Aicardi syndrome in a male patient

Aicardi syndrome ( OMIM 304050) is defined by the clinical triad of early-onset infantile spasms, agenesis of the corpus callosum and chorioretinal lacunae. Almost all patients are females showing severe cognitive and physical disabilities, and early onset seizures. Astrocytic inclusions containing filamin have been found, but the molecular defect in Aicardi syndrome is not yet known. We report a male patient with Aicardi syndrome characterised by agenesis of the corpus callosum, infantile spasms, chorioretinal lacunae, severe psychomotor retardation, periventricular heterotopias, and patent ductus arteriosus. As the latter two symptoms are suggestive of a mutation in the FLNA gene encoding filamin A, this gene was sequenced, but the sequence did not reveal a disease-causing mutation.

Fatal and non-fatal fire injuries in England 1995-2004: time trends and inequalities by age, sex and area deprivation

AIM

To examine time trends and deprivation gradients in fire-related deaths and injuries.

METHODS

A cross-sectional study and time trend analysis using data on fire casualties in England between 1995 and 2004 obtained from the Department for Communities and Local Government. Injury rates were calculated assuming a Poisson distribution. Incidence rate ratios (IRRs) were calculated to compare changes in deprivation gradients over time.

RESULTS

There were significant reductions in fatal and non-fatal fire injuries in children (fatal injuries IRR chi(2)(1) = 11.18, P < 0.001; non-fatal injuries IRR chi(2)(2) = 61.44, P < 0.001), adults (fatal injuries IRR chi(2)(1) = 15.99, P < 0.001; non-fatal injuries IRR chi(2)(2) = 183.25, P < 0.001) and older people (fatal injuries IRR chi(2)(1) = 56.88, P < 0.001; non-fatal injuries IRR chi(2)(2) = 54.09, P < 0.001) between 1995 and 2004. Adult and child fire deaths were most commonly caused by smokers' materials (e.g. cigarettes, cigars and tobacco), and cigarette lighters and matches, respectively. Cooking appliances caused most non-fatal fire injuries. Injury rates increased with increasing levels of deprivation and deprivation gradients did not change over 10 years.

CONCLUSIONS

Fire prevention interventions should promote the safe use of cooking and heating appliances and the responsible use of smokers' materials, lighters and matches, and should target those at greater risk of fire, including the socially disadvantaged.

The role of ENT surgeons in snoring assessment: some prospective preliminary evidence

OBJECTIVES

To determine (i) the prevalence of unsuspected upper aerodigestive tract disease in snorers, (ii) the diagnostic yield of routine flexible endoscopy and (iii) the relationship between symptoms of upper aerodigestive tract disease and examination findings in snorers.

DESIGN

Prospective analytical cohort study.

SETTING

Snoring clinic in Secondary Care Otolaryngology centre.

PARTICIPANTS

Ninety-three patients referred with disruptive snoring.

MAIN OUTCOME MEASURES

A structured history of upper aerodigestive tract symptoms was obtained by clinic interview. All patients underwent detailed ENT examination. Univariate analysis was undertaken on data collected.

RESULTS

The prevalence of oropharyngeal and laryngeal pathology in the cohort was 3%. No unsuspected upper aerodigestive tract pathology was found on routine flexible endoscopy. A history of Hard Nasal Symptoms was an accurate predictor of underlying nasal pathology.

CONCLUSION

The authors propose that the detailed examination of snorers by ENT specialists is unnecessary in the absence of Hard Nasal Symptoms, hoarseness or pain. We propose that a system of triage based on patient history could help identify the minority of snorers who require specialist assessment.

Use of laboratory data to reduce the time taken to detect new diseases: VIDA to FarmFile

The analysis of laboratory data can provide information about the health of livestock populations; in Great Britain the Veterinary Investigation Diagnosis Analysis (VIDA) system has provided such data since 1975. However VIDA covers only known diagnoses, with limited epidemiological characterisation. The unexpected outbreak of bse showed that it was necessary to improve surveillance to detect new diseases, and a necessary update of the VIDA database for the millennium date change provided the opportunity. The information required to enhance the value of laboratory data was identified, a new form and database, 'FarmFile', were designed to record it, and they began to be used in 1999. The detection of new diseases depends on making comparisons with the expected or 'usual' levels of unexplained disease. The data are analysed quarterly to assess any changes in the levels of unexplained disease in different species, categorised in terms of clinical sign or body system, by comparison with previous years. No new diseases have been detected either through FarmFile or more traditional means since the new analyses started in earnest in 2004, but they have indicated that an unexplained event was not a new disease of concern, and developments continue to improve the system's sensitivity and specificity.

