into the trial) was estimated up to 7 years using OS and DFS data from Trial 9735. Survival was extrapolated to lifetime using life expectancy estimates from the Canadian general population. Canadian resource utilization and unit costs were applied to estimate the costs of chemotherapy (including drug and administration costs), chemotherapy-related toxicities and disease recurrence. Quality of life (utility) weights for health states and events, used in the calculation of quality-adjusted life years (QALYs), were derived from the literature. Total costs, life years and QALYs were calculated for a lifetime horizon. Results: Life years and QALYs were higher for TC patients compared to AC patients, due primarily to longer survival and fewer recurrences for patients receiving TC. The predicted life expectancy of patients receiving TC and AC was 14.64 and 14.02 years, respectively. Mean total lifetime disease-related costs were $12,840 with TC and $8,579 with AC; the difference in costs was driven by higher drug acquisition costs for TC. Cost per life year gained (TC vs. AC) was $6,842 and cost per QALY gained was $8,251, discounting costs and outcomes at 5% per year. Base case results were most sensitive to assumptions regarding time horizon. In a sensitivity analysis conducted with a 7-year time horizon (the time frame of the clinical trial), cost per life year gained was $36,120 and cost per QALY gained was $43,248. In additional one-way sensitivity analyses conducted with a lifetime horizon and alternative assumptions regarding survival extrapolation, utility estimates, costs and discount rate, cost per life year gained remained between $2,982 and $7,538 and cost per QALY gained remained between $3,600 and $9,090. Conclusion: In patients with early stage, operable, invasive breast cancer, adjuvant treatment with TC provides gains in terms of life years and QALYs compared to AC and results in favourable cost-effectiveness ratios that should be acceptable in most jurisdictions.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6105.

Detection of DNA damage: effect of thymidine glycol residues on the thermodynamic, substrate and interfacial acoustic properties of oligonucleotide duplexes

Thymidine glycol residues in DNA are biologically active oxidative molecular damage sites caused by ionizing radiation and other factors. One or two thymidine glycol residues were incorporated in 19- to 31-mer DNA fragments during automatic oligonucleotide synthesis. These oligonucleotide models were used to estimate the effect of oxidized thymidines on the thermodynamic, substrate and interfacial acoustic properties of DNA. UV-monitoring melting data revealed that modified residues in place of thymidines destabilize the DNA double helix by 8-22 degrees C, depending on the number of lesions, the length of oligonucleotide duplexes and their GC-content. The diminished hybridizing capacity of modified oligonucleotides is presumably due to the loss of aromaticity and elevated hydrophilicity of thymine glycol in comparison to the thymine base. According to circular dichroism (CD) data, the modified DNA duplexes retain B-form geometry, and the thymidine glycol residue introduces only local perturbations limited to the lesion site. The rate of DNA hydrolysis by restriction endonucleases R.MvaI, R.Bst2UI, R.MspR9I and R.Bme1390I is significantly decreased as the thymidine glycol is located in the central position of the double-stranded recognition sequences 5'-CC / WGG-3' (W = A, T) or 5'-CC / NGG-3' (N = A, T, G, C) adjacent to the cleavage site. On the other hand, the catalytic properties of enzymes R.Psp6I and R.BstSCI recognizing the similar sequence are not changed dramatically, since their cleavage site is separated from the point of modification by several base-pairs. Data obtained by gel-electrophoretic analysis of radioactive DNA substrates were confirmed by direct spectrophotometric assay developed by the authors. The effect of thymidine glycol was also observed on DNA hybridization at the surface of a thickness-shear mode acoustic wave device. A 1.9-fold decrease in the rate of duplex formation was noted for oligonucleotides carrying one or two thymidine glycol residues in relation to the unmodified analog.