Comparison of combined urea and creatinine clearance and prediction equations as measures of residual renal function when GFR is low

BACKGROUND

UK, US and European guidelines recommend the decision to initiate dialysis should be based on a combination of measurements of kidney function, nutritional status and clinical symptoms. Such recommendations assume an accurate and reproducible measure of glomerular filtration rate (GFR).

METHODS

Prospective study of 97 patients with chronic kidney disease (CKD) and serum creatinine >200 micromol/l (2.26 mg/dl) who between them contributed 388 24 h urine collections. Our main outcome measure was the number of patients with low residual renal function identified by different tests, using widely accepted thresholds. We calculated sensitivity, specificity, positive and negative predictive values and receiver operating characteristic curves for each comparison using a combined urea and creatinine clearance of <15 ml/min to indicate the likely presence of end stage renal disease (CKD stage 5).

RESULTS

Seventy five patients had a combined urea and creatinine clearance <15 ml/min during the study. Using the highest measurement of serum creatinine for each patient, the best of the prediction equations was the 4-variable modification of diet in renal disease (MDRD) equation (area under ROC curve 0.93). This was followed by Kt/V (AUC 0.91) and Cockroft Gault with and without correction for ideal body weight (AUC 0.89). Further analyses showed that the 4-variable MDRD equation had higher NPV (64%) but lower PPV (89%) than the other tests (NPV 40-49%, PPV 92-100%), for identifying patients whose combined clearance was <15 ml/min.

CONCLUSION

The 4-variable MDRD formula is currently the best available prediction equation for GFR, but will nevertheless over estimate residual renal function when this is significantly impaired in up to 36% cases. Collection of 24 h urine samples may still have a role in the assessment of patients with stages 4 and 5 CKD.

A controlled release pilocarpine buccal insert in the treatment of Sjögren's syndrome

OBJECTIVES

To assess the efficacy of a novel hydrogel polymer buccal insert containing 5 mg pilocarpine in releasing the pilocarpine in a controlled fashion over a three hour period, and to assess the effects of this on quantitative tear and saliva production and the acceptability of the insert to the patient.

DESIGN

This was an open, uncontrolled pilot study for which Ethics Committee approval was obtained prior to starting. Hydrogel buccal inserts containing 5 mg pilocarpine were used three times a day for seven days.

SETTING

The Department of Oral Medicine, Glasgow Dental Hospital & School.

SUBJECTS

Eight patients with Sjögren's syndrome.

MAIN OUTCOME MEASURES

Changes over baseline in (1) Schirmer test, (2) whole saliva flow rate, (3) oral comfort score (VAS), (4) ocular comfort score (VAS), (5) patient acceptability.

RESULTS

The buccal inserts successfully released in excess of 85% of their 5 mg pilocarpine load over three hours. There was a general improvement in oral and ocular comfort scores assessed by visual linear analogue scale, and saliva and tear production generally increased. The inserts were well tolerated by all patients except one (who wore dentures). Adverse events were few and none was serious.

CONCLUSION

This novel form of buccal pilocarpine delivery demonstrated potential for use in treating patients with Sjögren's syndrome.

Large area mass analyzer instrument for the chemical analysis of interstellar dust particles

A new instrument to analyze the chemical composition of dust particles in situ in space has been developed. The large target area ( approximately 0.2 m(2)) makes this instrument well suited for detecting a statistically significant number of interstellar dust grains or other dust particles with a low flux. The device is a reflectron-type time-of-flight mass spectrometer that uses only flat electrodes for the generation of the parabolic potential. The instrument analyzes the ions from the impact generated plasma due to hypervelocity dust impacts onto a solid target surface. The SIMION ion optics software package is used to investigate different potential field configurations and optimize the mass resolution and focusing of the ions. The cylindrically symmetric instrument operates with six ring electrodes and six annular electrodes biased to different potentials to create the potential distribution of the reflectron. The laboratory model of the instrument has been fabricated and tested. Hypervelocity dust impacts are simulated by laser ablation using a frequency doubled Nd:YAG laser with approximately 8 ns pulse length. The experimental data show typical mass resolution m/Deltam approximately 200.

Varied presentations of pseudoxanthoma elasticum in a family

Pseudoxanthoma elasticum (PXE) is a hereditary disorder of elastic tissue. The characteristic skin changes are asymptomatic yellow papules around the neck and in body folds giving the skin a characteristic cobblestone appearance. The eyes, cardiovascular and gastrointestinal systems are also commonly involved. In this case-series, we present a family of four children, three of whom demonstrated diverse manifestations of PXE. The first child presented with sudden death at age 3 and showed marked coronary and renal arterial intimal fibrosis with prominent fragmentation of the internal elastic lamina, initially attributed to idiopathic arterial calcification. The second child presented with clinical features and histology of the skin typical of PXE at age 11 and the third child, with abnormal, but non-specific cardiological findings at age 8, which raised the possibility of an early stage of PXE. This report emphasizes the importance of considering pseudoxanthoma elasticum in diverse clinical settings, early diagnosis and appropriate screening for asymptomatic family members.

Ear protection as a treatment for disruptive snoring: do ear plugs really work?

BACKGROUND

In the absence of surgical treatments with demonstrable long-term efficacy, conservative treatments for snoring remain appropriate. Only limited evidence evaluating the use of ear protection by partners has been published.

METHODS

Eligible couples were invited to participate in a two-month trial, with each partner using custom-moulded ear plugs. Five questionnaires were completed by patients and their partners, at baseline and after two months: the snoring outcomes survey (SOS) or the spouse/bed partners survey (SBPS), the Epworth sleepiness scale (ESS), the general health questionnaire-12 (GHQ-12), the Nottingham health profile (NHP) and the Golombok-Rust inventory of marital status (GRIMS).

RESULTS

After two months, there was a significant improvement in the SOS score for patients (p = 0.005), the SBPS score for partners (p = 0.001) and the ESS for partners (p = 0.004).

CONCLUSIONS

For selected couples, ear plugs represent an effective short-term treatment for some of the social effects of disruptive snoring, as determined by the SOS, SBPS and ESS questionnaires.

FBN1, TGFBR1, and the Marfan-craniosynostosis/mental retardation disorders revisited

The recent identification of TGFBR2 mutations in Marfan syndrome II (MFSII) [Mizuguchi et al. (2004); Nat Genet 36:855-860] and of TGFBR1 and TGFBR2 mutations in Loeys-Dietz aortic aneurysm syndrome (LDS) [Loeys et al. (2005); Nat Genet 37:275-281] [OMIM 609192] has provided direct evidence of abnormal signaling in transforming growth factors beta (TGF-beta) in the pathogenesis of Marfan syndrome (MFS). In light of this, we describe the phenotypes and genotypes of five individuals. Patient 1 had MFS and abnormal cranial dura. Patient 2 had severe early onset MFS and an abnormal skull. Patients 3 and 4 had probable Furlong syndrome (FS). Patient 5 had marfanoid (MD) features, mental retardation (MR), and a deletion of chromosome 15q21.1q21.3. All patients had a condition within the MFS, MD-craniosynostosis (CS) or MD-MR spectrum. The names of these entities may become redundant, and instead, come to be considered within the spectrum of TGF-beta signaling pathway disorders. Two recurrent heterozygous FBN1 mutations were found in Patients 1 and 2, and an identical novel heterozygous de novo TGFBR1 mutation was found in Patients 3 and 4, in whom altered fibrillin-1 processing was demonstrated previously [Milewicz et al. (2000); Am J Hum Genet 67:279]. A heterozygous FBN1 deletion was found in Patient 5. These findings support the notion that perturbation of extracellular matrix homeostasis and/or remodeling caused by abnormal TGF-beta signaling is the core pathogenetic mechanism in MFS and related entities including the MD-CS syndromes.