No association between two polymorphisms of the serotonin transporter gene and combined type attention deficit hyperactivity disorder

Several independent studies have reported association between serotonin transporter gene (SLC6A4) polymorphisms and attention deficit hyperactivity disorder (ADHD). Five studies found evidence for association between the long-allele of a 44-bp insertion/deletion polymorphism (5-HTTLPR) and ADHD. Another two studies corroborated this finding while a further six studies did not find such an association. For a second polymorphism within the gene, a variable number tandem repeat (VNTR) within intron 2, one study demonstrated that the 12/12 genotype was significantly less frequent in ADHD cases compared to controls, while a second study found that the 12-allele was preferentially transmitted to offspring affected with ADHD. To provide further clarification of the reported associations, we investigated the association of these two markers with ADHD in a sample of 1,020 families with 1,166 combined type ADHD cases for the International Multi-Centre ADHD Genetics project, using the Transmission Disequilibrium Test. Given the large body of work supporting the association of the promoter polymorphism and mood disorders, we further analyzed the group of subjects with ADHD plus mood disorder separately. No association was found between either of the two markers and ADHD in our large multisite study or with depression within the sample of ADHD cases.

Endovascular repair of an aortic arch aneurysm using a branched-stent graft

INTRODUCTION

Aortic arch aneurysm repair continues to pose a formidable technical challenge in a patient population with significant co-morbidity.

REPORT

We present a successful endovascular repair of an 8.4 cm aortic arch aneurysm, in a 74 year old man, who's previous median sternotomy showed signs of delayed healing, precluding open repair.

DISCUSSION

Applied endovascular techniques obviated the need for aortic clamping, cardiac bypass, or hypothermic circulatory arrest, via an approach that was potentially infected.

Atherosclerotic aneurysms. Comparisons between thoracic stentgrafts--how do we know which stent graft to select?

Surgical intervention for thoracic aortic aneurysms (TAA) greater than six centimetres is warranted in most patients deemed fit enough to withstand surgery as the annual risk of death, rupture or dissection is estimated to be 16%. Traditional surgical repair of thoracic aortic aneurysms however carries an attendant risk of significant morbidity and mortality. Endovascular repair (TEVAR) has emerged as a feasible alternative which is associated with significantly improved patient outcomes even in the highest risk patients. Improvement in stent-graft design has increased the rates of technical success of aneurysm exclusion and promises to offer further mid-term reductions in the need for re-intervention and the risk of aneurysm related death. This review article highlights the advances made in thoracic stent-graft design and discusses patient outcomes for each of the most widely used endografts in clinical practice to date.

The red cell distribution width in sickle cell disease--is it of clinical value?

The red cell distribution width (RDW) has been studied during the clinical steady state in 1121 patients with homozygous sickle cell (SS) disease, 344 with sickle cell-haemoglobin C (SC) disease, 68 with sickle cell-beta+ thalassaemia, 49 with sickle cell beta 0 thalassaemia and in 130 control subjects with a normal (AA) genotype. The mean RDW was moderately increased in S beta + thalassaemia and SC disease and markedly increased in S beta 0 thalassaemia and SS disease. In SS, SC and S beta 0 thalassaemia genotypes, lower RDW values occurred in females and with alpha thalassaemia. The RDW correlated negatively with total haemoglobin, mean cell haemoglobin concentration, mean cell volume, and fetal haemoglobin (HbF) and positively with reticulocyte count in SS disease. A low RDW was associated with higher weight and less frequent dactylitis, painful crisis, acute chest syndrome, acute splenic sequestration, and hospital admissions. A low RDW in SS disease is consistent with a high total haemoglobin, high HbF, low reticulocyte count, alpha thalassaemia, and a more mild clinical course.

Objective risk-scoring systems for repair of abdominal aortic aneurysms: applicability in endovascular repair?

OBJECTIVES

Recent studies propose the use of objective risk-scoring systems as a clinical tool for selecting patients for open or endovascular abdominal aortic aneurysm repair (EVR). The aim of this study was to evaluate four established risk-scoring systems for accuracy of prediction of early mortality and morbidity following EVR.

PATIENTS AND METHODS

266 consecutive patients undergoing elective EVR at St. George's Vascular Institute between July 2001 and January 2007 were studied using a prospective database. The Glasgow Aneurysm Score (GAS), the Vascular Physiology and Operative Severity Score for the enUmeration of Mortality and Morbidity (V-POSSUM), the modified Customised Probability Index (m-CPI) and the Customised Probability Index (CPI) were applied for prediction of 30-day mortality and morbidity. Accuracy of prediction was compared using receiver operating characteristics (ROC) curve analyses.