Life threatening hyperkalaemia with diarrhoea during ACE inhibition

A 67 year old woman developed acute renal failure with serum potassium 9.4 mmol/l requiring emergency dialysis after seven days of diarrhoea while taking an ACE inhibitor for vascular disease. Review of the literature, the British National Formulary, and the patient information leaflets for each of the 11 ACE inhibitors currently marketed in the UK suggests that this potentially life threatening complication of ACE inhibition is not yet widely recognised.

Filamin A mutations cause periventricular heterotopia with Ehlers-Danlos syndrome

OBJECTIVE

To define the clinical, radiologic, and genetic features of periventricular heterotopia (PH) with Ehlers-Danlos syndrome (EDS).

METHODS

Exonic sequencing and single stranded conformational polymorphism (SSCP) analysis was performed on affected individuals. Linkage analysis using microsatellite markers on the X-chromosome was performed on a single pedigree. Western blotting evaluated for loss of filamin A (FLNA) protein and Southern blotting assessed for any potential chromosome rearrangement in this region.

RESULTS

The authors report two familial cases and nine additional sporadic cases of the EDS-variant form of PH, which is characterized by nodular brain heterotopia, joint hypermobility, and development of aortic dilatation in early adulthood. MRI typically demonstrated bilateral nodular PH, indistinguishable from PH due to FLNA mutations. Exonic sequencing or SSCP analyses of FLNA revealed a 2762 delG single base pair deletion in one affected female. Another affected female harbored a C116 single point mutation, resulting in an A39G change. A third affected female had a 4147 delG single base pair deletion. One pedigree with no detectable exonic mutation demonstrated positive linkage to the FLNA locus Xq28, an affected individual in this family also had no detectable FLNA protein, but no chromosomal rearrangement was detected.

CONCLUSION

These results suggest that the Ehlers-Danlos variant of periventricular heterotopia (PH), in part, represents an overlapping syndrome with X-linked dominant PH due to filamin A mutations.

Numerical solutions to a kinetic model for the plasma-sheath problem with charge exchange collisions of ions

A kinetic model of the plasma-sheath problem is presented that includes the effects of charge-exchange collisions of the ion. The collisions are modeled as a sink for accelerated ions and as a source of cold ions. Solutions are obtained by numerical integration of Poisson's equation from a point near the plasma midplane to the wall. In the quasineutral region, these solutions agree with earlier analytic work. As the mean free path is decreased, the current density at the wall decreases and the potential profile in the quasineutral region shows a smooth transition from a parabolic profile to a nearly cubic profile determined by the ion mobility. An approximate expression is found for the ion flux to the wall in the collisional limit.

Systematic generation of high-resolution deletion coverage of the Drosophila melanogaster genome

In fruit fly research, chromosomal deletions are indispensable tools for mapping mutations, characterizing alleles and identifying interacting loci. Most widely used deletions were generated by irradiation or chemical mutagenesis. These methods are labor-intensive, generate random breakpoints and result in unwanted secondary mutations that can confound phenotypic analyses. Most of the existing deletions are large, have molecularly undefined endpoints and are maintained in genetically complex stocks. Furthermore, the existence of haplolethal or haplosterile loci makes the recovery of deletions of certain regions exceedingly difficult by traditional methods, resulting in gaps in coverage. Here we describe two methods that address these problems by providing for the systematic isolation of targeted deletions in the D. melanogaster genome. The first strategy used a P element-based technique to generate deletions that closely flank haploinsufficient genes and minimize undeleted regions. This deletion set has increased overall genomic coverage by 5-7%. The second strategy used FLP recombinase and the large array of FRT-bearing insertions described in the accompanying paper to generate 519 isogenic deletions with molecularly defined endpoints. This second deletion collection provides 56% genome coverage so far. The latter methodology enables the generation of small custom deletions with predictable endpoints throughout the genome and should make their isolation a simple and routine task.

Diarrhoea, vomiting and ACE inhibitors:--an important cause of acute renal failure

The occurrence of severe acute renal failure in 3 patients who developed diarrhoea while taking angiotensin converting enzyme (ACE) inhibitors led us to undertake a retrospective cohort survey to determine the frequency with which diarrhoea and vomiting are associated with acute renal failure in patients taking this class of drug. Serum creatinine was measured as part of the diagnostic workup of 2398 consecutive admissions to an acute medical receiving unit in a district general hospital. Outcome measures were the presence of diarrhoea and/or vomiting, and whether taking an ACE inhibitor, NSAID or diuretic at the time of admission, also previous, initial and follow up serum creatinine concentrations. Peak serum creatinine in the 3 cases was 1159, 989 and 765 micromol/l. None of the 3 required dialysis and all recovered renal function completely after receiving large volumes of intravenous fluid. In the cohort study, 89 of 2398(3.7%) admissions had serum creatinine >/=200 micromol/l. Nine were regular dialysis patients. Of the remaining patients, 30 (37.5%) were taking an ACE inhibitor. Six of 30 (20%) gave a history of diarrhoea and/or vomiting. Median creatinine concentration in this group was 135 (range 111-209) micromol/l before admission, 292 (216-724) micromol/l when first seen in hospital, and 134 (94-219) micromol/l following the withdrawal of drug therapy and fluid replacement. In conclusion, volume depletion causing acute renal failure in patients taking ACE inhibitors is not uncommon. Such patients and their general practitioners should be aware that reversible renal impairment may occur during intercurrent illnesses, particularly if characterised by diarrhoea and/or vomiting.

High incidence of renal failure requiring short-term dialysis: a prospective observational study

BACKGROUND

Previous estimates of incidence of acute renal failure (ARF) requiring renal replacement therapy have varied from 18 to 75 patients per million per year, but have been beset by problems of definition.

AIM

To investigate whether the '90-day rule' provides a more reliable, reproducible and robust estimate of the need for short-term dialysis.

SETTING

District general hospital serving a population of 147 000.

DESIGN

Prospective observational study.

METHODS

Patients who received renal replacement therapy in Dumfries and Galloway between 01/01/94 and 31/12/2000 were divided into two groups: long-term dialysis (> or =90 days) and short-term dialysis (<90 days).

RESULTS

Of 302 patients, 193 received short-term dialysis, giving an incidence for short-term dialysis of 187 patient episodes per million per year (95%CI 170-203). Use of a more conventional definition for ARF (including all ARF and acute-on-chronic renal failure, but excluding patients with chronic renal failure who present acutely) produced a similar estimate at 176 patients per million per year (95%CI 160-193).

DISCUSSION

The 90-day rule estimated the incidence of short-term dialysis/ARF at nearly twice the incidence of chronic renal failure requiring dialysis, and more than twice the most recent estimate of the incidence of ARF in the UK. The main attraction of the 90-day rule is its simplicity. If the high level of short-term dialysis/ARF found in our study is confirmed by other centres, there are significant resource implications for the provision of renal care.

The use of snowboard boot bindings in a hip disarticulation prosthesis

This report describes a new technique for fastening a hip disarticulation socket. It was developed at the request of the patient who needed to fasten his prosthesis using only one hand, because of a left upper limb disability. Snowboard boot bindings were secured to the socket of the prosthesis and allowed it to be securely fastened and released using his dominant hand only. The design of the bindings permitted a high closing force with minimum one-handed effort by the user.

A randomized controlled trial of exercise to improve mobility and function after elective knee arthroplasty. Feasibility, results and methodological difficulties

OBJECTIVE

To assess the feasibility of comparing two types of exercise regime aiming to improve mobility and function following knee arthroplasty.

DESIGN

A single-blind randomized controlled trial.

SUBJECTS

Patients with primary, unilateral knee osteoarthritis undergoing elective knee joint replacement.

INTERVENTION

Home-based traditional exercise group (TEG) or home-based functional exercise group (FEG) following discharge from hospital.

OUTCOME MEASURES

These included goniometry; a knee-specific pain score, leg extensor power and a walking test. Patients were followed up at three, six and 12 months after surgery.

RESULTS

Forty-seven patients met the study criteria, 24 were randomized to the TEG and 23 to the FEG. There were marked improvements in mobility, leg extensor power and pain in the year after surgery (MANOVA p < 0.001). There were no statistically significant differences between the two exercise groups. Knee flexion decreased during the follow-up period and had not recovered by 12 months. Retention of patients was a problem, with nearly 50% lost to follow-up at 12 months. These patients were assessed as having low motivation during inpatient rehabilitation (p < 0.05).