RESULTS

30-day mortality and morbidity rates were 4% (11/266) and 8% (22/266) respectively. For prediction of mortality, GAS, V-POSSUM, m-CPI and CPI ROC curve analyses showed areas under the curves (AUCs) of 0.68 (95% confidence interval (CI), 0.48-0.87; p=0.046), 0.66 (95% CI, 0.51-0.81; p=0.067), 0.63 (95% CI, 0.45-0.81; p=0.148) and 0.65 (95% CI, 0.49-0.80; p=0.101) respectively. Corresponding AUCs for prediction of morbidity were 0.64 (95% CI, 0.51-0.76; p=0.511), 0.62 (95% CI, 0.51-0.74; p=0.505), 0.54 (95% CI, 0.41-0.67; p=0.416) and 0.55 (95% CI, 0.42-0.68; p=0.451).

CONCLUSIONS

GAS, V-POSSUM, m-CPI and CPI were poor predictors of early mortality and morbidity following EVR in this series. Caution should be applied to the use of these scoring systems for pre-operative risk stratification and treatment selection for endovascular repair of abdominal aneurysms.

A high-density SNP linkage scan with 142 combined subtype ADHD sib pairs identifies linkage regions on chromosomes 9 and 16

As part of the International Multi-centre ADHD Genetics project we completed an affected sibling pair study of 142 narrowly defined Diagnostic and Statistical Manual of Mental Disorders, fourth edition combined type attention deficit hyperactivity disorder (ADHD) proband-sibling pairs. No linkage was observed on the most established ADHD-linked genomic regions of 5p and 17p. We found suggestive linkage signals on chromosomes 9 and 16, respectively, with the highest multipoint nonparametric linkage signal on chromosome 16q23 at 99 cM (log of the odds, LOD=3.1) overlapping data published from the previous UCLA (University of California, Los Angeles) (LOD>1, approximately 95 cM) and Dutch (LOD>1, approximately 100 cM) studies. The second highest peak in this study was on chromosome 9q22 at 90 cM (LOD=2.13); both the previous UCLA and German studies also found some evidence of linkage at almost the same location (UCLA LOD=1.45 at 93 cM; German LOD=0.68 at 100 cM). The overlap of these two main peaks with previous findings suggests that loci linked to ADHD may lie within these regions. Meta-analysis or reanalysis of the raw data of all the available ADHD linkage scan data may help to clarify whether these represent true linked loci.

Circulating stromelysin-1 (MMP-3): a novel predictor of LV dysfunction, remodelling and all-cause mortality after acute myocardial infarction

INTRODUCTION

Changes to cardiac matrix are central to ventricular remodelling after acute MI and matrix metalloproteinase expression is implicated in this process. We investigated the temporal profile of MMP-3 and its relationship to LV dysfunction and prognosis following AMI.

METHODS

We studied 382 patients with AMI. Plasma MMP-3 was measured at 0-12, 12-24 h and for subsequent 24 h periods during admission. LV function (LVEF) was assessed by echocardiography pre-discharge and at a median of 148 days and clinical endpoints at a median of 313 days.

RESULTS

MMP-3 peaked prior to discharge thus pre-discharge levels were used in analyses. MMP-3 was associated with patient age (p<0.001), creatinine (p<0.001) and was higher in males (p<0.001) and hypertensives (p<0.001). MMP-3 inversely correlated with LVEF at follow-up (p=0.043), was higher in subjects with LVEF <40% (p=0.017) and in subjects with increasing EDV (p=0.017) or ESV (p=0.007) compared to those in whom volumes fell between visits. In the 58 patients reaching the endpoint of death or heart failure, MMP-3 was higher (p<0.001). On Kaplan-Meier analysis, subjects with levels above optimum cut off identified via ROC curves were more likely to suffer a clinical event (p=0.037).