CONCLUSIONS

There were trends in favour of the FEG that were of clinical relevance. A definitive study would need a sample size of at least 100 patients in each arm. It is essential to develop strategies to combat loss to follow-up.

The impact of relocation on elderly patients with mental illness

Twenty-three elderly patients with long-term mental illness were relocated from a large tertiary mental health facility to two extended care units (ECUs) in their district of origin. The patients were assessed on measures of functioning, aggression and agitation at 6 weeks pre-relocation, and again at 6 weeks and 6 months post-relocation. The impact of relocation on the group proved to be less dramatic than findings reported in the literature. The adverse affects of relocation were likely to have been offset by the preparation and planning undertaken prior to relocation, and the support provided to staff and patients in the period following relocation. The findings have implications for nursing staff involved in the relocation of people with mental illness between wards within a hospital or from one hospital to another.

Feline Pit2 functions as a receptor for subgroup B feline leukemia viruses

Different subgroups of feline leukemia virus (FeLV) use different host cell receptors for entry. Subgroup A FeLV (FeLV-A) is the virus that is transmitted from cat to cat, suggesting that cells expressing the FeLV-A receptor are important targets at the earliest stages of infection. FeLV-B evolves from FeLV-A in the infected cat through acquisition of cellular sequences that are related to the FeLV envelope gene. FeLV-Bs have been shown to infect cells using the Pit1 receptor, and some variants can infect cells at a lower efficiency using Pit2. Because these observations were made using receptor proteins of human or rodent origin, the role that Pit1 and Pit2 may play in FeLV-B replication in the cat is unclear. In this study, the feline Pit receptors were cloned and tested for their ability to act as receptors for different FeLV-Bs. Some FeLV-Bs infected cells expressing feline Pit2 and feline Pit1 with equal high efficiency. Variable region A (VRA) in the putative receptor-binding domain (RBD) was a critical determinant for both feline Pit1 and feline Pit2 binding, although other domains in the RBD appear to influence how efficiently the FeLV-B surface unit can bind to feline Pit2 and promote entry via this receptor. An arginine residue at position 73 in VRA was found to be important for envelope binding to feline Pit2 but not feline Pit1. Interestingly, this arginine is not found in endogenous FeLV sequences or in recombinant viruses recovered from feline cells infected with FeLV-A. Thus, while FeLV-Bs that are able to use feline Pit2 can evolve by recombination with endogenous sequences, a subsequent point mutation during reverse transcription may be needed to generate a virus that can efficiently enter the cells using the feline Pit2 as its receptor. These studies suggest that cells expressing the feline Pit2 protein are likely to be targets for FeLV-B infection in the cat.

Haemodialysis in a rural area: a demanding form of treatment

OBJECTIVE

To determine distances travelled and time spent waiting for transport among hospital haemodialysis patients living in a rural area.

DESIGN

Cross sectional survey comparing the subregional dialysis unit in south west Scotland with 12 of the other 13 Scottish Adult Renal Units.

SUBJECTS

Forty three Dumfries and Galloway patients and 935 other Scottish patients receiving hospital haemodialysis in November 1999.

RESULTS

At the time of the survey 8/43 (19%) Dumfries patients travelled in excess of 100 miles per dialysis day (15,000 miles per year) solely for the purpose of dialysis, compared to 20/935 (2%) elsewhere in Scotland (p < 0.001). Twenty seven (63%) Dumfries and 594 (64%) patients in other Scottish Units relied on hospital car, Patient Transport Service bus or ambulance for the journey home after treatment. Dumfries patients who travelled by Patient Transport Service or hospital ambulance had to wait twice as long before they left the renal unit as patients using a dedicated hospital car or private car.

CONCLUSION

Haemodialysis in a rural area has every reason to be considered a demanding form of treatment. Greater promotion of home based treatment would improve the quality of life for many of these patients, while dedicated hospital cars would reduce 'car to needle time' for those who remain on hospital haemodialysis.