CONCLUSION

MMP-3 is associated with left ventricular dysfunction, adverse left ventricular remodelling and prognosis after AMI.

Co-transmission of conduct problems with attention-deficit/hyperactivity disorder: familial evidence for a distinct disorder

Common disorders of childhood and adolescence are attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD). For one to two cases in three diagnosed with ADHD the disorders may be comorbid. However, whether comorbid conduct problems (CP) represents a separate disorder or a severe form of ADHD remains controversial. We investigated familial recurrence patterns of the pure or comorbid condition in families with at least two children and one definite case of DSM-IV ADHDct (combined-type) as part of the International Multicentre ADHD Genetics Study (IMAGE). Using case diagnoses (PACS, parental account) and symptom ratings (Parent/Teacher Strengths and Difficulties [SDQ], and Conners Questionnaires [CPTRS]) we studied 1009 cases (241 with ADHDonly and 768 with ADHD + CP), and their 1591 siblings. CP was defined as > or =4 on the SDQ conduct-subscale, and T > or = 65, on Conners' oppositional-score. Multinomial logistic regression was used to ascertain recurrence risks of the pure and comorbid conditions in the siblings as predicted by the status of the cases. There was a higher relative risk to develop ADHD + CP for siblings of cases with ADHD + CP (RRR = 4.9; 95%CI: 2.59-9.41); p < 0.001) than with ADHDonly. Rates of ADHDonly in siblings of cases with ADHD + CP were lower but significant (RRR = 2.9; 95%CI: 1.6-5.3, p < 0.001). Children with ADHD + CP scored higher on the Conners ADHDct symptom-scales than those with ADHDonly. Our finding that ADHD + CP can represent a familial distinct subtype possibly with a distinct genetic etiology is consistent with a high risk for cosegregation. Further, ADHD + CP can be a more severe disorder than ADHDonly with symptoms stable from childhood through adolescence. The findings provide partial support for the ICD-10 distinction between hyperkinetic disorder (F90.0) and hyperkinetic conduct disorder (F90.1).

Comparison of radial expansion of stents within mock vessels molded with a target bent radius versus straight mock vessels bent to a target radius

Testing of medical devices such as vascular stents generally require animal clinical studies to be conducted prior to approval for use in humans. In the recent years, several studies have shown that mock vessels serve as good alternatives or adjuncts to animal studies, having the ability to replicate some anatomical and physiological conditions [1,2]. Testing the medical device utilizing mock arteries is less time consuming and more cost effective than animal studies and is often able to predict clinical failures. Testing standards recommend that stents be tested under physiologically-relevant conditions of pulsating load. Under the pulsating load, characteristics of mock arteries play a very important role in the behavior of the stent. Distension of the mock artery controls the load applied on the stent and the shape of the mock artery ensures uniform loading of the stent [3]. The research described in this study is an effort towards determining the role played by the shape of the mock artery on distension of the stent. More specifically, does a molded curved vessel apply more uniform or less uniform loading to the stent than a straight vessel that was bent after fabrication and stent deployment?

Lemierre's syndrome complicating pregnancy

Lemierre's syndrome is an anaerobic suppurative thrombophlebitis involving the internal jugular vein secondary to oropharyngeal infection. There is only one previous case report in pregnancy which was complicated by premature delivery of an infant that suffered significant neurological damage. We present an atypical case diagnosed in the second trimester with a live birth at term. By reporting this case, we hope to increase the awareness of obstetricians to the possibility of Lemierre's syndrome when patients present with signs of unabating oropharyngeal infection and pulmonary symptoms.

The Use of an Extra-corporeal Graft to Maintain Cerebral Perfusion During Thoracic Endovascular Aneurysm Repair

Endovascular access for aneurysm repair can be challenging in patients with iliofemoral occlusive disease. The carotid artery is an alternative access site, but may increase the risk of cerebral hypoperfusion during stent delivery. We describe a novel approach, where temporary extra-corporeal bypass was used to maintain cerebral perfusion during endovascular thoracic aneurysm repair via the carotid artery, in a patient with significant aorto-iliac and arch vessel disease.